Complaint Investigation Report

At 2:23 p.m. LPA interview two (2) more residents. LPA's review of R1's physician report revealed the physician did not select yes or no for "able to leave the facility unassisted" question. According to the administrator the primary care physician was leaving the response up to R1 psychiatrist. According to the administrator the psychiatrist had verbally told them R1 cannot leave the facility unassisted. LPA's interview with administrator and S1 revealed R1 has gotten lost in the past and tends to pick up trash from the floor to eat. LPA's interview with S2 confirmed there was a piece of wood holding R1's door closed because R1 is prone to leaving the facility unassisted. LPA's interview with the Administrator confirms he found out about the wood and immediately instructed his staff to throw it away. According to the administrator R1 has had an escalation of behaviors due to R1's mental health diagnosis. Administrator states his staff informed him R1 has made threats to staff and residents prompting staff to keep R1 in their room afraid R1 may attack another resident. Interview with four (4) out of six (6) residents that responding to LPA's questioning state they feel safe with staff at the facility and are able to leave the facility when they want. Administrator states in-service training has been conducted regarding residents personal rights. Administrator provided copies of in-service sign in sheet to LPA. Based on LPA's interviews the allegation is deemed Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Exit interview conducted. Appeal rights provided and a copy of this report issued.