Incident investigation·January 8, 2025

Licensing Program Analysts (LPAs) Simi Rai and Marcela Yanez conducted an unannounced case management visit to conclude the investigation initiated on 10/24/2024. LPAs met Licensee/Administrator Amor Valin and Administrator Virgil Valin and stated the purpose of today’s visit. On 10/24/2024, the Department conducted a case management visit to follow up on an incident report received on 10/23/2024 regarding resident (R1) left the facility without staff knowledge and was reported missing by facility staff. On 10/24/2024, 3 staff were interviewed. 3 Out of 3 staff stated on 10/23/2024 during lunch time, approximately noon, they observed R1 present in the facility. Staff S2 stated during snack time which was at approximately 3:00pm, staff observed R1 was not present at the facility. Staff waited for R1 to return to the facility until dinner time at approximately 5pm and realized resident was not back at the facility. The facility staff searched around 3-mile radius but were not able to locate R1. R1 was reported to local law enforcement as missing person. 3 Out of 3 staff stated R1 had wandering behaviors and staff ensured R1 did not leave the facility and did not leave R1 alone. Staff stated they were not able to communicate and assess the R1’s needs because R1 did not speak English and they did not speak R1’s language. During today’s visit, LPAs interviewed ADM and LIC. R1 returned back to the facility on 10/24/2024 at 7pm. ADM stated all residents are supervised at the facility for the first month following their admission to the facility. ADM stated the day of 10/23/2024, R1 did not sign out of the log before leaving the facility. LIC stated R1 was displaying wandering behavior during the first couple of days of admission where R1 would leave the facility building and walk towards the gate located at the front of the facility. ADM stated R1 can understand English and speak English. Continuation on LIC 9099-C, Page 1 of 2. Page 2 of 2. During today's visit, LPAs interviewed R1. LPAs asked R1 questions and R1 would respond with one word answers such as "Yes" and "No". R1 was not able to answer basic questions as R1's name, date of birth or today's date. R1 is able to understand nonverbal cues such as pointing to the door when asked to close the door or pointing to the head when asked if R1's head hurts. Based on review of Incident Report 10/23/2024, Administrator stated the residents who leave the facility would return for dinner. Based on review of R1’s Physician’s Report dated 7/25/2024, R1 is able to leave facility unassisted but does not specify if R1 is confused/disoriented or has wandering behavior. Based on review of R1’s Appraisal/Needs and Services Plan 9/25/2024, R1 is monolingual and does not speak English. Based on review Visitor Sign In/Sign Out log, R1 did not sign out the day of 10/23/2024. Based on information provided by R1’s conservators (CO), the incident on 10/23/2024 was the first time out in the community and R1 was unfamiliar with the area and is very confused. CO stated R1 has been in a locked facility from 3/30/2019-10/2/2024 and R1 was admitted to the facility on 10/3/2024. Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. A civil penalty is being assessed for the amount of $500 for the absence of supervision at the facility. Please see LIC421IM. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Licensee/Administrator Amor Valin and Administrator Virgil Valin and a copy of the report was provided. Appeal Rights was provided.