Toluca Lake Manor Senior Assisted Living

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Staff did not prevent resident in care from leaving the facility without supervision

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint visit to investigate the above allegation. LPA arrived to the facility at 10:16 AM. LPA met with facility staff who contacted the Administrator Mariana Romano. Entrance interview conducted and the reason for the visit was explained. During today's visit LPA conducted a brief physical plant tour, conducted interviews with one (1) resident, two (2) staff members, the Administrator, and collected copies of pertinent documentation between approximately 10:16 AM and 02:30 PM. The allegation of “Staff did not prevent resident in care from leaving the facility without supervision.” Alleges that facility staff did not provide adequate supervision to Resident #1 (R1) which resulted in R1 leaving the facility without staff supervision. Prior to the investigation LPA was provided with a video filmed on 04/26/2026 which showed R1 outside of the facility without staff supervision.Continued on 9099C. Substantiated LPA interviewed the Administrator who stated that since the last visit, the facility has implemented 30-minute staff checks on R1. The Administrator stated that the facility has implemented a motion activated auditory alert device on the facility’s gate, but they had been experiencing issues with a tree near the gate causing false alarms due to detected motion. The Administrator stated that a gardener is scheduled to prune the tree on Saturday (05/09/2026) to diminish the number of false alarms. The Administrator stated that they were unaware that R1 had left the facility without supervision on 04/26/2026. The Administrator stated that they would speak with R1’s responsible party to discuss the implementation of a 1:1 caregiver to supervise R1. LPA interviewed facility staff who confirmed that they had implemented thirty (30) minute checks on R1 throughout the day. Additionally, staff confirmed that they had been trained to respond to auditory alerts throughout the facility. LPA interviewed R1 who stated that there are enough activities at the facility to keep them entertained including pet therapy and exercise. R1 stated that the facility walks with them through the neighborhood when they are able to. LPA reviewed R1’s resident file and observed a physician’s report dated 04/15/2026. The physician’s report indicated that R1 is unable to leave the facility unassisted. LPA informed the Administrator that they were recently cited for a violation of Health and Safety Code section 1569.312(a) on 04/08/2026. LPA informed the Administrator that since this is their second (2nd) violation of this licensing regulation within a twelve (12) month period a civil penalty in the amount of $250 is being assessed on today’s date (05/05/2026) for a repeat violation. Based on the interviews conducted, evidence submitted, and file review, there is sufficient evidence to support to the allegation of “Staff did not prevent resident in care from leaving the facility without supervision.” Therefore, the allegation is deemed Substantiated at this time. The following deficiency was cited and civil penalty assessed (Refer to LIC 9099D). Exit interview was conducted, a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 5, 2026 · control 29-AS-20260427105806

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312(a) · Plan of correction due date: May 19, 2026

Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews, evidence provided, and file review, the licensee did not comply with the section cited above as on 04/26/2026 R1 left the facility without staff assistance which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 5, 2026

Plan of correction: Administrator agreed to conduct a meeting with R1's responsible party to discuss the implementation of a 1:1 caregiver and/or the facility's inability to meet R1's care needs and the possibility of the issuance of a 30-day eviction notice. Administrator agreed to provide proof of the completed meeting and... ... the outcome of the meeting to CCLD no later than POC due date.

Allegation investigated: Staff did not prevent resident in care from leaving the facility without supervision.

