Incident investigation·January 13, 2026

On January 13, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case-management visit to follow up on an incident that occurred on 1/1/26. LPA met with Assistant Administrator, Paula Madrigal and explained the purpose of the visit. The Licensee reported on 1/1/26 at around 5:30pm, Resident 1 (R1) was no where to be found in the facility. 911 was called. According to the Licensee, the police notified the administrator that R1 is using two names. During the visit, LPA reviewed R1's file, interviewed assistant administrator, and reviewed documents. According to the assistant administrator and day-shift manager, R1 left without staff being aware. When staff on shift were interviewed, they indicated that they did not see R1 leave the facility. R1 has still not returned back to the facility and is still missing. Based on R1's file reviewed, R1 has a diagnosis of a traumatic brain injury with neurological deterioration and is unable to leave the facility unsupervised due to his/her poor judgement. In addition, based on the sign in/sign out log reviewed, R1 did not sign out prior to leaving the facility so staff were not aware where R1 went. Nevertheless, the facility failed to provide care and supervision to R1 resulting in an elopement. 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 $250.00 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.