Incident investigation·December 3, 2024

On 12/3/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with caregiver Louis Dizon(S1). On 11/27/24, the department received an incident report for R1 having left the home unassisted on 11/22/24. LPA reviewed the LIC 602 for R1 and found that R1 is to not leave unassisted. On 11/22/24, S1 was the lone caregiver present, while S1 was assisting R2, R1 left the facility. S1 discovered R1 missing, called 9-1-1 for assistance. R1 was found by police and returned unharmed. This licensee has received a prior citation related to R1 leaving in June 2023. It is found that there were not adequate staff present to meet the needs of residents. While LPA was present, a Health and Safety Check was conducted for all residents. LPA conducted a file review for R2. R2 was receiving home health care for pressure injuries. LPA attempted to contact home health regarding the status of R2's pressure injuries. R2 was unwilling to be interviewed by LPA. LPA may return after receiving further information regarding R2. During this inspection, LPA observed, accompanied by S1, that facility staff had installed locking mechanisms on several exit doors and has a locking mechanism for the front door on the overnight. Mechanisms were removed while LPA was present. These locks violate fire safety regulations. File reviews for R1 and R2 found that there are not current detailed needs and services plans for R1's wandering or for R2's wounds, incontinence or bed repositioning. Licensee was advised during a 5/29/24 Annual inspection to have needs and services plan in place. Caregiver S2 has worked at this facility greater that 5 days without transfer of criminal record clearance. LPA checked clearance and found S2 to have clearance but was not associated to this home. Given the issues found during this visit, it was found that Administrator, Vivek Mahajan, is not present at the facility to fulfill the duties and responsibilities of the facility/ residents. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights provided