Incident investigation·January 27, 2026

On January 27, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management in relation to an incident that occurred on 1/8/26. LPA met with Regional Sales, Ruth Ocon and explained the purpose of the visit. The Licensee reported on 1/8/26 at 10:40am, Resident 1 (R1) asked the front desk to call a cab to go to T-Mobile to purchase a new phone. At 12am, the regional sales asked the front desk to call T-Mobile to let them know that R1 was there and tell them that if R1 needed help to get a cab back to the facility, to call the facility and they would send the bus driver to pick R1 up. At 12:30pm, the regional sales sent the bus driver to R1's area to see if the bus driver could find R1 and offer him/her a ride back, however the bus driver was unable to locate R1. At 4:30pm, R1 was still not back to the facility, the facility notified R1's responsible party and the regional sales went to where R1 was dropped off to see if she could find him/her. Regional sales drove around for an hour and then went to the police department to file a report. At 6:30pm, a good samaritan called the facility and notified the facility that R1 is in front of the police department and found R1 walking around Daly City. R1 came back to the facility at 7pm. During the investigation, LPA reviewed R1's file, reviewed sign in/sign out log at the front desk, and interviewed staff. Based on R1's file reviewed, R1 is not able to leave the facility unassisted. According to the staff interviewed, they were not aware that R1 could not leave unsupervised. In addition, staff indicated that R1 has left the community unsupervised many times. Deficiency was observed during the visit and cited from the California Code of Regulations, Title 22 and Health and Safety Code. See LIC809-D. Report is reviewed with Regional Sales, Ruth Ocon and a copy is provided with appeal rights.