Complaint Investigation Report

On 02/03/23 at around 9:13 AM, LPA conducted a case management to follow up on the above stated incident. LPA obtained copies of the facility records relevant to the investigation and interviewed staff and residents and conducted a thorough physical plant inspection.

During the course of the investigation, Investigator Doulglas interviewed the administrator and obtained records from Burbank Police Department (BPD), Hospital and County Medical Examiner. LPA’s interview with staff on 02/03/23 at around 12:30 PM revealed that only the maintenance staff has access to the third floor leading to the roof as it was off limits to residents and other staff and was always locked. Further interview revealed that staff were working on the roof to fix a leak but must have left the door unlocked giving R1 access. LPA’s interview with another two (2) staff also revealed that after the incident happened, police came, and these two (2) staff escorted the police to the rooftop and observed that the door leading to the rooftop was unlocked. The police were immediately able to enter and found the portable oxygen machine of R1 on the rooftop. Investigator Douglas review of the information obtained from BPD revealed that the incident was ruled out as suicide by jumping off the roof of the facility.

Based on the information gathered during the course of the investigation, the allegation is deemed substantiated at this time.

Citation issued, appeal rights discussed and given. Exit interview conducted. Copy of this report issued.