Complaint Investigation Report

The administrator stated that the resident had a key to unlock the door but lost it. Interviews with staff and witnesses revealed that R1 had tried to leave the facility unsupervised several times. LPA obtained a video footage of R1's previous door. It showed that the keyhole was placed inside of the room and was locked. R1 would need to use a key to unlock the door or someone from the outside would need to open the door. R1 would pound on the door because the door could not be opened from the inside. Staff would immediately open the door when R1 called out. Witnesses stated that while they were in R1's room and closed the door, they could not get out. Administrator and Staff acknowledged that the door knob was recently changed.

Based on LPA observations and interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted. The Plan of Corrections were reviewed and developed with the licensee via telephone. A copy of this report and appeal rights were given to the staff.