Complaint Investigation Report

In-Service Training (dated 12/10/2025), Sign In and Out Sheet (dated 12/09/2025), La Palma Intercommunity Hospital Medical Records (dated 09/19/2025), and Kaiser Permanente Downey Medical Center Admission and Discharge Records (dated 12/09/2025 and 12/10/2025).

On 12/19/2025, between 10:00 a.m. and 3:00 p.m., LPA Pamela Bunker conducted interviews with staff members #1–#4 (S1–S4) and with residents #2–#6 (R2–R6). Resident #1 (R1) was unavailable for an interview as they no longer reside at the facility. R1 transferring to a higher level of care facility.

The investigation revealed the following.

Allegation: Staff did not provide adequate supervision, resulting in a resident eloping from the facility.

LPA interviewed staff #1–4 (S1-S4). All four staff members (4 out of 4) stated that the facility staff ensure they are providing adequate care and supervision to prevent any resident from eloping from the facility. 4 out of 4 staff members reported that R1 signed out on 12/09/2025. They stated that R1 typically remains on the premises and is known to walk around inside the facility, the patio area, or the outside parking lot. On this date, however, R1 left the facility and went for a walk in the community. During routine rounds conducted every two hours, staff noticed that R1 was no longer at the facility and immediately initiated a search. Staff stated they were able to locate R1 later that same day. S1-S4 stated on 12/09/2025, R1 was admitted to Kaiser Permanente Downey Medical Center for observation. R1 was discharged 12/10/2025. 4 out of 4 staff interviewed stated that R1's CT scan showed no evidence of head trauma, and that a full body check revealed no injuries or bruising. On 12/12/2025, R1 was transferred to a higher-level care facility for continued treatment. Staff confirmed that they self-reported the incident to all the appropriate agencies, responsible parties, family members, and R1's physician in a timely manner. According to staff, 4 out of 4 stated that the facility followed Title 22 regulations and implemented the necessary precautions to ensure resident safety at all times.

Residents #2–#6 (R2–R6) stated that staff provide adequate care and supervision. 5 out of 6 residents reported that staff are always available to assist and consistently check on residents throughout the day and night. 5 out of 6 residents stated that they did not witness any resident eloping from the facility. R2–R6 also reported that their daily needs are being met and that they are happy living at the facility, expressing no problems or concerns. See continued LIC812-C page 2.