Facility Evaluation Report

Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced Case Management – Incident visit today and met with Executive Director Nancy Rubio.

The purpose of the visit was, on 09/03/2021, the Department received an incident report regarding a resident (R1) left the facility unassisted on 09/02/2021. R1 was later found outside by a police officer without any injury.

LPA conducted a wellness check with R1 and observed R1 without injury. LPA interviewed the Executive Director. The Executive Director stated an inspection on the egress doors and alarms was conducted. No malfunction was observed. The Executive Director also conducted an in-service training with staff to educate and to remind the staff to make sure the doors are locked and check the surroundings when the alarms sound.

Record review of R1’s physician’s report showed R1 has mild cognitive impairment who is unable to leave facility unassisted. Deficiency was cited during visit today. See LIC809-D.

This report was reviewed with the Executive Director.

A copy of this report and appeal rights were provided.