Facility Evaluation Report

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced Case Management visit. LPA was met by Natalie Carlborg, Executive Director (ED), and was granted entry into the facility. At the time of the visit, there were 91 residents currently in care.

This visit was initiated due to a self-reported incident involving Resident 1 (R1), which was received by Community Care Licensing (CCL) on August 11, 2025 (08/11/25). The incident involved R1 eloping from the facility unassisted and sustaining a fall that resulted in hospitalization. R1 was later diagnosed with multiple facial fractures and transferred to a trauma center for further evaluation.

During the investigation, interviews were conducted with facility staff and outside sources. Interviews revealed that R1 had a documented history of dementia and Parkinson’s disease and required assistance with medications and eye drops.

Staff acknowledged that R1 had cognitive impairments but in interviews consistently described R1 as “independent.”

Several staff members confirmed that on the day of the incident, R1 was last seen walking out the front door unassisted and that staff did not intervene due to their “independent” status. Interviews with Outside Source 1 (OS1) about R1 reported that R1’s cognitive condition had declined significantly in recent months, including increased confusion and reduced verbal communication. This decline was reported to facility staff and UCSD Neurology - Memory Care Program and should have triggered a reappraisal of R1's condition and care needs. Record review indicated that R1’s cognitive function had been gradually declining, and that R1 had been having increasing difficulties with confusion, recognizing their own handwriting, and decreasing levels of alertness as of their last visit on 7/24/2025.