Follow-up·April 3, 2026

On 04/03/2026 at 12:15 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported AWOL incidents that occurred on 03/28/2026. LPA met with Administrator (ADM), Divina Fernandez, and explained the purpose of the visit. On 04/01/2026, LPA P. Manalo received an incident report that indicated that on 03/28/2026, R1 and R2 AWOL’D from the facility at different times. R1 AWOL'D from the facility at approximately 11:00 AM and was found down the street using the GPS monitoring system. Incident report also indicated that during the time R1 AWOL'D, the alarm system was not working. Another incident dated 03/28/2026 revealed that R2 AWOL'D from the facility at approximately 2:15 PM during shift change and was also found outside near the street with the use of the GPS monitoring system. During the visit, LPA and ADM observed R3 test if the front door would set off while the resident attempted to leave. The front door alarm did not set off, and ADM stated that the door will not alarm if the resident's waunder guard bracelet is covered by the resident's clothing. However, when R1 tested the front door to see if it would alarm, the sound still did not set off and R1's waunder bracelet was observed to not be covered with anything. It was also observed that the facility installed a facial recognition. Interview with ADM revealed that the facial recognition recognizes the residents' who are known wanderers and will notify the facility via telephone if a resident attempts to leave through the front or side doors. It was observed that the facial recognition was working and it would call the facility's phone if a resident attempted to go out. Continue to LIC809-C... Continued from LIC809... LPA reviewed R1 and R2's physician report indicated that they are both not able to leave the facility unassisted. A review of the Medroom Communication Log indicated that for both residents it was noted that the resident was nowhere to be found and the facility staff were able to locate the residents with the GPS monitoring system. Interview with ADM and S1 confirmed that during the time of the residents' AWOL'D, the alarm system was not working. S1 also stated that the system was fixed the next day, but based on the observations done today, the alarm sound was still not working at the front door. The following deficiencies was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalty. Exit interview conducted. Appeal Rights, LIC421FC, and a copy of this report provided.