Complaint·May 15, 2026

The investigation revealed the following: Regarding the allegation "Staff do not provide adequate supervision resulting in residents eloping", it is being alleged that the facility is very understaffed which resulted in resident(s) eloping from the facility. Record reviews revealed that on 09/10/25 a resident was found by first responders, unassisted, out in the community. CDSS Interviews revealed that one (1) staff denied CDSS interviews, three (3) out of eight (8) staff disagreed with the allegation, while four (4) out of eight (8) staff agreed with the allegation. One (1) out of four (4) residents denied CDSS interviews, one (1) out of four (4) residents disagreed with the allegation, while two (2) out of four (4) residents agreed with the allegation. Interviews with witnesses have revealed that one (1) out of three (3) witnesses have disagreed with the allegation, while two (2) out of three (3) witnesses have agreed with the allegation. S1 has stated, “A lot of staff called out in unison”. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated . California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D. Based on record reviews and interviews conducted, the licensee failed to provide adequate resident supervision by staff. There has been one (1) deficiency cited during today’s inspection. An exit interview was conducted with Esperanza Naaktgeboren - Executive Director (S9), and a copy of this report has been provided.