Complaint Investigation Report

Allegation: "Staff are not supervising residents adequately." Based on interviews conducted the findings indicate that at on at least three (3) occasions during a course of 3 weeks in April 2022, client (C1) has been observed unsupervised in the front yard and sidewalk area. The facility driveway gate was in disrepair and it is alleged C1 was able to walk out the driveway without staff supervision. Staff stated that client (C1) is typically supervised when it goes outdoors, but due to the broken gate in the driveway C1 walked to the front yard area. Staff stated that when that occurs staff immediately go redirect the client. However, neighbor interviews revealed that C1 has walked out to the front yard, and staff are not always seen near the client. In addition, on April 26, 2022 neighbors observed C1 alone in the sidewalk. A few minutes later a male staff was seen redirecting C1 back to the facility. Client (C1) paces and walks around the yard throughout the day. Administrator stated that on April 13, 2022 a plumber was at the facility and may have left the driveway gate opened. However, per IPP C1 is not to be left unsupervised.

Allegation: Client was able to leave the facility without staff supervision. Based on interviews conducted on April 13, 2022, client (C1) exited the facility through the dining room French doors and walked out through the driveway to the front yard. A plumber that was completing repairs at the facility notified staff (S1) that the client was in the unfenced front yard grass area unsupervised. It is unknown of C1 exited the facility through the side door that did not have an auditory alarm because it was moved to the bathroom in order to mitigate another client's behavior. Or if C1 exited through the dining room French doors that did have a working auditory alarm. Staff (S1) stated that the alarm chime was not heard. Staff stated that around that time there are shift changes with staff coming in and out, and opening doors. Staff interviews revealed that sometimes the French doors are left opened so that clients can go in and out to the backyard. The incident was captured on surveillance video. It confirmed that C1 walked to the front yard without supervision. Per, C1's Regional Center Individual Program Plan (IPP) client (C1) requires supervision and "lacks safety awareness." C1 "is not able to navigate in the community without staff assistance." C1 is not able to identify or read street signs and does not understand it must stop at a crosswalk.

Allegation: Facility gate is in disrepair. It is alleged that the driveway gate was in disrepair. Based on interviews conducted it was confirmed that the driveway gate was not working properly for approximately four (4) days. Due to windy weather staff placed a rock so that the gate would not swing back and forth. Staff had to manually open the gate. A repair work order was sent on Thursday, April 14, 2022 and on Saturday April 16, 2022 the driveway gate was repaired. Staff were instructed to monitor the clients closely in order to prevent anyone from exiting the facility.

Based on document 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. Civil penalty was assessed for repeat violation 85078(a)(1).

An exit interview was conducted with Hazel Gatan. A copy of the report an appeal rights were provided.