Complaint Investigation Report

The investigation revealed the following: regarding the allegation “Due to lack of supervision, resident eloped” it is alleged that C1 was taken to USC Arcadia Hospital under a 5150 hold for being gravely disabled due to a sheriff’s department call about someone found wandering in the middle of the street. It was reported that C1 is non-verbal, developmentally delayed, and has the mental capacity of a child. No identifying information such as name, date of birth, or address was obtained, therefore C1 was brought to the Emergency Room as a John Doe. Interviews with staff revealed staff was aware of C1 walking away from the facility. Per facility protocol, staff followed C1 at a safe distance asking C1 to wait. C1 continued walking away. Staff kept their distance to avoid triggering C1’s elopement. Staff lost sight of C1 in a shopping center familiar to clients and staff, as they walk to the shopping center 2-3 times a week. After a few hours of searching for C1 at the shopping center and other familiar stops along their usual walk route, S1 returned to the facility and called law enforcement. With the assistance of the Sheriff’s department, S1 located C1 at a local hospital. S1 was able to retrieve C1 from the hospital with proper identification. A review of C1’s physician’s report signed 07/17/2025, revealed C1 is able to leave the facility unassisted.

Based on interviews and record review, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Marites Jacinto , DSP.