Incident investigation·January 16, 2026

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to the facility to conduct a case management visit. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Assistant Administrator (AA) Franco Puzon was present and assisted on today's visit. LPA is following up on a self reported incident report that was received by the Orange County Regional Office on January 5, 2025, regarding an elopement by Resident 1 (R1). The incident reported R1 left the facility at 11:10pm on January 4, 2025. Staff called R1 on their phone and R1 stated they had fallen and a passerby called 911 to take R1 to the hospital. R1 was treated at the hospital for intoxication. R1 returned to the facility at 1:07am on January 5, 2025. LPA, accompanied by AA, conducted a tour of the physical plant. LPA observed the facility to be clear of any obstructions and hazards. No health or safety concerns were observed. LPA conducted one staff interview. LPA additionally reviewed and obtained resident records. R1's physician report dated September 3, 2025 indicates R1 cannot leave the facility unassisted. Interview conducted confirmed the incident report that was received by the Orange County Regional Office was accurate. 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, LIC421IM, and appeals right was provided at exit.