Complaint Investigation Report

-Regarding allegation: Facility is not properly secured. On 3/22/22 LPA reviewed the camera footage and observed that on 3/17/22 approximately 8:35am there wasn’t a staff at the front desk, nor was there staff around the area to supervise that dementia residents do not wander outside unsupervised. On 3/22/22 LPA interviewed administrator, Susana Fuentes and asked if there are auditory devices to notify staff when someone walks through the backdoor. Susana states that the facility is not a locked facility, and there are no alarms, however facility has an auditory device on exits. There’s a box located at the front desk, and when the backdoor is opened it will make a sound to notify staff. Staff will then review the camera to ensure its not a resident with dementia attempting to exit unassisted. On 3/22/22 at approximately 1:06pm LPA asked Susana to test the backdoor auditory devices, S1 opened the backdoor, however there was no alarm heard at the front desk. On 5/4/22 at approximately 9:31am LPA observed resident walk out the backdoor and LPA didn’t hear an auditory alarm go off to notify backdoor was opened. LPA asked S1 about the auditory device, in which she replied; the backdoor was replaced recently and the alarm was disabled. Facility is working to get the auditory device to work.

Based on LPA’s interviews, and record review(s), the preponderance of evidence standard has been met, therefore the allegation, is found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC9099-D. Exit interview conducted and a copy of this report and appeal rights provided to facility representative.

-Regarding allegation: Resident wandered from the facility. Per Unusual incident report (UIR) dated 3/17/22; on 3/17/22 an outside pedestrian came to notify facility that resident was walking outside and was requesting to go to Torrance. S2 went out to check and determined that it was R2. Per Physician report R2 is diagnosed with Dementia and requires supervision to leave facility. Per Preplacement Appraisal dated 3/4/13 R1 has no sundowning, aggression, nor wandering behaviors. A reappraisal was not available at time of visit. On 3/22/22 LPA Cardenas reviewed the camera footage and observed that on 3/17/22 R2 walked out of the facility front entrance unassisted by a staff at approximately 8:35AM and was assisted back to the facility by staff at 9:03AM.