Incident investigation·January 13, 2026

On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced Case Management visit to follow up on an incident report Department received. LPA discussed purpose of visit with Executive Director (ED) Nancy Rodriguez. On January 6, 2026, department received an incident report with elopement incident that occurred on December 25, 2025. According to incident report Resident 1 (R1) had left facility and around 6:19 AM facility staff received a call by nearby Hotel that R1 was in their hotel lobby. Report stated that resident was last checked in their room during 5:00AM rounds. LPA Tirre discussed incident with ED Rodriguez who stated that R1 resided in second building located at 4775 Katella to which R1 would come back and forth to main building steps away (located 4889 Katella) to eat in dining area. R1 was able to exit building but apparently did not have key Fob to get back in facility that morning, prompting R1 to walk over next door to nearby hotel. Main building doors are locked to the public from 8PM to 7AM, residents and staff have access with Key Fobs or pass code. LPA Reviewed R1’s recent Physician’s Report dated 7/30/2025, has R1 with diagnosis of Encephalopathy unspecified with abnormalities of gait mobility, muscle weakness, mild cognitive impairment, history of falling and hyperlipidemia. R1’s Physicians Report under capacity for self care is marked not able to leave facility unassisted. R1’s Care Plan states Resident is independent and needs no assistance with care. Based on information gathered, facility did not adequately supervise resident and the following is being cited on 809 D-page per California Code of Regulations (title 22 Division 6 Chapter 8). An exit interview was conducted with Executive Director Rodriguez. A copy of report and Appeal Rights were provided to facility Representative.