Westmont of la Mesa.

(Continued from LIC9099) Department staff interviews revealed R1 frequently refused to sleep in the bed and instead slept in a recliner, which contributed to repeated falls or near falls. Staff stated that R1 did not consistently use ambulatory devices. Staff confirmed multiple unwitnessed falls and stated they responded promptly, contacted 911 when needed, notified the POA, and assisted R1 back to bed or chair as appropriate. Staff stated R1 was monitored with regular rounds. Department was unable to interview R1 due to discharge from the facility and subsequent placement. Department outside source interview revealed (OS1) they observed R1 attempting to stand from the recliner in an unsafe manner. OS1 reported never witnessing a fall during visits but observed balance issues, weakness, and progressive decline. OS1 also reported that staff appeared attentive and caring and observed multiple staff on duty and throughout the building during their visits. Department records review revealed that facility care notes documented repeated unwitnessed falls dating back to September 2025. Records repeatedly documented that R1 refused to sleep in the bed and preferred to sleep in a recliner, which may have contributed to falls when attempting to get up without lowering the footrest. Records also documented refusal or inconsistent use of the cane and shoes, intermittent confusion, and several instances of R1 sliding, kneeling, or being found on the floor. Department observations revealed on multiple occasions over the months that staff were present and attentive. Staff demonstrated knowledge of resident care needs and fall-risk protocols. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Wes Hebner, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

R1’s care reported no concerns and confirmed that R1 appeared well cared for and content. Records Review: No documentation indicated any incidents of mistreatment. R1’s LIC 602 showed no cognitive impairments and confirmed R1’s ability to make decisions. LPA Observations: R1 was observed to be well-groomed, alert, and oriented. The living environment was clean and organized, with no signs of neglect or mistreatment. On 7/2/24, it was alleged staff yell at a resident. Staff denied yelling at residents and described using calm, respectful communication. Residents, including R1, denied being yelled at or witnessing staff yelling at others. Outside Source Interviews, no reports or concerns were raised regarding staff yelling at residents. A review revealed no incident reports or documentation supported this allegation. LPA Observed observed staff interacting with residents in a calm and professional manner during the visit. On 7/2/24, it was alleged that staff inappropriately grabbed a resident. Staff denied any physical misconduct and described appropriate handling techniques. R1 and other residents denied being grabbed or witnessing inappropriate physical contact. Outside Source Interviews revealed no concerns regarding physical handling of residents. Records Review revealed no documentation or incident reports supported the allegation. LPA Observations: No signs of injury or distress were observed. R1 had no visible bruising or open areas. On 7/2/24, it was alleged staff are not properly feeding a resident staff Interviews reported that meals are served regularly and residents are offered adequate food and hydration. R1 and other residents confirmed that meals are satisfactory and food is available throughout the day. Outside sources confirmed that R1 has not expressed concerns about meals and appears well nourished. Records Review revealed no documentation indicated issues with nutrition or feeding. LPA Observations revealed R1 appeared well nourished and reported satisfaction with meals and food availability. On 7/2/24, it was alleged staff left a resident unattended. Staff reported regular monitoring of residents and confirmed that R1 is non ambulatory and in the memory unit but still checked on routinely. R1 stated that staff are consistently present and responsive. Other residents confirmed staff availability. Outside Source Interviews revealed no concerns were raised regarding residents being left unattended. Records Review revealed R1’s LIC 602 indicates independence in daily living activities and no need for constant supervision. LPA Observations revealed staff were present and engaged with residents during the visit. R1 was not observed to be unattended. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On 7/2/24, it was alleged that a resident sustained unexplained injuries while in care. Staff denied any incidents involving unexplained injuries to R1 and reported that they bump into things while using the wheelchair and the staff attend to their bumps on their hands. Resident Interviews: R1 denied sustaining any injuries and reported no issues with care. Outside Source Interviews revealed no reports or concerns were raised regarding injuries. Records Review revealed bumps to R1's hands that needed bandages but no broken skin. LPA Observations revealed bandaged on R1 hands that were from bumping into the walls and the bumps were being monitored as needed. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred. Therefore, all allegations are UNSUBSTANTIATED. An exit interview was conducted with WesHebner, Executive Director], to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management visit. The LPA introduced herself and disclosed the purpose of the visit to Executive Director Wes Hebner, later Memory Care Director River Jon Pagala joined the visit. Today's visit was in response to an Incident Report (Dated 3/19/2026) submitted to the Department for Resident 1 (R1). Per facility reporting, R1 sustained a fall on 3/13/2026, which resulted in a clavicle fracture. Reports indicate R1 was taken to the hospital and returned to the facility the same day. LPA conducted a review of R1's pertinent records and interviewed staff. LPA conducted a health and safety check for R1. No health and safety concerns were identified and no deficiencies were cited during today's visit. An exit interview was conducted with Memory Care Director Pagala, to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058 03/22) were provided.

