Incident investigation·December 3, 2025

On 12/03/2025 at 2:30 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported AWOL incident that occurred on 10/19/2025 and 11/22/2025. LPA met with Administrator, Divine Fernandez, and explained the purpose of the visit. On 10/20/2025, LPA P. Manalo received an incident report that indicated that on 10/19/2025, R1 AWOL’D from the facility. Staff was able to locate R1's location with the GPS monitor system. On 11/25/2025, LPA P. Manalo received an incident report that indicated that on 11/22/2025, staff noticed that R1 was not present in the dining area. R1 was then found using R1’s GPS monitor. Both incidents, R1 was found sitting on the pavement being assessed by Emergency Medical Services (EMS) and was sent to the hospital for further evaluation. During the visit, a review of the facility’s communication log indicated that the facility’s alarm was not working during R1’s AWOL’d on 11/22/2025. Interview with S1 and S2 revealed that all the staff were busy assisting residents during that time and did not hear the alarm. LPA verified that both alarms on the side and front of the facility are in operational. A record review of R1’s physician report dated 10/05/2025 revealed that R1 is unable to leave the facility unassisted. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiency within a 12-month period may result in civil penalty. Exit interview conducted. Appeal Rights and a copy of this report provided.