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint visit to investigate the above allegation. LPA arrived to the facility at 09:46 AM. LPA met with Administrator Mariana Romano. Entrance interview conducted and the reason for the visit was explained. During today's visit LPA conducted a brief physical plant tour, conducted interviews with one (1) resident, two (2) staff members, the Administrator, and collected copies of pertinent documentation between approximately 09:50 AM and 04:00 PM. The allegation of “Staff did not prevent resident in care from leaving the facility without supervision.” Alleges that facility staff did not provide adequate supervision to Resident #1 (R1) which resulted in R1 leaving the facility without staff supervision. Prior to the investigation LPA was provided a video filmed on 04/03/2026 which showed R1 outside of the facility without staff supervision. Continued on 9099C. Substantiated LPA reviewed R1’s resident file and observed R1’s physician report dated 10/01/2024. LPA observed that the physician report indicated that R1 was not able to leave the facility without assistance. While reviewing the physician report LPA observed out of date information that did not accurately reflect R1’s changes in condition since the report was created. LPA notified the Administrator that Community Care Licensing Division (CCLD) is requesting that the Administrator obtain an updated physician’s report (LIC 602A 4/25) for R1. The Administrator agreed to obtain the report and to send a copy to CCLD once obtained. During the physical plant tour LPA observed the living room sliding door, bedroom #3, R1’s bedroom, and the front gate to the facility to be missing auditory alarms or to have auditory alarms that were not sufficiently audible to notify staff members when the entrance was utilized. LPA informed the Administrator that that the facility must have an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement. The Administrator expressed understanding and installed new functioning auditory alarms on the living room sliding door, bedroom #3, and R1’s bedroom at the time of the visit. LPA interviewed R1 who stated that staff treat them well and activities are offered to them at the facility. R1 expressed that they prefer to walk around the neighborhood on their own and don’t always have staff assist. LPA interviewed staff members who stated that they are aware that R1 can not leave the facility without staff assistance. Staff stated that they offer to take R1 out on walks throughout the neighborhood multiple times a day but R1 does not always accept the offer. Both staff members interviewed were unaware that R1 had left the facility without assistance on 04/03/2026. LPA interviewed the Administrator who stated that they were aware of the elopement behavior that R1 expresses but were unaware that R1 had left the facility without supervision on 04/03/2026. The Administrator stated that facility staff are trained to offer R1 walks throughout the day and R1 is offered a wide variety of activities to cultivate their interests including: pet therapy, art projects, current event discussion, religious support, and various household activities. The Administrator stated that they understood their role and responsibility for ensuring adequate supervision of R1 and agreed to have R1 re-evaluated and to implement timed checks on R1’s wellbeing throughout the day. Based on the interviews conducted, evidence submitted, and file review, there is sufficient evidence to support to the allegation of “Staff did not prevent resident in care from leaving the facility without supervision.” Therefore, the allegation is deemed Substantiated at this time. The following deficiencies were cited (Refer to LIC 9099D). Exit interview was conducted, a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 8, 2026 · control 29-AS-20260406084627

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312(a) · Plan of correction due date: Apr 22, 2026

Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews, evidence provided, and file review, the licensee did not comply with the section cited above as on 04/03/2026 R1 left the facility without staff assistance which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2026

Plan of correction: Administrator enabled motion tracking on their RING camera covering the front patio area. Administrator agreed to implement 30-minute checks by facility staff on R1 and to log the checks to ensure completion. Administrator agreed to have R1 re-assessed by their physician Administrator agreed to submit 1 week of 30 minute check logs and the physician's updated assessment to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(d) · Plan of correction due date: Apr 22, 2026

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates... This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as the living room sliding door, bedroom #3, R1's room, and the front gate of the facility were missing properly functioning auditory alarms which posed a potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2026

