Facility Evaluation Report

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Richard Vergara and explained the purpose of the visit.

LPA Moleski received an incident report from Vergara on 11/8/25. According to the incident report, a resident (R1) grabbed a bottle of isopropyl alcohol and fled from the facility through the front door around 9:30 p.m. on 11/7/25. Two staff members on duty (S1 and S2) lost sight of R1 and could not determine where R1 went. Facility personnel called 911, and R1 returned to the facility voluntarily shortly before 11 p.m., per the report. R1 returned exhibiting slurred speech, an unsteady gait, and no longer had the bottle of isopropyl alcohol, according to the report. Despite these signs of intoxication, facility staff only called for emergency medical personnel after R1 vomited, and after they overheard R1 discussing feelings of suicidal ideation over the phone with a family member, around 11:30 p.m. R1 was kept overnight at a local hospital, and was released the next day, according to Vergara.

In an interview, S1 said they witnessed R1 grab the isopropyl alcohol from S2's hand before running out of the facility. In interviews, both S1 and S2 said S2 got the alcohol out to clean the facility. In an interview, R1 admitted to snatching the bottle "really powerfully" from S2.

LPA Moleski reviewed R1's IPP, dated December 2024. According to the IPP, R1 does not have a history of elopements or substance abuse. R1's IPP did not indicate similar behaviors of grabbing prohibited items with little notice, or any previous suicidal ideation. LPA Moleski reviewed R1's LIC 602, dated July 2025. According to the LIC 602, R1 is not allowed to leave this facility unassisted.