Complaint Investigation Report

The preliminary cause of death for R1 was acute cocaine and ethanol intoxication. This facility is a voluntary program, and residents are free to leave the facility under a certain set of rules. R1's physicians report documented that she was able to leave the facility unassisted. On November 28, 2023, R1 initially followed policy when she left the facility but failed to return. Staff followed protocol by calling the resident when she did not show up for her medication and checking in on her periodically. They also filed a missing person’s report with Oakland Police Department within 24 hours of her going missing. Although R1 had a history of substance abuse, she came from a sober living environment. She had only been at the facility for 10 days and did not show signs of substance abuse. R1 case manager (unknown name, not a facility staff member) was responsible for implementing and encouraging R1 to participate in a substance abuse recovery program.

Based on interviews and record reviews conducted, the above allegations are unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview was conducted and a copy of this report was provided.