Plan of correction: Administrator installed functioning auditory alarms on all identified exits except the front gate at the time of the visit. Administrator agreed to conduct training with all staff shifts on the importance of responding to auditory alerts throughout the facility. Administrator agreed to submit proof of completed training and installed front gate alarm to CCLD no later than the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 09:31 AM. LPA met with facility Administrator Mariana Romano. Entrance interview conducted and the reason for the visit was explained. Beginning at 09:33 AM, the LPA, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS: There are four (4) bedrooms in the facility; all four (4) are designated for resident use. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. All bedrooms were observed to contain direct exits to the outdoors of the facility. Bedroom #1 is the bedridden approved room. BATHROOMS: There are two (2) bathrooms at the facility. Both bathrooms are designated for resident use. Bathrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed near the resident toilet and in both resident showers and all were properly secured. The water temperature was measured between 105.6 and 108.1 degrees Fahrenheit, which is in compliance with regulation. LPA observed bathroom #1’s under sink cabinet to contain additional care supplies. Continued on LIC 809C. COMMON AREAS: This includes the living room, hallway, sunroom, and dining room areas. LPA observed the common areas to be clean and properly furnished at the time of the visit. The living room was observed to contain adequate seating for resident use. Additionally, the living room contained a television, activities, and a fireplace that was appropriately screened and contained no tools. The hallway was observed to be clean and free from any obstructions. The sunroom was observed to contain the facility’s emergency water supply and a cabinet that contained additional care supplies. The dining room was observed to be clean and contained adequate seating for resident use. Smoke detectors and carbon monoxide detectors were tested at 10:21 AM and were functional at the time of the visit. KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. The LPA observed a locked drawer to contain knives and other sharp objects. LPA observed a secured cabinet to contain resident medications. LPA observed the under-sink cabinet to contain cleaning chemicals stored locked and inaccessible to clients in care. LPA observed a locked cabinet located adjacent to the kitchen to contain adequate emergency food supplies. LPA observed a wall mounted fire extinguisher to be fully charged and last serviced on 02/06/2025. OUTDOOR SPACE: LPA observed two (2) exit gates located on either side of the facility. LPA observed clear passageways for emergency exit use. The outdoors of the facility has adequate shaded seating for resident use. LPA observed the backyard to contain an appropriately screened pool that was locked and inaccessible to clients in care. LPA observed a secured shed that contained pool cleaning supplies. LPA observed cameras located on the outdoors of the facility. RECORD REVIEW: Record review began at 10:24 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Four (4) staff files were reviewed. All staff files contained all required documentation and trainings. Five (5) resident files were reviewed. Two (2) resident files were observed to be missing signatures on the inventory of resident’s personal property. One (1) resident file was observed to be missing a medical assessment and proof of a negative TB test. One (1) additional resident file was missing proof of a negative TB test. LPA informed the Administrator of the missing files and signatures. The Administrator agreed to obtain the missing documents and/or signatures and send copies of the completed documents to LPA. Continued on LIC 809C. MEDICATION REVIEW: Medications for 2 (two) of five (5) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheets. No deficiencies were observed during medication review INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. The last emergency disaster drill was conducted 06/03/2025. The facility’s emergency disaster plan is up to date and adequate. Both the infection control plan and the facility’s emergency disaster plan are reviewed/updated annually by the facility Administrator. INTERVIEWS: LPA interviewed one (1) staff and two (2) residents. Both residents stated that staff treat them well and are attentive to their needs. The staff member interview was conducted with the assistance of the Administrator acting as a translator. The staff member interviewed was knowledgeable on the resident rights, the different forms of abuse, and the appropriate reporting procedures for suspected abuse. During today’s visit LPA obtained a copy of the facility’s updated LIC500, resident roster, and liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted, a copy of the report was issued, and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 13, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced plan of correction (POC) case management visit to the facility above. The reason for this visit was to conduct a follow-up in reference to deficiencies that were cited during a complaint investigation (Complaint Control Number: 29-AS-20240910144537) that occurred on 09/17/2024. The LPA met with facility staff member Abdul Kadir, at 10:17 AM and explained the purpose of the visit. Facility staff contacted the facility administrator Marianna Romano who arrived at the facility at 10:20 AM. Entrance interview conducted and the reason for the visit was explained. During today’s visit LPA Byrne interviewed the facility administrator. The facility administrator stated that they have contacted a physician’s assistant to update resident 1’s (R1) physician’s report. The facility administrator also stated that R1 is scheduled for a psychological evaluation sometime next week. During the visit Administrator contacted Good Choice Home Health and asked them to provide the updated physician’s report for R1. The document that was received was a Home Health Certification and Plan of Care form and not an updated physician’s report. The document provided did not satisfy the requirements of the POC. The facility administrator was advised during the original complaint investigation that failure to correct deficiencies would lead to additional penalties. The facility administrator did not provide the LPA with the required documentation within the appropriate timeframe. As this is a failure to correct the POC within the given timeframe and no extension was requested a civil penalty is being assessed in the form of $700. The total of the civil penalty is calculated at $100 per day starting after the due date of the POC. The POC for this deficiency was due on 09/25/2024 and today’s date is 10/01/2024. LPA informed administrator that failure to correct the deficiency may lead to additional penalties. Exit interview conducted, civil penalty assessed, and a copy of the report delivered.the state’s words, verbatim · CDSS document, Oct 1, 2024

