Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – deficiencies visit. LPA met with Designated Administrator, Mario Lagan and Licensee, Marie Pendar.

The purpose of the visit is to address Title 22 violations observed during a complaint investigation ( Control Number 26-AS-20250124153302).

During the investigation, staff stated that on 01/23/2025 the only 2 staff working at the facility both left the facility to walk about 200 feet away (0.2 miles) to pick up R1, after R1 eloped from the facility. The staff instructed 1 resident to supervise 3 other residents for about 5-10 minutes while the staff went to get R1. Staff stated that the 1 resident who was asked to supervise the other resident was the most “reliable” to watch the remainder of the residents, as the resident had the most cognition.

During the investigation, it was stated that R1’s elopement behavior began in the beginning of January 2025. Based on review of R1’s appraisal/needs and services plan it was last updated in year 2023. R1’s appraisal/needs and services plan was not updated to address R1’s new elopement behavior.

During today's visit, LPA observed a pad lock device located at the bottom left side of the front entrance door. It was stated that the pad lock was installed to help reduce R1's elopement behavior. LPA observed an audible door alarm located at the top left of the front door, however, the door alarm was not working. Page 1 of 2.