Complaint Investigation Report

374604300-2-24-2026-08-AS-SMOA-DRSSH4-20260302125256

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SAN DIEGO RO , 7575 METROPOLITAN DR. #109

This is an official report of an unannounced visit/investigation of a complaint received in our office on

05/19/2025 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 08-AS-20250519111234

Facility Business Office Manager, Virginia Rodriguez

Lack of supervision resulting in elopement and injury

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on a complaint investigation. LPA Hurt met with Facility Business Office Manager, Virginia Rodriguez, and explained the purpose of today’s visit.

Regarding the allegation of lack of supervision resulting in elopement and injury, the investigation determined that on 05/17/2025 at approximately 12:00 AM, resident 1 eloped from the facility and was found outside with injuries including a hematoma and a laceration. Facility staff intervened, and Resident 1 was transported to Tri-City Hospital for evaluation and treatment. Staff and administrative interviews confirmed that Resident 1 had wandered on multiple prior occasions (including an incident on 04/04/2025), and facility records show a care plan meeting was held on 05/14/2025 to discuss moving her to the Memory Care unit due to her exit-seeking behavior. Despite the identified need for a higher level of care, the resident was not relocated immediately, reportedly due to hesitation from her family. Investigators concluded that the resident clearly required more supervision than was being provided in Assisted Living and should have been moved to a secured Memory Care environment sooner to ensure her safety. Based on interviews conducted, and records reviewed the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.

The following deficiencies are being cited (see LIC 9099D) from the California Code of Regulations, Title 22, and the California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on H&S Code section 1569.49(f). Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted with Facility Business Office Manager, Virginia Rodriguez, and appeal rights provided.