Complaint Investigation Report

Allegation: Resident is missing after eloping from the facility.

Staff is not providing adequate supervision.

The detail on allegations states, resident #1 (R1) is a resident at Carson Senior Assisted Living who eloped from the facility and now is missing. According to the complainant (R1) had wandered off from the facility multiple times and the staff is not providing adequate supervision. According to administrator Ginger Enriquez, on 10/23/21, ((R1) had dismantled the window locks in room #21. (R1) was able to take apart one of the slider windows of its track and left through by pushing out the window screen at 10:30 pm. Enriquez reported that the staff searched for (R1) throughout the entire interior and exterior sections of the facility and that no traces of (R1) was found. Enriquez claims the facility immediately contacted the Carson Sheriff's Department and filed a missing person report. Enriquez asserts the incident had occurred when the afternoon shift was transitioning to the night shift. The afternoon shift had three (3) staff working from 2:30 pm - 10:30 pm and two (2) staff working 10:30 pm - 6:30 am for the graveyard shift when the incident occurred. Enriquez admitted that this was not the first time (R1) had fled the facility and that (R1) had disappeared on 8/28/21 and was found by law enforcement within a few hours. At that time, (R1) entered through the same room #21 and managed to get out the same process through the slider window by breaking the window. According to Enriquez, the staff in Arbor Hall were doing hourly checks with all the residents at 11 pm when caregivers discovered (R1) was missing. The Department reviewed (R1's) service records and it states in (R1's) Physician's Report is not able to leave the facility unassisted and may get lost or not maintain safety.

The Department interviewed resident #2 (R2) who was an actual witness when the incident happened and confirmed details on how (R1) was able to escape from the facility through her room window. (R2) reported that no staff was available during the time it occurred to supervise. An interview with staff #2-#3 (S2-S3) recalls the incident and verifies the time and date when it happened. (S2) reports the incident that occurred during shift changes. (S2) states at around 10:30 pm she was doing her normal routine round checks and that (R1) was not found inside her room #27. During her inspection of the entire floor for (R1), (S2) observed the window slider was taken off its track and the locks were broken. (S2) immediately notified management and law enforcement. (S2-S3) both acknowledge that (R1) had a history to wander.

Evaluation Report continues on LIC 9099-C