Facility Evaluation Report

On 06/16/2026 at 12:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit regarding an incident report received by the Community Care Licensing Division (CCLD) on 05/07/2026. LPA met with Executive Director, Liza Elegado, and explained the purpose of the visit.

CCLD received an Unusual Incident Report (UIR) on 05/07/2026 indicating that Resident (R1) was discovered missing during rounds conducted at approximately 3:00 AM on 05/06/2026. LPA interviewed Staff (S1), who stated that the incident occurred during the night shift. According to S1, S2 and S3 were on duty at the time of the occurrence. S1 stated that S2 was completing laundry duties while S3 was assisting another resident with a diaper change.

S1 stated that during routine rounds, S2 discovered that R1 was not in their bed. S2 and S3 immediately conducted a room-to-room search of the facility but were unable to locate R1. S1 stated that S2 contacted the local police department to report R1 missing. The police department subsequently informed facility staff that R1 had been located and would be transported to the hospital emergency room for evaluation. S1 stated that law enforcement advised facility staff that R1 had sustained a fall.