Routine inspection·September 25, 2025

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit and met with Administrator Xi-Hua Luo. During the visit, LPA observed 6 residents and 3 staff. LPA explained the purpose of the visit was to conduct the annual inspection, continue the complaint investigation for the complaint 26-AS-20250115102820 and follow up on an incident report regarding an elopement. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 5 restrooms and 6 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. While touring the side of the facility, adjacent to the kitchen/ family room, LPA observed the side gate had a lock, obstructing the side exit. (Photograph of the lock gate was taken.) ADM stated the gate is locked because resident R1 has wandering behaviors. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 79 degrees F, and hot water temperature was measured at 106.7 degrees F to 113 degrees F in resident bathrooms. Fire extinguisher was serviced in July 2025. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on 8/26/2025. . LPA reviewed 3 resident medications and centrally stored medication records. LPA reviewed facility records for 3 staff and 3 residents. Based on a review, resident R1's needs and services plan has not been updated, and does not address R1's wandering behavior. Page 1 Out of 3. While touring the home, LPA's observed resident R2 seated in a wheel chair in front of the dinning room. LPA's then noted resident's wheel chair was tied to the dinning table. (Photograph was taken.) LPA's asked staff S1 why R2 was tied. S1 stated R2 will sit on his/her wheel chair alongside the dinning room table and push him/herself. S1 stated she doesn't know since when R2 was being tied. S1 stated R2 isn't being tied everyday. Staff S2 stated the ADM, S1, S3 and him/herself has been tying R2 to the table since the past 2 weeks. S2 stated they tied R2 because he/she pushes him/herself against the dinning room table, which almost causes R2 to fall. Staff S3 stated the care givers on shift, including him/herself has been tying R2 when he/she is sitting at the dinning room table. S3 stated the tying has been occurring for over a month. ADM stated R2 has been pushing him/herself against the table the past week. ADM stated he/she doesn't know since when R2 has been tied. LPA asked ADM if she has ever tied R2, ADM stated During the tour of the facility, LPA's noted facility cameras throughout the facility. LPAs asked ADM if the cameras record with audio. ADM stated confirmed the cameras inside the facility do record with audio. LPA asked ADM how often she checks the video cameras. ADM stated she checks everyday. Incident Report, dated September 19, 2025 On September 19, 2025, the Department received an incident Report regarding resident R1. The incident Report stated, on September 16, 2025, at 3:00pm, R1 had episode of wandering out of the facility. Staff checked on R1 around 2:30pm and R1 was asleep in bed. Around 3:00pm, staff went to R1’s room and couldn’t find him/her. Staff checked all inside and outside of facility, but R1 wasn’t found. The facility has camera around all exit doors and R1 wandered out from side yard gate. All exit door have alarms. The alarm was working when R1 exited, but staff did not check the alarm. Staff had searched all neighborhood, still could not find R1. Staff received call from EMT stating they received a call from people walking in the street regarding R1. R1 sent to hospital. On September 19, 2025 LPA Partoza interviewed staff S1. S1 stated R1 has a wandering behavior and they have an alarm on all the doors. S1 stated that at 2:30 p.m. R1’s Family member (FM) came and asked for R1. FM stated that R1 was not in the room, S1, proceeded to go look for R1 inside the facility. S1 stated when he/she went outside at the backyard, he/she saw the backyard gate open. Page 2 Out of 3. On September 19, 2025, LPA Partoza interviewed Administrator Julia Zhang. ADM stated that R1 has a wandering behavior and likes to walk around the house and the backyard. ADM stated they keep a latch on the backyard gate, but at 2:00 p.m. another resident was dropped off by a driver from a transportation provider. The resident came from his/her dialysis appointment and went through the side gate. The side gate was left open by the driver and did not close the gate. ADM stated that's what she was told by the staff. ADM stated that a neighbor saw R1 and called the ambulance. ADM stated he/she received a call from the EMT. ADM stated that EMT called the care facilities in the neighborhood and used the CCLD website and contacted the facilities around the neighborhood. ADM stated usually R1 doesn’t leave the facility, this was the first time this happened after being at the facility for 10 months. R1 was brought to Good Samaritan Hospital and was released back to the facility. On September 25, 2025, LPA Monter interviewed ADM. ADM stated she was informed about R1's elopement around 3:29pm. ADM stated she was near the facility and when she arrived, she searched for R1. ADM stated at 3:45pm, she received a call from EMT stating they found R1 by his/herself. As a result, An immediate civil penalty of $500.00 is being assessed against the facility today for violation the absence of supervision, which resulted in R1 eloping from the facility. Deficiencies cited during today's visit. Administrator refused to sign. ADM stated he wanted LPA to delete photos of inside of shed. LPA stated, the ongoing complaint investigation regarding the shed is still under investigation. LPA informed ADM the photos taken of the shed will not be deleted. Page 3 Out of 3. END OF REPORT