Continued form LIC9099) The facility initiated 24/7 one-on-one care using a third-party agency without prior family consent. ED Armour revealed that during the care conference, the family was not clearly informed that one-on-one care would be implemented. ED Armour also revealed a written notice was sent later via email after the service began. The department interviews with R1's Family members confirmed they were not informed prior to the initiation of one-on-one care and did not consent to its start. They later continued the service and paid for it but stated they never agreed to the initial implementation. The department's records review revealed the admission agreement authorizes the facility to require one-on-one care if the resident is a danger to self or others. However, the agreement and Health & Safety Code 1569.657 require written notice within two business days of initiating services at a new level of care, including a detailed explanation of additional services and charges. No documentation was provided showing timely written notice or a reassessment prior to initiating one-on-one care. LPA observations on October 27,2021 revealed R1 was receiving one-on-one care from a third-party agency during the visit. The facility failed to provide timely written notice within two business days of initiating one-on-one care and did not involve the R1's responsible person in care planning as required by the admission agreement and Health & Safety Code §1569.657. Regarding the allegation of an unlawful eviction, more specifically, the Reporting Party (RP) alleged that Resident #1(R1) eviction notice was invalid and retaliatory.  The department interviewed staff revealed that Executive Director David Armour confirmed R1's eviction notice was sent via email body only on 10/15/21, without attachments, and admitted it did not include Ombudsman contact or appeal rights. The department records review revealed that R1's  eviction notice lacked multiple required elements under HSC §§1569.682 and 1569.683, including specific facts supporting the eviction (dates, witnesses, circumstances): Relocation evaluation and resources for alternative housing; Ombudsman and CCL contact information; Complaint rights information; Mandatory unlawful detainer statement explaining court process; Formal written format (notice was sent via email body only). Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violations occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Wes Hebner to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Records reviewed revealed no incident reports or documentation indicated any occurrences of staff yelling at residents. R1's care notes and logs reflect routine care and monitoring of R1. There were no entries indicating behavioral incidents other than R1's forgetfulness, complaints, or concerns related to staff yelling at R1. R1’s records show consistent engagement in daily activities, episodes of confusion which is R1's baseline condition related to dementia. During the facility visit, LPA Domingo observed staff interacting with residents respectfully and professionally. Staff were attentive to residents’ needs, communicated clearly and calmly, and demonstrated patience and compassion in their approach. Residents appeared comfortable and engaged, and no instances of inappropriate behavior, yelling, or mistreatment were observed. On 10/21/24, it was alleged that Facility staff did not safeguard a resident’s personal property. Staff Interviews revealed that residents’ personal belongings are stored securely and that procedures are in place to safeguard property. Staff were aware of the facility’s policies regarding resident property and described steps taken to prevent loss or damage. Resident Interviews revealed that R1 and other residents did not report any missing or damaged personal items. R1 stated that their belongings were intact and that staff respected their property. Outside Source 1 (OS1) confirmed that R1 does not have any property missing. OS1 stated that R1 has memory deficits and has a history of claiming they have missing items. Records reviewed revealed documentation in R1's records regarding R1's report of missing money, there was an investigation, and there was no record of R1 having money in their wallet or in their room. OS1 verified that R1 did not have any money in their room or wallet. The facility theft and loss policy was reviewed, and the facility followed its policy and began an investigation. R1 had a personal property inventory that did not reflect any money. During the facility visit, LPA Domingo observed R1's room and personal belongings. The room was clean, well-organized, and clutter-free. R1’s personal items—including clothing, hygiene products, and mobility equipment—were present, properly stored, and appeared to be in good condition. There were no signs of missing, damaged, or mishandled property observed. LPA did not observe any unsecured valuables or items that would indicate a lack of safeguarding. This agency has investigated the complaint alleging the above allegations. The Department has found that although the allegations may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted with Mayra Rodriguez Business Office Manager, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA's) Amy Rodgers and Angelica Boyles conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA's Rodgers and Boyles was welcomed by, identified themselves to, and discussed the purpose of the visit with Operations Specialist Benjie Doctolero. According to the facility’s license, the facility has a maximum capacity of one hundred sixty four (164) clients, non ambulatory, of which 12 may be bedridden. Approved for delayed egress and a hospice waiver for 12. This facility does not feature a secured perimeter and does feature delayed egress in the memory care community LPA Boyles, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was complaint Hot water temperature at taps accessible to residents were all compliant. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Operations Specialist Benjie Doctolero, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

