Follow-up on corrections·August 27, 2025

Licensing Program Analysts (LPAs) Triel Lindstrom and Vincent Moleski arrived unannounced to conduct a complaint investigation. However, during that investigation, LPAs Lindstrom and Moleski observed an unrelated deficiency. A resident of this facility (R1) left to walk their dog on or around the morning of Saturday, August 23, 2025, according to facility administrator Valarie Pais. R1 was discovered at the bottom of a steep hillside on the evening of Sunday, August 24, 2025, according to the Tuolumne County Sheriff’s Office, which led search and rescue efforts. LPAs Lindstrom and Moleski reviewed R1’s service plan, dated November 22, 2024. The service plan indicates that R1 had a “history of wandering outside the community,” and that “health and safety may be jeopardized.” LPAs Lindstrom and Moleski reviewed R1’s LIC 602, which was signed by a physician on January 6, 2025. The LIC 602 does not indicate that R1 had a history of wandering behaviors. However, the actual exam of R1 took place on September 24, 2024, according to the LIC 602, which is before the aforementioned service plan identified a significant change in R1’s behavioral expressions. LPA Moleski asked Pais if R1’s physician was notified of the behaviors noted in the service plan. Pais said she was not aware of any such notification, and said that resident’s physicians should be notified if there is a significant change in condition. LPA Moleski spoke with the facility’s resident care director (S1), who had modified the service plan as of April 15, 2025. S1 said they were not aware of any such behavioral expressions. S1 said that R1’s physician should have been notified in the event that these behavioral expressions were identified. [continued on 809-C] LPAs Moleski and Lindstrom provided Pais an opportunity to acquire documentation showing that R1's physician was notified. Pais was unable to provide such documentation during this visit. 22 CCR Section 87755 states that " the licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. " 22 CCR Section 87463(e) states that “the licensee shall immediately, or as soon as reasonably possible, bring any significant change in condition … to the attention of the appropriate licensed medical professional … documentation of such communication shall be added to the resident’s record…” This facility is hereby cited per 22 CCR Section 87463(e). An exit interview was held with Pais. Appeal rights and a copy of this report were left with Pais.