Incident investigation·April 9, 2025

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management visit for the incident that was reported on 10/23/2024 and investigation was initiated on 10/24/2024. LPA met Licensee/Administrator Amor Valin and Virgil Valin and stated the purpose of the visit is to amend the report that was delivered on 1/8/2025 based on additional information. On 10/24/2024, the Department conducted a case management visit to for the incident report received on 10/23/2024 regarding resident (R1) who left the facility without staff's knowledge. R1 was found the next day by law enforcement (10/24/2024). On 10/24/2024, the Department interviewed 3 staff (S1, S2 & S3). 3 Out of 3 staff stated on 10/23/2024 during lunch time, approximately noon, they observed R1 was present at the facility. Staff S2 stated during snack time which was served at 3:00pm observed that R1 was not present at the facility. Staff reported to ADM that R1 was missing and law enforcement was called as soon as R1 was confirmed to be missing from the facility. The facility staff searched within the 3 mile radius but was not able to locate R1. Based on staff interview, 3 Out of 3 staff, stated that R1 recently moved to the facility and will always go to the gate, wanting to leave. 3 Out of 3 staff stated that ADM have instructed all staff to watch over R1 because R1 is new and is not familiar with his/her current surroundings. 3 Out of 3 staff stated that there will always be a staff by the gate to watch over the residents who are coming and going through the gate. Continuation on LIC 9099-C, Page 1 of 3. Based on observation and interview with staff, the gate is equipped with a bell alarm system alerting staff when a person/individual opens the gate. 3 Out of 3 staff stated R1 appears to have a wandering behavior and does not communicate well in English. Staff stated that R1 likes to speak with his/her roommate who spoke the same language as himself/herself. Staff stated based on R1s assessment, R1 can leave the facility unassisted. Staff were instructed by ADM because of the fact that R1 was new and still adjusting to his/her new environment should be supervised and assisted until R1 adjust to the new environment. 3 Out of 3 staff stated R1 was recently admitted and been in the facility for less than a month. 3 Out of 3 staff stated that during the time of the incident 10/23/2024, around 2:00 p.m. ADM called for a staff meeting and most staff were present except for one. 2 out of 3 staff stated the door was closed because it was cold. 1 out of 3 stated that the door was open. 3 Out of 3 stated they did not see R1 leave because they were all facing towards the office. 3 Out of 3 staff stated, one staff was left behind to look after all the resident's coming and going while the meeting is in progress. 3 Out of 3 staff stated the meeting lasted for less than an 30 minutes. 3 Out of 3 staff stated they were alerted that a resident opened the gate because of the loud alarm when the gate opened, but did not see R1 leave. 3 Out of 3 stated it was another resident that they saw. 3 out of 3 staff stated that the window in the office is huge so they can see residents passing when the gate alarms. R1 was found on 10/24/2024 by law enforcement and R1 was brought to the hospital for assessment. R1 returned back to the facility at approximately 7:00 p.m. On 4/9/2025, the Department interviewed ADM who stated that new residents are supervised at the facility for the first month after admission. ADM stated the day of 10/23/2024, R1 did not sign out of the log before leaving the facility and was not seen on the surveillance camera. LIC/ADM stated R1 was displaying wandering behavior during the first couple of days of admission. R1 would leave the facility building and walk towards the main gate, however, staff is able to stop R1 prior to the incident from leaving because staff was always present by the front gate. ADM stated R1 can understand English and speak English. Continuation on LIC 9099-C, Page 2 of 3 On 4/9/2025, LPA Partoza, attempted to interview R1 by asking questions. R1 would respond with one word answers which are "yes" or "no" . R1 was not able to state his/her name, date of birth or today's date but will communicate with ADM and facility staff. 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, states R1 is monolingual and does not speak English. Based on review of 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 for 5 years (3/30/2019-10/2/2024) R1 was admitted to the facility on 10/3/2024. Based on interviews and observation/inspection of the facility, the preponderance of evidence has been met therefore the above allegations is found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 on 1/8/2025 visit, see LIC 9099-D. However the case does not meet the criteria of absence of supervision, there for no civil penalty is warranted. The Plan of Correction (POC) have been submitted to Community Care Licensing (CCL). An exit interview was conducted with LIC/ADMs Virgil Valin and Amor Valin and a copy of the report was provided. Page 3 of 3 End of Report