Balboa Nursing & Rehabilitation: Resident Elopement - CA
Resident 1, as he is identified in state inspection records, was last seen on August 16, 2025, at approximately 12:18 p.m., stepping into an elevator. He was not found until August 19.
The California Department of Public Health received a report of the elopement on August 18, and an inspector arrived at the facility the following day. By then, the resident had already been gone for three days.
The facility's own records captured the uncertainty in plain language. A note entered August 17 read: "Resident left facility without MD's order, not informing staffs or signing out. Received a report that Resident left the unit around lunch time. Resident has not back yet, unknow location at this time. Staff has searched the building and surrounding neighborhood."
Staff who knew the resident described him as independent and mobile. A certified nursing assistant told the inspector that Resident 1 routinely roamed the building and used the elevator on his own. The Quality Assurance Nurse confirmed he had a history of walking throughout the premises and returning to his room without help. That independence, it turned out, also made him easy to lose.
The building has three entrances and exits: the front lobby, a side entrance near the parking area, and a back entrance. The receptionist told the inspector that the front entrance stays open from 8 a.m. to 8 p.m. and that some residents are allowed to be in the lobby area on their own. The receptionist said nurses were supposed to inform her when a resident needed supervision near the entrance, and when one could be left alone. Nobody flagged Resident 1.
The back entrance was locked, according to the Quality Assurance Nurse. That left two unsecured exits during daylight hours.
When the administrator and QA nurse sat down with the inspector that afternoon, the administrator acknowledged that this was not an isolated incident. There had been three elopements at the facility in the past six months. Two of them happened in August alone, the same month Resident 1 disappeared.
The administrator noted that the elopement occurred on a weekend, when staffing levels were lower. The QA nurse said nobody saw Resident 1 leave the building.
The administrator said the facility planned to increase surveillance. The QA nurse said her expectation was that elopement would not happen again.
What the inspection report does not say is where Resident 1 was found, what condition he was in when he was located, or what happened to him during the three days he was missing. The record shows only that he was found on August 19, 2025, and that inspectors rated the level of harm as minimal or potential for actual harm.
Three elopements in six months. Two in a single month. A building with two unlocked exits during daytime hours. A resident last seen on an elevator at 12:18 on a Saturday afternoon, and a facility note written the following day still spelling his location as "unknow."
The QA nurse told the inspector she expected elopement would not occur again. She said it after the third time.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Balboa Nursing & Rehabilitation Center from 2025-08-19 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
BALBOA NURSING & REHABILITATION CENTER in SAN DIEGO, CA was cited for violations during a health inspection on August 19, 2025.
Resident 1, as he is identified in state inspection records, was last seen on August 16, 2025, at approximately 12:18 p.m., stepping into an elevator.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.