Complaint Investigation Report

Allegation: Client was allowed to leave the facility without staff supervision. Based on interviews conducted and document review the findings indicate that on September 1, 2021 client (C1) exited facility property unsupervised. At approximately 1:00 PM the client was seen by three neighbor witnesses walking in the middle of street two houses down from the facility. Client (C1) approached the neighbor's car as it pulled into the driveway. Witnesses stated C1 appeared disoriented and was not able to communicate. NOTE: Client (C1) is non-verbal with diagnosis of profound intellectual disability. Client (C2) was interviewed and confirmed that C1 left the facility.

Per client (C1's) Regional Center Individual Program Plan (IPP) the client is not allowed to be left unsupervised and has "very little knowledge of street and community safety." A total of two staff (S1 & S2) were on duty during the incident. They were assisting another client in the bathroom. The third staff was taking a car lunch break outside. Client (C1) exited through the dining room door and left the facility property through the side gate door that was left unlocked by another new staff that had left earlier. According to community witness a staff was observed parked outside while C1 was with the neighbors. Two neighbors walked over client (C1) to the facility after being found in the street. The client did not sustain any injuries. The exit doors have auditory alarms that at times cannot be heard depending on the location of where staff are at inside the home. Staff stated that client (C1) was unaccounted for a total of 4 minutes. LPA reviewed video surveillance footage and confirmed the total amount of time the client was unsupervised outdoors.

Based on document review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiencies are being cited according to California Code of Regulations, Title 22. Civil penalty was assessed for repeat violation.

An exit interview was conducted with Administrator Edward Velarde A copy of the report an appeal rights were provided.