Facility Evaluation Report

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on December 15, 2025, regarding Resident #1 (R1). LPA met with Administrator (AD) James Trazo and explained the reason for today’s inspection. During today’s inspection, LPA inspected the facility, interviewed AD and witnesses, and requested and reviewed copies of the resident roster, staff roster, and resident files. Per the incident report received in the OCRO on December 15, 2025, on December 13, 2025, R1 was taken via medical transport to a routine doctor’s appointment at 7:00AM, refused to return to the facility after the appointment was over, is now missing, and local law enforcement and R1’s family were notified. LPA inspected the facility, conducted health and safety checks on residents present, and observed no health and safety issues. LPA reviewed R1’s Physician’s Report dated November 21, 2025, which indicates R1 does not have Dementia or Mild Cognitive Impairment, R1 is not able to leave the facility unassisted because R1 is “bedbound”, R1 is bedridden, and R1’s ambulatory status is based only on physical condition. Per a letter from R1’s medical provider, R1 was placed at the facility on November 21, 2025. LPA interviewed AD who stated that R1 had always previously gone to these daily doctor’s appointments with their family as their family transported them there, this was the first time R1 went by themselves via medical transport without their family, and after the appointment was over R1 refused to return to the facility with the medical transport. LPA reviewed a communication from the medical transport confirming that R1 refused to return to the facility and had signed documentation confirming their refusal. Per AD, staff at the doctor’s office observed R1 leaving with someone, R1’s family and local law enforcement were notified immediately, and law enforcement documented the case as a voluntary missing person.