Complaint Investigation Report

The Administrator was advised that R-1 had been found at the Kaiser Hospital ER by R-1's daughter via telephone. R-1 was provided with an examination at the ER and subsequently returned to the facility on the same day.

LPA Tsui and LPA Yelena Avetisyan conducted an initial investigative visit at the facility on 9/9/21. A tour of the physical plant was conducted as well as interviews with Staff and the Administrator and a review of facility records for R-1. During the tour of the physical plant the LPA's observed that two of the auditory alarms were not operational. An interview with the daughter of R-1 was conducted via telephone by LPA Tsui and LPM Miller on 9/21/21 at 8:30am.

Based on the content of the interviews conducted on 9/9/21 from 2:00pm and 3:10pm and the interview with the daughter of R-1 on 9/21/21 as well as a tour of the physical plant on 9/9/21, LPA Tsui was able to substantiate the allegation that due to a lack of care and supervision by Direct Care Staff R-1 was able to leave the facility without their knowledge placing R-1 at risk.

Citations issued, appeal rights provided and exit interview conducted.