Complaint Investigation Report

Staff #1 (S1) stated that R1 exited the facility through the side door located in the backyard on 05/22/26 afternoon. S1 mentioned that staff were unaware that R1 had left the facility until a neighbor knocked on the front door and informed staff that R1 was outside on the street. S1 further stated that R1 subsequently returned to the facility through the same side door. Interview with the Administrator confirmed the incident and stated that the side door remained unlocked as part of the facility's emergency evacuation procedures. The Administrator further indicated that R1 appeared to have taken advantage of a time when only one staff member was on duty. Administrator stated that S1 mentioned that R1 was gone for 10 minutes or less near the front door. LPA attempted to interview R1; however, R1 was not present at the facility during the visit. LPA reviewed R1's Medical Assessment dated 06/24/2025, which indicated that R1 was not capable of leaving the facility unsupervised due to physical and cognitive limitations.

Based on interviews conducted and records reviewed, there is sufficient evidence to support the allegation that the facility failed to provide adequate supervision to prevent R1 from leaving the facility unsupervised. Therefore, the allegation is deemed Substantiated at this time.

An exit interview was conducted. A citation was issued pursuant to Title 22, California Code of Regulations, as referenced on the LIC 9099-D. A copy of this report was reviewed with and provided to the facility Administrator.