Complaint Investigation Report

During the course of the investigation, LPA conducted interviews with S1, S2, S3 and S4 regarding the facility's AWOL reporting procedures. S1 reported that when a client is AWOL, the incident is first reported to the on-duty security guard, who then notifies the Medication Technicians (MTs). The MT notifies the client's Responsible Party (RP) and files a missing persons report with the San Pablo Police Department within 24 hours. S2 reported that when a client is AWOL, the information is reported to the security guard, who then notifies the MTs. S3 reported that when S3 and other clients returned to the facility, C1 stood on the corner adjacent to the facility but did not enter. S3 stated that C1 informed S3 that C1 was not returning to the facility and indicated that C1 is an adult and able to make decisions. S3 reported this incident to the security guard. S4 reported that when a client is AWOL, the incident is reported to the security guard, who then notifies the MTs. The MT informs the RP and files a missing persons report with the San Pablo Police Department within 24 hours. LPA also conducted a record review which revealed that C1 left the facility on January 9, 2026. The incident was reported to the RP and the San Pablo police Department on January 11, 2026. Therefore, this allegation is SUBSTANTIATED.

ALLEGATION: Facility staff falsified resident records

During the course of the investigation, LPA conducted interviews with S4 regarding the facility's reporting false documents. S4 reported that the facility is required to report when a client misses medications. LPA conducted a record review, which revealed that the facility reported to the RP and the client's physician on January 10, 2026, that C1 had "refused all AM medications". However, records indicate that C1 went AWOL on January 9, 2026, and was not present at the facility to receive medications. Additionally, the facility did not notify the physician until January 11, 2026. S4 reported that an internal investigation would be initiated to determine the cause of the inaccurate reporting. Therefore, this allegation is SUBSTANTIATED.