Incident investigation·March 19, 2026

Licensing Program Analyst (LPA) Michael Tea conducted a case management visit to follow up on an incident report received by Community Care Licensing (CCL) on March 4, 2026, submitted by Wellness Director (WD) Veronica Mata. LPA was greeted and granted entry by Executive Director (ED) Carmen Galicia, and the purpose of the visit was explained. During the visit, LPA toured the facility with ED Galicia and inspected Resident 1’s (R1) room. R1’s personal belongings remained in place, and the facility reported that no items had been moved or disturbed. LPA conducted a health and safety check of the facility and observed no immediate hazards. Facility staff reported that R1 eloped from the facility and has stated they do not wish to return. The facility followed elopement protocol by contacting local law enforcement to report R1 as missing. Staff further stated they were unaware of R1’s prior history of elopement at a previous assisted living facility until informed by R1’s family after the incident. Documentation reviewed, including R1’s physician’s report, indicates that R1 is not permitted to leave the facility unassisted. Based on LPA’s observations, record review, and interviews, the facility failed to provide adequate supervision, resulting in R1 leaving the facility unassisted. A deficiency is being cited in accordance with California Code of Regulations, Title 22, Section 87464(f)(1). An immediate civil penalty of $1000 is assessed. An exit interview was conducted with the facility. A copy of this report, along with LIC 809-D and appeal rights, was provided to the facility at the time of the visit.