(Continued from LIC9099 2 of 3) On the 1st of July 2023, R1 companion hours were decreased from 24 hours, 7 days a week, to 8:00 AM until 8:00 PM. Facility staff checked on R1 every two hours while they were in their room at night. R1 suffered an unwitnessed fall on July 6, 2023. During a routine check on R1, they were found on the floor in their room by a caregiver between 5:00 AM to 5:30 AM. The on-duty Med-Tech was called, and R1 was assessed for injuries. The Med-Tech immediately notified hospice, and a hospice nurse arrived at 6:30 AM to reassess R1. X-rays were conducted the same day (July 6, 2023), and initially, the report indicated there were no breaks or fractures. R1 was treated at the facility by hospice for pain management. A second X-ray report was sent on July 10, 2023, which revealed R1 had a fractured hip. R1 was then sent to the hospital for further evaluation at the request of Outside Source 1 (OS1). Facility staff were proactive in trying to mitigate the risk of falling and sustaining injury. Once it was determined that R1’s risk of falling had increased, R1 was placed in hospice and provided a companion. In addition, staff were conducting regular checks on R1 while they were in their room at night. It was alleged that neglect/lack of care and supervision resulted in a resident not getting timely medical attention. R1 was found on the floor in their room on July 6, 2023, between 5:00 AM and 5:30 AM. The on-duty Med-tech was immediately called to assess R1. R1 had cuts/abrasions on both elbows, but there were no head or other visible injuries. The Med-Tech immediately notified hospice, and a hospice nurse arrived at 6:30 AM to reassess R1. X-rays were conducted the same day, July 6, 2023, and initially, the report indicated there were no breaks or fractures. R1’s care was discussed amongst the hospice nurse and OS1, and it was decided R1 would remain at the facility and be treated by hospice for pain management. A second X-ray report was sent on July 10, 2023, which revealed R1 had a fractured hip. R1 was then sent to the hospital for further evaluation at the request of OS1. Interviews were conducted with 3 (Three) residents. The residents reported that they received adequate care and supervision from the staff and have not experienced or witnessed any neglect or lack of supervision. Interviews were conducted with outside sources, and they confirmed that they have observed staff providing attentive care and supervision to their loved ones and have no concerns about a lack of supervision or neglect. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continued from LIC9099C 3 0f 3) During the visit, the resident’s living environment and interaction with the staff were observed. Staff were seen providing attentive care and supervision, ensuring the safety and well-being of residents. The environment was found to be free from hazards. A review of the resident's care plan, medical records, and incident reports for the past quarter showed that the resident received appropriate care and supervision. The records indicated that the resident's fall and resulting hip fracture were promptly addressed, with immediate medical attention provided. The facility's policies on care and supervision were reviewed and found to be comprehensive and in compliance with Title 22 and California Health and Safety regulations. The policies outline procedures for monitoring residents and preventing falls. The Department has investigated the above-mentioned allegations and based on observations, interviews, and records review. The Department has found that although the allegation may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report and licensee rights (LIC 9058 03/22) was provided. Operations Specialist, Benjjie Doctoloero signature on this form confirms receipt of these rights.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Sabrina Priesman Today’s visit was in response to an incident which licensee self-reported via an SOC341. On 09/17/2024 The report described Resident #1 (R1 – See LIC811 Confidential Names List for identification of R1. R1's Personal belongings were missing from R1's apartment. R1's apartment was thoroughly searched and Local Law enforcement, and the Ombudsman was notified. LPA briefly interviewed staff, and obtained copies of pertinent facility records. No deficiencies were observed or cited on this date. An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (03/22)  were left with the Director, whose signature on this form confirms receipt of these documents.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Domingo was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Sabrina Priesman. According to the facility’s license, the facility has a maximum capacity of one hundred sixty four (164) clients, non ambulatory, of which 12 may be bedridden. Approved for delayed egress and a hospice waiver for 12. During today’s inspection, there were a total of ninety two (92) clients in care, and per medical records, all were ambulatory. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 73 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 112 F, Bathroom #1 sink was 111 F, and Bathroom #2 sink was 112 F. Refrigerator temperature was 31 F and freezer temperature was 0 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance and surety bond. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Sabrina Priesman Executive Director , to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

