Incident investigation·May 20, 2025

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Eunice Ambal. Today's visit was in response to an LIC624 Incident Report, which Licensee self-submitted to the CCLD San Diego Regional Office (received on 5/15/25). According to the LIC624: on 5/15/25, at approximately 7:50am Resident #1 (R1) refused to go with the Outside Agency transportation to attend their day program. R1 advised staff that they were going to the DMV and staff encouraged R1 to wait for the Administrator. R1 left the building and staff followed. [See LIC 811 Confidential Names List for a description of R1.] Local police were called; later that same morning police brought R1 back to the facility unharmed. During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying that they were unharmed. LPAs also collected copies of pertinent records and interviewed staff. According to R1’s latest LIC602 Physician’s Report (dated 8/6/24), R1 had a primary diagnosis of dementia and was unable to leave the facility unassisted. R1 occasionally wandered and was also confused and disoriented at times. Interviews and records showed: Licensee had a written Absentee Notification Plan, and that staff followed this plan during the incident. Licensee also notified R1’s physician of the incident and performed a timely reappraisal of R1’s care needs. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] No deficiencies were cited during today's visit. An exit interview was conducted with Eunice Ambal, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.