Complaint Investigation Report

Staff does not provide adequate supervision resulting in resident wandering away from facility.

LPA reviewed a sample of Residents records (R1, R2, R3). The LIC602 dated 02/25/25 for R1 revealed the R1 has macular degeneration, essential tremors, Mild Cognitive Impairment (MCI), and is unable to leave the facility unassisted. R1’s LIC 624 dated 05/20/25 reports that on 05/13/25 R1 left the facility without supervision and was returned to the facility by El Cerrito Police department. S6 stated that the staffing was questionable, and both Assisted Living and Memory Care's staffing should be assessed, and S7 stated that there should be more focus on the actual care of the residents.

Based on information obtained, the allegation is SUBSTANTIATED . A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview conducted, appeal rights and a copy of this report provided Tracy Gibson, AED.