Facility Evaluation Report

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Activities Director Gabriela Ortiz.

Community Care Licensing received an Incident Report on 9/17/25 in which it was reported that Resident #1 (R1) had eloped from the facility and was found by a passerby down the road outside the community. Per the report, staff had observed R1 to be anxious and repeatedly attempting to leave the facility during that evening. Staff redirected resident back to their room and approximately 30 minutes later, staff received a call from R1's responsible party stating R1 was found along the street. The passerby had contacted emergency services and R1 was taken to the hospital and returned the same night to the facility. Per review of security cameras, R1 had eloped from an exterior door leading to the trash bins. The report states that staff did not hear the door alarm. R1's Responsible Party and Primary Care Physician (PCP) were notified.

During today's visit, LPA conducted interviews, file review, a health and safety visit with R1, and consultation with Activities Director Ortiz. Activities Director Ortiz informed LPA that the facility implemented increased status checks for R1 and also that the facility was planning to conduct an in-service staff training to ensure a similar incident does not occur in the future.

One Deficiency was cited during the visit for lack of secured perimeter resulting in resident elopement. An exit interview was conducted with Activities Director Ortiz to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.