Incident investigation·December 22, 2025

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on December 15, 2025, regarding Resident #1 (R1). LPA met with Administrator (AD) James Trazo and explained the reason for today’s inspection. During today’s inspection, LPA inspected the facility, interviewed AD and witnesses, and requested and reviewed copies of the resident roster, staff roster, and resident files. Per the incident report received in the OCRO on December 15, 2025, on December 13, 2025, R1 was taken via medical transport to a routine doctor’s appointment at 7:00AM, refused to return to the facility after the appointment was over, is now missing, and local law enforcement and R1’s family were notified. LPA inspected the facility, conducted health and safety checks on residents present, and observed no health and safety issues. LPA reviewed R1’s Physician’s Report dated November 21, 2025, which indicates R1 does not have Dementia or Mild Cognitive Impairment, R1 is not able to leave the facility unassisted because R1 is “bedbound”, R1 is bedridden, and R1’s ambulatory status is based only on physical condition. Per a letter from R1’s medical provider, R1 was placed at the facility on November 21, 2025. LPA interviewed AD who stated that R1 had always previously gone to these daily doctor’s appointments with their family as their family transported them there, this was the first time R1 went by themselves via medical transport without their family, and after the appointment was over R1 refused to return to the facility with the medical transport. LPA reviewed a communication from the medical transport confirming that R1 refused to return to the facility and had signed documentation confirming their refusal. Per AD, staff at the doctor’s office observed R1 leaving with someone, R1’s family and local law enforcement were notified immediately, and law enforcement documented the case as a voluntary missing person. AD stated that staff at the doctor’s office noted that R1 did not want to reside at the facility and AD believes that, when R1’s family did not accompany them during this appointment, R1 took the opportunity to not return to the facility. Per AD, R1’s family reported that a family friend saw R1 after they went missing, but for unknown reasons R1 was not returned to the facility, and R1’s family also reported that a police officer had made contact with R1, R1 is doing well, and R1’s family has a general idea of where R1 is and is planning to try to convince R1 to return to the facility or go to the hospital. LPA made contact with R1’s family, but was unable to obtain information from R1’s family. LPA interviewed the La Habra Police Detective overseeing R1’s case who stated that R1 had lied and said they were being picked up from the doctor’s appointment by their family, but had actually coordinated with someone who met them at the doctor’s office to wheel them out in their wheelchair, R1 was found in Whittier and is living on the streets by choice, R1 does not want to return to the facility, R1 is able to make their own decisions and has no cognitive issues or court orders that would allow law enforcement to further intervene, and the case has been closed. LPA interviewed staff at R1’s doctor’s office who confirmed the details of the incident and stated that R1 actually returned to the office on December 16, 2025, but has not returned since. Per AD, the facility did not purposefully send R1 to the doctor’s appointment without supervision and believed R1’s family would meet them at the appointment. However, it was still the facility’s responsible to ensure R1 was supervised at all times, as R1 is unable to leave the facility unassisted, and in this case R1 was unsupervised while on the medical transport, as the communication from the medical transport indicates the transport personnel do not have a duty to supervise passengers and would allow passengers to exit any time during transit, and R1 was unsupervised at the doctor’s office. In addition, this was the first day R1 was taking medical transport to their daily doctor’s appointments, as opposed to being transported by their family, and the facility needed to confirm with R1’s family that they would meet R1 at the appointment and it appears there may have been some miscommunication. Based on the information obtained, R1 is no longer a resident of the facility after refusing to return and choosing to make alternative living arrangements as R1 had the capacity to make those decisions. AD stated that R1’s placement agency terminated R1’s placement at the facility the day R1 left. LPA noted R1’s file was not present at the facility. Per AD, R1 took the paperwork with them to complete it with their family and that is why it is not present. Based on this information, the facility did not maintain a file for R1 as it is not present at the facility and it was not complete.Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.