Incident investigation·November 19, 2025

On November 19, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit to follow up on a case-management incident visit that was conducted on 11/12/25. LPA met with Assistant Administrator, Gabriel Mendoza and explained the visit. On 11/12/25, LPA conducted a visit to follow up on an incident that occurred on 10/24/25. The Licensee reported on 10/23/25, Resident 1 (R1) left the facility without signing out and did not come back overnight. On 10/24/25 at around 8:45am, the facility received a call from R1 stating that he/she is at Peninsula Medical Center due to rapid heart rate. According to the assistant administrator, he indicated that both him and the administrator observed R1 leaving the facility on 10/23/25 between 9am-10am. Both assistant administrator and administrator asked R1 where he/she was going and R1 indicated he/she was going to the doctors. Based on R1's file reviewed, R1's physician's report dated 6/13/25 indicates R1 is not allowed to leave the facility unassisted. Despite staff being aware that R1 was leaving, R1 still left the facility unassisted on 10/23/25. Based on information collected, there was an endorsement from the med-tech to the NOC shift caregivers that R1 is out. In addition, there was a text message sent to a group chat at 10:35pm by PM med-tech stating if R1 does not return back to the facility by 12am to call the police. The NOC shift caregivers have access to the phone so they were aware of the text message. There was no documentation provided to show that the police were called. According to the assistant administrator, PM Shift and NOC conduct safety checks every 2 hours. Assistant administrator indicated that NOC shift caregivers did not call 911 even though they were aware that R1 was not back at the facility. The NOC shift caregivers indicated they notified the assistant administrator, however he was not on shift during the time and the facility's protocol is to call 911 if there are any emergencies/incident. Deficiency was observed during the visit and cited from the California Code of Regulations, Title 22 and Health and Safety Code. See LIC809-D. A Civil penalty of $1,000.00 is assessed for a repeat violation within the last 12 months for CCR 87464(f)(1). Report is reviewed with the assistant administrator and a copy is provided with appeal rights. A copy of the civil penalty is also provided with appeal rights.