Facility Evaluation Report

Licensing Program Analyst (LPA) Correia conducted an unannounced Case Management visit to issue a deficiency related to a self reported AWOL incident involving Client #1 (C1). Upon arrival, LPA was greeted by facility caregiver Harrison, identified herself, and explained the purpose of the visit.

The Department received a Special Incident Report indicating that on November 12, 2025 , C1 left the facility to a neighborhood store. At approximately 11:00 AM , the Licensee received a call from Grossmont Hospital notifying them that C1 had been transported to the hospital after sustaining a fall, which was witnessed by a Good Samaritan who called 911.

An interview with the Licensee revealed that they instructed hospital staff to notify them when C1 was ready for discharge. However, C1 was released independently with a bus pass at approximately 4:00 PM . That evening, law enforcement was contacted, and the Licensee was notified at approximately 11:00 PM that C1 had been transferred to a psychiatric hospital review of C1’s records and interviews with outside sources confirmed that C1 was not permitted to leave the facility unassisted due to mobility limitations and a history of concerning behaviors while in the community.

An exit interview was conducted with Caregiver Harrison. A copy of this report, along with the Licensee/Appeal Rights (LIC 9058 [03/22]) and LIC 809D, will be provided at the conclusion of the visit.

In accordance with Health and Safety Code §1548 , an immediate civil penalty of $500 was assessed (see attached LIC 421IM) for a violation determined by the Department to have resulted in the injury or illness of a person in care. The Licensee was advised that additional civil penalties are under review and may be assessed at a later date.