Incident investigation·January 12, 2026

Licensing Program Analyst (LPA) Erica Mosley conducted a Case Management - Incident visit to follow up on a self-reported incident which took place on 1/4/2026. At 9:46 a.m. LPA Mosley was greeted by staff who called the Administrator. LPA met with Marisol Flamenco, Administrator and Magdalena Garcia, Assistant Administrator and the reason for the visit was explained. Entrance interview. On 01/04/2026 it was reported that at approx. 3:20 p.m. Staff #1 (S1) called the Administrator to inform them that it has been about 15 minutes and Staff #2 (S2) has not yet shown up to their scheduled shift and they had to leave. At that time the Assistant Administrator made calls to find coverage and Administrator was less than 15 minutes away and drove to the facility. Once the Administrator arrived to the facility at approx 3:35 p.m. they noted seeing S1 on their bike two (2) houses down. The Administrator immediately checked on the welfare and well-being of the residents, no injuries or incidents were noted. The Administrator called Licensing leaving a voicemail briefly informing them of the incident and request a call back. Subsequently S1 was terminated for not following the facility policy : Residents Must Not Be Left Unattended and all staff received an in service training regarding the same policy. During today's visit, from 9:50 a.m. LPA and staff conducted a physical plant tour to ensure there were no immediate health and safety concerns. Starting at 10:00 a.m and throughout the visit LPA conducted four (4) in person staff interviews including the Assistant Administrator and Administrator, four (4) resident interviews and record review along with obtained copies of pertinent documents relevant to the incident. Report Continued on LIC 809C... Report Continued from LIC 809... Interviews with the staff revealed that they are not allowed to leave the residents unattended. If a staff is running late they must notify administrative staff immediately. The administrative staff typically find coverage relatively fast. They were not present on the incident date of 01/04/2026. They recently received an in service training regarding the facility policy : Residents Must Not Be Left Unattended. Interview with the Administrator revealed that on the day of the incident, 01/04/2026 they received a call from S1 informing them that S2 has not yet arrived for their shift and that they had to leave. The Administrator called the Assistant Administrator to get a hold of S2 and being finding coverage while they drove to the facility with the intention to relieve S1. They were about 13 minutes away from the facility and when they arrived they saw S1 on their bike two (2) houses down. They immediately checked on all the residents safety and well being, no injuries or incidents were observed or noted. It was noted that all five (5) residents at the time were on the couch in the living room, watching the television. Interviews with the residents revealed that they were unaware of being unattended. To their knowledge they are never left unattended and staff are always available to them. They are happy with the care they are provided and no concerns were noted or voiced. Record review and interviews support that there has not been any past incidents related to supervision. In service training was conducted from 01/08/2026 - 01/11/2026 to cover all shifts on the facility policy: Residents Must Not Be Left Unattended with a signed statement of acknowledgment from all staff. Guardian background check system revealed that S1 was separated from the facility roster on 01/04/2026. Personnel report - LIC 500 dated 01/06/2026 does not list S1. No deficiencies were cited at this time. Exit interview conducted. Report was reviewed and a copy was provided.