complaint·April 23, 2026

*THIS IS AN AMENDMENT OF REPORT DATED 04/23/2026* On 04/23/2026 at 10:30 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to deliver findings in regards to the allegation above. LPA met with Administrator Ferdinand Gutierrez and explained the purpose of the visit. Allegation: Lack of supervision resulted in resident elopement Investigation Findings: It was reported to the department that there was an elopment of a resident due to the lack of coverage, as the resident was attempting to get to the hospital. This specific incident had already been reported to the department and addressed in a case management report dated 11/26/2025. The facility sent the department an Unusual Incident Report (LIC624) detailing that R1 left the facility. On 11/26/2025 at 11:45 AM, LPA A.Gharachorloo went to the facility. LPA interviewed staff. S2 reported to LPA that S2 followed R1 as R1 walked to Kaiser. S2 called 911 right after and filed a police report. It was determined by the department that the facility was observed to have followed protocol during this incident, therefore this allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during the visit. Exit interview conducted and a copy this report was provided. u