Complaint Investigation Report

Regarding the allegation: Facility staff did not provide adequate supervision to resident in care. It is being alleged that resident #1 (R1) is housed in the memory care area of the facility and made it to the lobby area pass the egress doors. Let it be noted, the lobby area is part of the assisted living area of the facility. LPA reviewed R1’s file and it is documented that R1 has dementia and is housed in the memory care area of the facility. During LPA’s interview with R1, R1 denied leaving the memory care area but did state "they will not be staying at any facility and will try to leave and go home.” LPA interviewed three (3) staff that confirmed R1 has left the memory care area and made it to the lobby area. Staff #1 (S1) confirmed that R1 was informed by another staff that R1 was in the lobby are and needed to go back to the memory care area of the facility. Staff #2 (S2) confirmed that R1 has left the memory care area on multiple occasions and has been seen walking in the assisted living area of the facility. Staff #3 (S3) confirmed that they have seen R1 by their office which is outside of the memory care living area and located in the assisted living area of the facility. After LPA reviewed R1’s file it was determined that R1 was not given adequate supervision and did not have an updated appraisal. LPA attempted to interview six (6) residents in the memory care area, but they were not able to respond to LPA’s interview. Therefore, based on the LPA's record review, staff and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time.

This report supersedes the previous report issued on 03/17/2025 to dismiss and change citations. An appeal was granted.

Licensing Program Analyst (LPA) Gina Saucedo visited the facility to issue an amendment to the Licensing Report previously issued on 03/17/2025. The LPA met with Administrator and explained that the report was amended to correct the type of citation issued during the visit conducted on 03/17/2025. Citation CCR-87705(6)(A) is dismissed and Citation CCR-87411 (d)(3) is being changed to CCR-87468.2(a)(4).

An exit interview was conducted, citation(s) were issued, appeal rights was given and a copy of this report was given to the Administrator.