Routine inspection·January 24, 2025

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with licensee Justice Ehimamiegho and explained the purpose of the visit. LPA Moleski reviewed four resident files (R1-R4) and three staff files (S1-S3). LPA Moleski observed in R3's file three incident reports dating between 6/27/24 and 8/28/24 describing elopements by R3 wherein he was unsupervised in the community. An incident report dated 6/27/24 indicated that R3 was walking around in the backyard around 8 a.m., but when staff checked on him he had evidently left the property through a rear gate. Staff tried to find R3, but could not, so they called 911, according to the incident report. R3 was later found around 8:36 a.m. A second incident report dated 7/01/24 indicated that R3 left the facility through the front door around 9 a.m. and could not be redirected. Staff notified the licensee, who looked through the neighborhood, but could not find R3, according to the incident report. 911 was called, but at the time the incident report was written, R3 had not been found. LPA Moleski reviewed ongoing progress notes for R3 and observed a note dated 7/2/24 that indicated R3 was brought back to the facility by police on 7/2/24 around 7 a.m. LPA Moleski reviewed an after-visit summary from a hospital visit on 8/27/24, which showed R3 was diagnosed with acute psychosis. A third incident report dated 8/28/24 indicated that R3 became irritable and broke the facility television without apparent cause. Later in the day, around 4 p.m., R3 broke a bathroom window and left the facility through the window, according to the incident report. Staff called 911, but a neighbor notified staff that R3 was found in their backyard. R3 is diagnosed with mild cognitive impairment, and is non-ambulatory, according to R3's LIC 602, dated 11/15/23. R3 suffers from confusion and disorientation, and is not able to independently transfer, according to the LIC 602. R3 also has a history of seizures. LPA Moleski asked Ehimamiegho if he felt it is safe for R3 to be in the community independently. Ehimamiegho said that R3 would not be entirely safe, as R3 does require care, and R3 may also be unable to remember how to return to the facility if gone for too long. [continued on 809-C] Upon arrival, LPA Moleski observed a noticeable odor of urine in the facility. While reviewing facility records, LPA Moleski observed staff cleaning bedding and removing diapers from resident rooms. While touring this facility, LPA Moleski observed a noticeable odor of urine remaining in R1 and R4's shared room. LPA Moleski toured the facility with Ehimamiegho and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 105 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives. LPA Moleski interviewed one staff member (S1) and one resident (R2). This facility is hereby cited per HSC Section 1569.312(d) and 22 CCR Section 87625(b)(3) . An exit interview was conducted and a copy of this report was left with Ehimamiegho.