Allegation investigated: Staff do not provide adequate care and supervision to a resident

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced 10-day complaint visit to investigate the above allegation. LPA arrived to the facility at 09:46 AM and was greeted by facility staff. Staff contacted Mariana Romano, Administrator, via telephone call. The Administrator arrived at 09:51 AM, entrance interview conducted and the reason for the visit was explained. During today's visit, starting at 09:52 AM, the LPA along with the facility Administrator conducted a brief physical plant tour. The LPA also conducted interviews with residents, staff, and administrator between 10:30 AM and 11:40 AM and obtained copies of pertinent records. During the physical plant tour, LPA observed all facility exits to contain functioning auditory alarms. The facility has an appropriately screened pool in the backyard. The facility has a camera near the front door to the house that has clear line of sight to the front gate. Continued on 9099C. Substantiated The allegation of ‘Staff do not provide adequate care and supervision to a resident’ alleges Resident #1 (R1) was observed to be wandering outside the facility without the presence of staff. The Reporting Party also provided video evidence of R1 outside of the facility without staff present which allegedly occurred on 09/03/2024. Record review revealed that R1 was admitted to the facility in August 2023. R1’s physician’s report indicates R1 cannot leave the facility unassisted due to a diagnosis of dementia. Interviews with residents and staff revealed that R1 has, in the past, left the facility without the assistance of a caregiver. Previously on 07/09/2024, the Department received a complaint, (CONTROL NUMBER 29-AS-20240709121224) alleging staff do not provide adequate care and supervision to R1, as R1 was observed to be wandering outside of the facility unassisted. The allegation was substantiated on 07/11/2024. The Administrator’s plan of correction for the deficiency was to install auditory alarms on facility exits, schedule walks for R1 with the supervision of a caregiver, swap R1’s coffee to decaf, and Increase R1’s inhouse activities. During today’s inspection, the LPA showed the Administrator the video of R1 allegedly being outside of the facility without supervision on 09/03/2024. The Administrator confirmed the person in the video was R1 but stated they were unaware R1 was outside of the facility without staff supervision. During the inspection, the LPA did observe the presence of two caregivers, of which one caregiver being assigned as R1’s 1:1 caregiver. During the interview with Staff #1 (S1) they confirmed they are R1’s 1:1 caregiver although they stated they have been working as R1’s 1:1 caregiver for “One month, couple of months.” R1 stated that S1 had been their caregiver since “last week, maybe the week before.” Based on the interviews conducted, evidence submitted, and file review, there is sufficient evidence to support to the allegation that staff do not provide adequate care and supervision to a resident. Therefore, the allegation of staff do not provide adequate care and supervision to a resident is deemed Substantiated at this time. LPA informed the Administrator that they had been cited on 07/11/2024 at a previous complaint visit (CONTROL NUMBER 29-AS-20240709121224) for failing to follow the same regulation. As this is a repeat violation of the same section of Title 22 Regulations [HSC 1569.312(a)] within last 12 months a civil penalty of $250 is being assessed. LPA informed administrator that failure to correct the deficiency may lead to additional civil penalties. Exit interview was conducted, Appeals Rights discussed, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 17, 2024 · control 29-AS-20240910144537

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1596.312(a) · Plan of correction due date: Sep 18, 2024

Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews conducted, evidence submitted and file review, the licensee did not comply with the section cited above. Facility staff failed to provide the necessary care and supervision to Resident #1 which allowed Resident #1 to elope from the facility unassisted, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2024

Plan of correction: Licensee will provide the Department with a staff schedule outlining the hours worked of resident #1's 1:1 caregiver and a written plan of action outlining the actionable changes the facility will take to prevent resident 1's elopement behavior.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility to conduct an unannounced 10-day complaint visit (CONTROL NUMBER 29-AS-20240910144537). While conducting record review for the complaint investigation, LPA observed Resident 1's (R1) file. R1's physician report was not dated but was faxed to the facility on 07/28/2023. R1 has a diagnosis of dementia and their physician's report was not updated annually. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 17, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Sep 24, 2024

(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by: Based on record review, the licensee failed to comply with the section cited above as one resident, with a diagnosis of dementia, did not have their physicians report updated annually which poses a potential health risk to clients in care.the state’s words, verbatim · CDSS document, Sep 17, 2024

Plan of correction: Licensee will submit an updated physician's report to CCL no later than POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 10:22 AM. LPA was greeted by Facility staff who contacted the facility administrator Mariana Romano. Facility administrator arrived to the facility at approximately 10:28 AM Entrance interview conducted. Beginning at 10:28 AM, the LPA, along with facility administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. A camera was observed in the Living room. The LPA observed the fire extinguisher to be fully charged and serviced on 03/08/2024. At 10:30 a.m. LPA observed an unlocked cabinet that contained a prescription Ipratropium bromide and albuterol sulfate inhaler box. Smoke detectors and carbon monoxide detectors were tested at 01:01 p.m. and were functional at the time of the visit. KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food and emergency water. The LPA observed one designated drawer where knives and sharps are stored locked and inaccessible to residents. At 10:45 a.m. LPA observed expired condiments located in the refrigerator. BATHROOMS: There are two (2) bathrooms for resident use. Bathrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed next to all toilets and in all showers and all were properly secured. The water temperature was measured between 105.4 and 106.7 degrees Fahrenheit, which is in compliance with regulation. Report Continued on LIC 809-C Continued from LIC 809-C BEDROOMS: There are four (4) bedrooms in the facility; all four (4) are designated for resident use. One (1) staff room is designated as an ADU attached to the property that has a different address from the facility. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. OUTDOOR SPACE: The backyard has sufficient patio furniture including shaded tables and chairs for resident use. An outdoor pool was observed to be appropriately screened. One outdoor shed was observed to contain pool care equipment. Facility has two exit gates, LPA observed clear passageways for emergency exit use. RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Resident 1’s (R1) file identified them as a bedridden patient. R1 currently resides in a room that is not approved in the facility’s fire clearance for bedridden residents. Staff 1’s (S1) file contained a positive TB test. No chest x-ray was present at the time of the file review. MEDICATION REVIEW: Medications for 2 (two) of four (4) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheet. PRN medication administration was not logged at the time of medication review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Last emergency disaster drill was conducted 06/01/2024. The facility’s emergency disaster plan is up to date and adequate. INTERVIEWS: LPA interviewed two (2) staff and two (2) residents. One resident stated that the food is sometimes cold. One resident stated that they enjoy the amount of activities offered. All residents stated that staff treat them well and are attentive to their needs. Both staff were knowledgeable on resident rights, the different forms of abuse, and their roles and responsibilities. Report Continued on LIC 809-C Continued from LIC 809-C During today’s visit LPA obtained a copy of the facility’s updated LIC500 and liability insurance. The following deficiencies were observed (See LIC 809-Ds) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Licensee was advised that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 5, 2024

The state marks this report as 9 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: . Staff do not provide adequate care and supervision to a resident

