Facility Evaluation Report

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA was greeted by and met with Resident Services Director Richard Tibi, to discuss the purpose of the visit.

Today's visit is in response to the self reported incident involving Resident 1 (R1- see LIC811 Confidential Names List) who eloped from the facility and was found later that same day in La Mesa.

An Incident report was submitted to CCLD reporting the following: On 10/03/2025 at approximately 9:30 AM , staff conducted a routine check and discovered that Resident 1 (R1) was not in their room. Staff immediately began searching inside and outside the facility. During the search, a staff member who was on break informed the Executive Director (ED) that they saw R1 a few blocks away from the facility. After about one hour of unsuccessful searching, staff notified R1’s Power of Attorney (POA) and contacted the Sheriff’s Department to report the incident. The Sheriff’s Department initiated a search; however, R1 was not located at that time. At approximately 7:50 PM , a staff member received a call from a Transit Security Officer stating that they had R1 at the trolley station in La Mesa on Spring Street and La Mesa Boulevard. The officer reported that R1 was very intoxicated and had shown them the facility’s business card, stating, “That is where I live.” After receiving this information, staff contacted the ED, who immediately went to pick up R1. R1 returned to the facility around 9:00 PM . The POA was notified, and R1’s primary care physician was also informed.

On 12/22/2025, LPA interviewed R1 in the facility’s patio area. R1 was well-groomed and appropriately dressed. R1 stated that prior to the incident, they believed they had a stroke and had gone to the hospital several times to get checked. On the day of the incident, R1 said they intended to visit their spouse and child’s graves at Glen Abbey Cemetery.