On April 4, 2024, Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced case management visit at the facility. LPA was greeted by Sheryl McCaskill Operation Specialist and granted entry after identifying herself. LPA met with Sheryl McCaskill Operation Specialist and explained the purpose of the visit. The facility self-reported an incident to Community Care Licensing on March 21, 2024 regarding an incident that occurred on March 19, 2024. Reporting indicated that Resident 1 (LIC811 Confidential Names list provided to Administrator to identify R1) had an unwitnessed fall which resulted in a change in condition. R1 refused to go to the hospital the day of the fall on March 19, 2024. On March 20, 2024 at 1:15 pm R1 was sent by ambulance to the hospital for further evaluation and treatment. During today’s visit, LPA conducted a Health and Safety check of R1 and requested facility records. No deficiencies were cited at this time. An exit interview was conducted with Sheryl McCaskill Operation Specialist and a copy of this report and Licensee/Appeal Rights (LIC 9058 03/22) was provided.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Kimberly Garcia. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 01/29/2024). According to the LIC624: on 01/27/2024, Resident #1 (R1) eloped from the facility (meaning they left without staff supervision). [See LIC 811 Confidential Names List for a description of R1.] Staff responded to a door alarm, located R1 in the facility’s parking lot, and brought R1 back inside, unharmed. During today’s visit, LPA performed a brief facility tour and welfare check, verifying that R1 was indeed unharmed. LPA inspected the facility’s delayed-egress doors in its memory care section, finding them audible and operational. LPA also collected copies of and reviewed pertinent records and interviewed relevant staff. According to their latest LIC602 Physician’s Report (dated 03/31/2023), R1 was diagnosed with Dementia and their doctor determined that they were not able to safely leave the facility unassisted. The LIC603 Preplacement Appraisal, Care Assessment, and Plan of Care which Licensee performed on R1 corroborated these same points. Due to their baseline memory-loss and language impairment, R1 was not able to participate as a reliable historian/interviewee in this case. Per LPA observation and corroborated by staff interviews: R1 lived in the facility’s secured “Compass Rose” memory care section. This section features four (4) delayed-egress doors, which unlock and open 30 seconds after the panic bar is pressed (assuming staff do not first enter a code to reset/rearm the door and its associated alarm). [CONTINUED ON LIC 809-C] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [CONTINUED FROM LIC 809] According to date and time stamped records, which were corroborated by staff interviews: On 01/27/2024 around 4:35 PM, staff heard one of the Compass Rose delayed-egress door alarms go off. When staff arrived at this specific door, no resident was near it. Staff, per their training, performed a team search of the interior and exterior of the facility building. Staff located R1 in the facility’s parking lot at 4:46 PM, unharmed. Per manager interviews: The Compass Rose PM Shift is considered “fully staffed” with one (1) Medication Technician and four (4) Caregivers. According to the staff work schedule, and corroborated by staff interviews: During the incident, Compass Rose had two (2) Medication Technicians and four (4) Caregivers on duty. No deficiencies were cited during today’s visit. However, LPA issued two (2) Technical Violations (TVs), regarding signage affixed to delayed-egress doors and reporting requirements (see the LIC 9102-TV pages). LPA also issued Technical Assistance (TA) regarding electronic equipment issued to care staff (see the LIC 9102-TA page). An exit interview was conducted with Garcia, to whom a copy of this report, the LIC9102-TV, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

