Facility Evaluation Report

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Faith Tuiteleleapaga, House Manager.

Today's visit was in response to Licensee’s self-reported AWOL of Client #1 (C1), received at the CCLD San Diego Regional Office on 04/02/2026. [See LIC 811 Confidential Names List for a description of C1]. Per the report, C1 AWOL'd from the County Mental Health (CMH) when staff were picking them up on 04/01/2026. Interviews revealed that the staff scheduled a pickup for 3pm. Staff was picking C1 up and when C1 walked over to the staff they spoke and while the staff was talking to the psychiatrist and getting discharge papers C1 punched the staff twice in the face. Interviews revealed the on site security detained C1 and staff asked CMH psychiatrist were they going to readmit C1 for assaulting them. They refused to readmit C1 and while talking with the Sheriff C1 overheard them state that since C1 is not conserved they didn't have to go with the staff back to the facility. C1 left towards the trolley station and staff jumped in the car and tried to follow C1. Interviews revealed that the sheriff stopped staff and asked them where they were going, and staff replied after the client.

While talking in front of the Sheriff C1 made a statement that they didn't want to go back to the home and the sheriff told staff that if they followed the client or picked them up that they would be arrested for kidnapping. Interviews revealed that staff followed closely and notified the house manager. While following the client they jumped in front of a moving Amtrak train and the staff lost sight of the client at that time. Once the train was done going by they couldn't find or see the client. They called the police to file an at risk police report. Staff returned to the facility at 8pm without the client.