Facility Evaluation Report

Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced visit to initiate a case management visit. LPA Rodgers identified herself and was granted entry by concierge Jacqueline Aceves. LPA Rodgers stated the purpose of the visit and reviewed the basic elements of the visit with Associate Executive Director Aileen Spence.

This visit is in response to an Unusual Incident/Injury Report (IR) that was received at the San Diego Regional Office on November 21, 2025. The IR stated that there was an incident that transpired on Monday, November 17, 2025, with resident #1 (R1 – see LIC811 for confidential names list) who eloped from the facility. The facility made notifications to R1’s responsible party, their Medical Doctor (MD), and the Department.

During today's visit LPA Rodgers briefly toured the facility, spoke with staff and R1, and requested and obtained relevant documents pertinent to this incident. LPA Rodgers verified R1 eloped from the facility, but staff found R1 within about 10 minutes from notification that R1 was absent without leave (AWOL). Records showed that a wander guard (exit alert pendant) was placed on R1 on 11/17/2025, the same day of AWOL. R1 responsible person was present while wander guard was presented to R1. (Continued on LIC809C)