Allegation 1: Staff do not ensure that the facility remains free of odors. The investigation revealed that there were no instances where staff members failed to keep the facility free of odor. No odors were present at the time of visit. Allegation 2: Staff do not assist resident with incontinence needs. The investigation found that staff members had followed policy and procedures for changing incontinence wear. Allegation 3: Staff do not ensure resident's hygiene needs are being met.  The investigation revealed that there were no instances where staff members failed to meet residents' hygiene needs.  Staff followed schedule for bathing/showering of resident. Allegation 4: Staff are not providing adequate food service to resident. The investigation revealed that resident would skip meals because they did not want to be awaken to eat. However, staff will provide a snack prior to the next meal served. Based on the findings of this investigation, the allegations of Staff do not ensure that the facility remains free of odors; Staff do not assist resident with incontinence needs; Staff do not ensure resident's hygiene needs are being met; Staff are not providing adequate food service to resident were found to be unsubstantiated.  A finding that is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Kimberly Garcia, Director.  A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Director and her signature on this report confirms receipt of the Licensee Rights.

Licensing Program Analyst (LPA) Riza Alvarez conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Kimberly Garcia and Resident Services Director Jeunesse Holmes. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 09/20/2023). According to the LIC624: on 09/19/2023, facility staff received a call from the La Mesa Police asking if there was someone missing at the facility, giving a description of the person. Three (3) facility staff went to pick up Resident #1 (R1) half a block from the facility premises. Per LIC624 R1 was unharmed, but was unable to state what happened. Facility will fax R1's doctor about the elopement. R1 was placed on alert charting for 3 days. (See LIC811 Confidential Names List for a description of R1.) During today’s visit, LPA performed a facility tour/welfare check on residents in care, obtained records and reviewed those records, and interviewed staff. LPA also met R1. Based on observation, R1 is safe. According to R1’s latest LIC602 Physician’s Report (dated 03/31/2023), R1 should be escorted by staff due to cognitive impairment. Interviews and records showed that Licensee has an AWOL Policy, and that staff followed the procedures under "If Resident is Found" Section. No deficiencies were cited for this incident. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Administrator K Garcia, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

[Continued from LIC9099] It was alleged that R1 was not allowed visitors.  LPA Domingo reviewed records and there is sufficient evidence that R1 was allowed visitors.  OS1 was interviewed and stated that R1 was allowed visitors. F1 verified by visitor sign in that R1 was allowed visitors. The Department has investigated the allegations listed above.  Based on evidence obtained, including interviews and records reviewed, the above allegations are determined to be unsubstantiated as the Department could not meet the preponderance of the evidence standard. An exit interview was conducted with Executive Director Kimberly Garcia and a copy of this report and Licensee/Appeals Rights (LIC 9058 03/22) were provide.

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Kimberly Garcia. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 6/22/2023). According to the LIC624: on 6/18/2023, Resident #1 (R1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of R1.] R1 returned to the facility unharmed on 6/18/2023. During today’s visit, LPA performed a facility tour / welfare check, collected records, and interviewed staff. LPA was unable to interview R1 due to R1 being offsite on vacation with family. According to R1’s latest LIC602 Physician’s Report (dated 3/22/2023), their doctor determined that R1 was not able to safely leave the facility unassisted. LIC602 states that R1 should be escorted by staff due to cognitive and physical impairment. Interviews and records showed that Licensee had a written Absentee Notification Plan as part of R1’s record of care, and that staff followed this plan. No deficiencies were cited for this incident. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Garcia, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.