Complaint Investigation Report
Allegation: Staff abandoned resident in an unlicensed facility.
It was alleged that the facility had abandoned a resident at an unlicensed facility. Interview with administrator (S1) revealed that resident #1 (R1) had been at the facility on 3.18.2026 at 6:00PM and on 3.19.2026 at 9:00PM was sent via medical transportation to another facility after S1 contacted their consultant. S1 communicated with the consultant they work with regarding R1’s need of higher level of care due to R1’s aggressive behavior towards staff and safety of other residents in the facility. S1 was not aware exactly where R1 was going. S1 did not communicate or disclose with R1's family where R1 will be going. Facility did not send an incident report to the department. S1 did not conduct a pre-placement appraisal for R1 before R1 left for another facility. Interview with S1 revealed that they just received the complete address of unlicensed facility where R1 was transferred to on 4.20.2026 at 11:00 AM in front of LPA. Proper placement did not meet the residents’ needs and S1 did not ensure facility was licensed for R1 to be transferred.
Based on information obtained from review records and interviews, the above allegation is deemed substantiated .
Allegation: Staff did not communicate with responsible party regarding resident's changes.
It was alleged that facility staff did not communicate with R1 responsible party regarding resident changes. An interview with residents revealed that they have no issue with facility staff communicating with their responsible party. Interview with S1 revealed that they have no information as to where R1 is going and let the referral agent communicate with R1 family.
Based on information obtained from review records and interviews, the above allegation is deemed substantiated .
Second deficiency remains the same as noted in the report on 04/20/26. Third allegation remains unsubstantiated as noted on 04/20/26.
Exit interview conducted, appeal rights discussed, and a copy of this report issued.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction