Complaint Investigation Report

Regarding allegation: Resident wandered away from the facility due to lack of supervision.

During interview with Administrator, Harvey was informed by staff via telephone that residents were outside and when staff went to look for residents outside residents were not on the facility premises. During interview S1 stated they were informed residents were outside when S1 checked on residents, they were not present and were not aware of residents whereabouts. S2 stated caregivers were preoccupied with residents who wander and when staff checked on resident #1 and #2 outside they were gone. S3 stated residents were in the dining area and after went outside, caregivers were not present, S3 was on break and once caregivers were notified about residents being outside, caregivers checked on residents and they had left facility. Interview with R3 stated staff are on their cellphones and not preforming their duties, R1's family stated facility stated that R1 disappeared and facility did not know where R1 went and left with another resident and they called Monrovia Police Department. S1 was informed by kitchen staff who was on her break that the residents had eloped; the residents eloped through the back gate that was known by staff to sometimes be open/unlocked; after review of records, it was determined that both residents were not able to leave the facility unassisted; and that during the visit the signal system was tested/working. Residents were both found and returned to the facility.

Based on observation, record review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22. See LIC 9099D.

Exit interview was conducted with Substitute Administrator- Stephany Perez . A copy of the report and appeal rights were issued.