Incident investigation·December 22, 2025

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit.  LPA was greeted by and met with Resident Services Director Richard Tibi, to discuss the purpose of the visit. Today's visit is in response to the self reported incident involving Resident 1 (R1- see LIC811 Confidential Names List) who eloped from the facility and was found later that same day in La Mesa. An Incident report was submitted to CCLD reporting the following: On 10/03/2025 at approximately 9:30 AM , staff conducted a routine check and discovered that Resident 1 (R1) was not in their room. Staff immediately began searching inside and outside the facility. During the search, a staff member who was on break informed the Executive Director (ED) that they saw R1 a few blocks away from the facility. After about one hour of unsuccessful searching, staff notified R1’s Power of Attorney (POA) and contacted the Sheriff’s Department to report the incident. The Sheriff’s Department initiated a search; however, R1 was not located at that time. At approximately 7:50 PM , a staff member received a call from a Transit Security Officer stating that they had R1 at the trolley station in La Mesa on Spring Street and La Mesa Boulevard. The officer reported that R1 was very intoxicated and had shown them the facility’s business card, stating, “That is where I live.” After receiving this information, staff contacted the ED, who immediately went to pick up R1. R1 returned to the facility around 9:00 PM . The POA was notified, and R1’s primary care physician was also informed. On 12/22/2025, LPA interviewed R1 in the facility’s patio area. R1 was well-groomed and appropriately dressed. R1 stated that prior to the incident, they believed they had a stroke and had gone to the hospital several times to get checked. On the day of the incident, R1 said they intended to visit their spouse and child’s graves at Glen Abbey Cemetery. After visiting, they took a bus and ended up at Fashion Valley Mall. R1 then boarded a trolley, thinking it would take them back to Chula Vista, but they ended up in La Mesa. R1 stated that they told an officer they were lost and showed the officer the facility’s business card. The officer then contacted the facility, and the ED picked R1 up. R1 believes they may have had a stroke that caused confusion that day and stated they were checked out and are doing well now. LPA reviewed R1’s records. According to the physician’s report dated 08/05/2025 , R1 has mild cognitive impairment, hypertension, and a history of alcohol use disorder. R1 is not permitted to leave the facility unsupervised and is disoriented to time and date. LPA interviewed Executive Director (ED) who stated that on the date of the incident R1 eloped during lunch service. ED stated that R1 usually sits near the front door of the facility and believes that due to lack of supervision R1 was able to exit the building and walk away from the facility. Based on the information obtained, the facility did not ensure that R1 remained under supervision as required. This poses a potential health and safety risk to residents in care.California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Resident Services Director Richard Tibi. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22), was provided to Richard Tibi at the conclusion of the visit. The signature below confirms the receipt of these documents.