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegation and was let into the facility by Stella Cardoza, Staff. Staff contacted Mariana Romano, Administrator, via telephone and she arrived at 10:31am to conduct the visit. Also present on today's visit was Sylvana Ramirez, Staff. LPA Yee explained the reason for today's visit. On today's visit, LPA Yee conducted an interview with Mariana Romano at 10:35am, Staff #1 at 11:52am and a telephone interview with Witness #2 at 11:34am. A written statement from Witness #1 was also obtained prior to today's visit. Per information obtained from the interviews conducted, Resident #1 was admitted to the facility in October 2023. Per interview with the Administrator, Resident #1, started leaving the facility recently and wandering Substantiated into the neighbors' yards and collecting dried leaves, fallen flowers, rocks, twigs and going into neighbors trash cans and taking out discarded items such vases and picking up discarded furniture and taking it back to the facility. Resident #1 elopes very fast from the facility in bare feet and without the staff's knowledge. Resident #1 sustained a foot injury as a result of wandering around barefooted. Per interviews conducted with the Administrator, Resident #1 would elope for only a few minutes before staff realizes that Resident #1 is gone and they will look for her and bring her back. Upon inquiry about auditory devices on all 5 outside exiting doors, the Administrator admitted they used to have them on the doors but they were removed. Per statement received from Witness #1, they have observed Resident #1 alone on multiple occasions , wandering around in the neighborhood collecting leaves, rocks, flowers and un-escorted. Per review of Resident #1's file, the physician has determined that Resident #1 is not able to leave the facility unassisted. Per interview with Witness #2, they arrived at the facility on 7/9/24 for a visit and saw Resident #1 rummaging through the trash cans placed outside the facility with staff close by re-directing the resident. Resident #1 was observed with dirty nails and matted hair. Per interviews conducted, Resident #1 refuses to shower and refuses to have the injured foot treated. Witness #2 also believes that Resident #1 may have also shoved a staff. Per the Administrator, due to this unusual behavior, she has had a discussion with Resident #1's conservator and social worker and they all agreed that Resident #1 be sent to the hospital to be assessed for possible infection and medication adjustment. Resident was taken to the emergency room by the Administrator on 7/10/24 and was still hospitalized as of today's visit. Witness #2 confirmed that upon discharge, arrangements have been made to relocate Resident #1 to the facility's sister facility. Based on the interviews conducted and file review, there is sufficient evidence to support to the allegation that staff do not provide adequate care and supervision to a resident. Deficiencies cited under Health and Safety Code, Title 22, Division 6, Chapter 3.2 Exit interview was conducted, Appeals Rights discussed and a copy was provided.the state’s words, verbatim · CDSS document, Jul 11, 2024 · control 29-AS-20240709121224

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312(a) · Plan of correction due date: Jul 18, 2024

Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: interviews conducted and file review, the licensee did not comply with the section cited above. Facility staff failed to provide the necessary care and supervision which allowed Resident #1 to easily elope from the facility on multiple occasions which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 11, 2024

Plan of correction: Licensee will provide the Department with a written plan of action that will be implemented to ensure that all residents are provided with the appropriate level of care and supervision based on the needs identified in their care plan by 7/18/24.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst(LPA) conducted an unannounced case management visit due to the deficiency noted during a visit to the facility today. LPA Yee met with Mariana Romano and the reason for today's visit was explained. During today's visit to the facility to investigate a complaint, LPA Yee observed that all 5 outside exiting doors were not equipped with any auditory devices to alert staff when residents exit the facility. The facility accepts and retains clients with dementia. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted, Appeals Rights discussed and a copy was provided.the state’s words, verbatim · CDSS document, Jul 11, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(j) · Plan of correction due date: Jul 18, 2024

Care of Persons with Dementia: The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by: All 5 outside exiting doors were not equipped with auditory devices, which poses a potentional health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Jul 11, 2024

Plan of correction: Licensee will ensure that all outside exiting doors are equipped with an operational auditory device to alert staff when residents exit the facility. Monthly checks will also be performed to ensure the batteries are operational. Provide evidence that the doors have been equipped with auditory device by 7/18/24. ****Auditory devices were installed on all 5 doors at the time of the visit*****