Complaint Investigation Report

The investigation revealed the following: Allegation-Staff did not provide adequate supervision, resulting in a resident wandering away from the facility.

The details of the complaint alleged that the facility did not provide adequate supervision of client resulting in the client wandering away from the facility and ending up in an emergency room. On 10/2/25, from 9:30am-2:00pm, the department interviewed staff (S1-S3) regarding the allegation. 3 of 3 staff (S1-S3) corroborated that client (C1) did wander away from the facility on 09/22/2025. Staff (S1) stated that on 9/22/25, their staff member (S3) was helping another client get ready for the day and assisting them with personal care. When the staff (S3) went to check on C1 to get them ready for the day program, they could not find C1. Staff called 911 and South-Central Regional Center and reported that the client went awol from the facility. Staff (S3) corroborated this account and stated that the client ended up at Martin Luther King hospital where they picked them up later that day and returned them to the facility unharmed with no bruises.

The department reviewed the South-Central Regional Center Incident report during the department’s complaint investigation on 10/2/2025 and observed that a report was filed. However, the facility failed to notify Community Care Licensing Division about the incident within seven days, which Title 22 regulations require.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not provide adequate supervision, resulting in a resident wandering away from the facility, is found to be Substantiated . California Code of Regulations, Title 22, Division (6) and chapter (1) and (2) are cited on the attached LIC 9099D.

Note: *Citations that are not cleared by the due date of 10/10/25 will have a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. Deficiency was cleared at the time of the visit.

Deficiencies were issued and plans of corrections were discussed.

An exit interview was conducted with Chimenem Cyril-Eziwhou, Administrator, and a hard copy of this Complaint Investigation Report was provided.