Incident investigation·December 18, 2025

On 12/08/2025 at 1:35 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported AWOL incident that occurred on 12/08/2025. LPA met with Administrator (ADM), Divina Fernandez, and explained the purpose of the visit. On 12/09/2025, LPA P. Manalo received an incident report that indicated that on 12/08/2025, R1 AWOL’D from the facility. Staff used the R1's GPS tracking device to locate R1, and it showed that R1 was transported to the Emergency Room. Interview with Administrator revealed R1 returned back to the facility later that day. During today's visit, LPA reviewed and obtained the following documents such as R1's physician report, Appraisal Needs and Services Plan, After-Visit Summary, and facility's communication log. LPA interviewed and observed ADM with the Wander Guard Bracelet walk out of the facility's side door and the alarm in operational condition. A review of R1's physician report dated 07/04/2025 showed 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, LIC421FC, and a copy of this report provided.