Complaint Investigation Report

Allegation: Staff do not ensure adequate supervision is provided resulting in residents eloping from the facility

During investigation, the department conducted interviews of facility staff & responsible partes and reviewed resident (R2, R3) documents. Review of incident reports dated 10/16/23 showed that at 11AM two memory care residents (R2, R3) were able to push open the memory care delayed egress side door and managed to walk outside the parking lot without the alarm sounding due to a faulty delayed egress system. LPA interviewed responsible parties (POAs) who stated that R2, R3 were found by a third party who alerted staff to escort them back to the memory care unit. Staff did not know that they were missing. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff do not ensure adequate supervision is provided resulting in residents eloping from the facility was found to be substantiated.

Allegation: Staff do not ensure residents medications are securely stored in the facility

During investigation, the department conducted interviews of facility staff & responsible party (POA) and reviewed resident (R1) documents. LPA reviewed video footage on 05/31/24 around 8:36PM which showed the memory care medication room door was unlocked/open with no staff present inside or outside the medication room. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff do not ensure residents’ medications are securely stored in the facility was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted, appeal rights and copy of report provided.