Incident investigation·November 14, 2025

Licensing Program Analyst (LPA) Michael Tea conducted a case management incident visit to follow up on an incident report received by Community Care Licensing (CCL) on November 4, 2025, submitted by Health & Wellness Director (HWD) Veronica Mata. LPA was greeted and allowed entrance into the facility by Executive Director (ED) Carmen Galicia and explained the reason for the visit. During the inspection, LPA and Business Office Manager (BOM) Lakhena Lor toured the facility and inspected Resident 1 (R1)’s room. LPA conducted health and safety checks on R1 and observed no health and safety issues. LPA toured and observed the rest of the facility and found no health and safety issues. R1 had eloped and was found at a Target store and sent to hospital due to injuries. R1 does not recall the incident and sustained a minor nasal fracture. R1's physician report shows resident can not leave the facility unassisted. Based on LPA's review of records, observations and interview, the facility failed to supervise resident in which the resident left the facility unassisted. A deficiency and immediate $500 civil penalty are being given per California Code of Regulations 87464(f)(1). An exit interview was conducted with the facility and a copy of this report, along with the LIC809D, and appeals right was provided at exit.