Incident investigation·February 20, 2025

On 2/20/2025 at 4:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to an incident report. LPA met with Executive Director (ED), Janice Gombio and Campus Director, Isabel Poderoso. While LPA was at the facility for another visit, ED provided LPA a copy of a recent incident report. Based on the incident report dated 2/20/2025, at around 1:35PM on 2/19/2025 staff went to the front lobby and noted the front door was propped open. Staff immediately searched the area and conducted a head count of residents. It was noted that two residents (R1 and R2) were not in the building. Staff searched for residents and called 911. R1 and R2 was found by staff and police at a nearby grocery store. R1 and R2 returned back to the facility with staff. During visit, LPA interviewed staff and reviewed R1 and R2's file including physician's report and incident report. R1 and R2's physician's report stated that R1 and R2 cannot leave the facility unassisted. Interview with staff revealed that the front door delayed egress door was propped open and there was no staff at the front desk during that time. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.