Facility Evaluation Report

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit to the facility for a self-reported incident. LPA Lopez identified herself and was granted entry by Facility Manager Deborah Alvarado. LPA stated the purpose of the visit and reviewed the basic elements of the visit with manager Alvarado and Majid Syde, Administrator, who later arrived and joined the visit.

The facility self-reported an incident regarding Client #1 (C1- see Confidential Names List) to Community Care Licensing on 9/04/25. The facility self-reported that on August 29, 2025, C1 eloped from the facility at around 6:00 PM. According to the report and staff #1 (S1), the facility notified law enforcement 24 hours after C1 had not returned, on 08/30/25.

During today’s visit, LPA conducted a health and safety check, observed the clients in care, requested and obtained client records, and interviewed staff. Facility Records show that staff conducted rounds every two hours and notified the Facility Manager of the absence of C1. Staff #2 (S2) said that they saw C1 at around 6 PM at the facility. About 10 minutes later, at 6:10 PM, the S2 was observed that C1 left the facility but thought that they would return as the client usually leaves the premises but returns from their outing for their night medications. During medication pass, at about 7:15 PM, S2 observed that C1 had not returned and logged the information. S2 again did their rounds at 8 PM, and C1 had not returned. According to the log at 11:45 PM, the facility had not observed C1 during their shift and wrote the information into the log. S2 said they contacted law enforcement the following day. According to C1 Physician’s Report, they are able to leave the facility unassisted. According to the S1, they were informed the morning of 09/04/25 by C1’s third-party agency that C1 had been admitted to the hospital.