Incident investigation·April 2, 2025

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit to the above facility. The LPA met with Administrator Edwin Paul Oyasan. Entrance interview conducted. The reason for today's inspection is to follow up on a self-reported incident report that was received at the Woodland Hills Regional Office on 03/26/2025. Incident report indicates that on 03/25/2025, Resident #1 (R1) was found on the sidewalk outside a neighbor's home. 9-1-1 was called, as R1 appeared to have fallen while outside the facility. R1 was transported via ambulance to the hospital. LPA called Administrator on 04/01/2025 for additional information and the incident was discussed via telephone at that time. During today's visit, the LPA reviewed R1's file and obtained copies of pertinent documents, LPA conducted staff interviews at 01:55PM and 02:04PM, interview with R1 at 02:15PM, Facility Administrator at 02:42PM, and LPA toured the facility with Administrator at 02:48PM. Record review revealed that R1 is unable to leave the facility unassisted. Staff were aware that R1 expressed they want to leave the facility and R1 had previously attempted to leave the facility unassisted. R1's physician's report indicates R1 requires assistance with toileting, however, on 03/25/2025, R1 was left in the restroom unsupervised. R1 walked down the hall, through the laundry room and staff office area and exited the home unnoticed. R1 then opened the side gate and exited the facility property unsupervised. R1 walked down the sidewalk and appeared to have fallen by the neighbor's house. Further medical treatment was required at the hospital, as R1 sustained injury during the elopement incident. Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided via email.