Incident investigation·October 16, 2025

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Engage Life Director Naomie Peterson. LPA also met briefly with Resident Services Director Ashley Baino-Jaimes, LVN. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 10/13/2025). According to the LIC624, on 10/13/2025, Resident #1 (R1) eloped from the facility (left without staff supervision), walking to a nearby grocery store to buy beer. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report.] Facility staff located R1 around 1 to 2 hours later and brought them back to the facility, unharmed. During today’s visit, LPA performed a brief facility tour and welfare check and interview of R1, verifying that they were safe and uninjured from the incident. LPA interviewed multiple pertinent managers and frontline staff and collected relevant care records on R1. According to their LIC602 Physician’s Report, R1’s diagnoses included Mild Cognitive Impairment (MCI), and their doctor had determined that R1 was not safe to leave the facility unassisted. The Needs and Services Plan (Care Plan) which Licensee authored reiterated, “[R1] must be supervised when leaving the community.” [CONTINUED ON LIC 809-C, 1 of 2] [CONTINUED FROM LIC 809] Records and interview showed: Prior to 10/13/2025, R1 had no prior elopements or elopement attempts, and did not exhibit agitation, wandering, or exit-seeking behaviors. On 10/13/2025, facility receptionist Staff #1 (S1) last saw R1 enter the facility's first floor public restroom around 3:00 PM. R1 was calm at that time; R1 did not say anything to S1 about wanting to go to the store or wanting to leave the facility. Around 4:00 PM, caregiver Staff #2 (S2) went to R1’s bedroom to escort them to dinner in the dining room. Upon finding R1 and their walker absent from their bedroom, S2 alerted teammates. Facility managers placed timely phone calls to R1’s responsible person (RP) and physician/hospice personnel, to notify them of the problem. A dining room waitstaff/server Staff #3 (S3) quickly came forward to report that sometime earlier around 3:10 PM, they had personally observed R1 on the sidewalk outside the facility, walking up a hill and near a crosswalk that was less than 100 yards from the facility. (However, S3 at that time did not recognize this as a safety problem and did not notify their teammates; S3 was unsure whether R1 was allowed to leave the facility unassisted.) Two (2) facility managers thus got into cars and traveled in that general direction, locating R1 in a grocery store parking lot around 4:45 PM. R1 was unharmed, and given a ride back to the facility. Per LPA’s interview of R1, although they were somewhat forgetful, R1 confirmed on the date in question, they walked went to the store to buy beer, and that they exited the facility via the lobby front door. During today’s visit, LPA observed/evaluated the layout of the facility’s lobby from different angles, with a focus on where the receptionists’ chair at the front desk is positioned in relation to the facility’s front door. LPA observed that the receptionist’s line of sight, from their chair to the front door, is currently partially impeded, due to the chair not being well-aligned with the front door. It was therefore possible for a resident to exit the common area “activity room” and reach the front door, all without the receptionist seeing them. LPA observed that by slightly rearranging items on the existing front desk (without changing out or moving the desk), it would be possible to slide the receptionists’ chair over by one (1) foot and thus give them full view of the lobby front door, from where they sit. LPA queried two (2) receptionists, who agreed such an arrangement could comfortably work for them. [This will be part of Licensee’s Plan of Correction.] [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809-C, 1 of 2] CCLD’s investigation concluded: Licensee had an Absentee Notification Plan for R1, as required, and essentially followed it during this incident. However, R1 was able to leave the facility without S1 observing/noticing, which represents a temporary lapse in supervision. S3 saw R1 outside the facility but did not immediately recognize this as a safety risk, which represents a lapse in competency/training. CCR 87468.2(a)(4) guarantees residents’ right to care and supervision that “meet their individual needs and are delivered by staff that are sufficient…in competency to meet their needs.” One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Engage Life Director Naomie Peterson, to whom a copy of this report, the LIC809-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.