Facility Evaluation Report

On 8/7/2025 at 1:00PM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit in regards to incident report received on 8/5/2025. LPA met with Resident Care Director, Nelsa Alferos and explained the reason for the visit.

Based on the incident report received on 8/5/2025, resident (R1) eloped from the facility.

During visit, LPA reviewed R1's file including medical assessment, physician's notification, and care plan. R1's physicians report stated that they can not leave unassisted. Resident Care Director (RCD) states that S1 disabled the wander guard alarm when they saw R1 outside because they thought they were being picked up by family because there was a car in front of the facility. However R1 was not being picked up and required assistance. S1 does not provide care to residents and has since been informed not interact with residents. RCD states that R1 did have a wander guard. R1 was located and returned unharmed and has since been moved to memory care. Police and responsible party notified.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.