Complaint Investigation Report

LPA interviewed the Administrator who stated that since the last visit, the facility has implemented 30-minute staff checks on R1. The Administrator stated that the facility has implemented a motion activated auditory alert device on the facility’s gate, but they had been experiencing issues with a tree near the gate causing false alarms due to detected motion. The Administrator stated that a gardener is scheduled to prune the tree on Saturday (05/09/2026) to diminish the number of false alarms. The Administrator stated that they were unaware that R1 had left the facility without supervision on 04/26/2026. The Administrator stated that they would speak with R1’s responsible party to discuss the implementation of a 1:1 caregiver to supervise R1. LPA interviewed facility staff who confirmed that they had implemented thirty (30) minute checks on R1 throughout the day. Additionally, staff confirmed that they had been trained to respond to auditory alerts throughout the facility. LPA interviewed R1 who stated that there are enough activities at the facility to keep them entertained including pet therapy and exercise. R1 stated that the facility walks with them through the neighborhood when they are able to. LPA reviewed R1’s resident file and observed a physician’s report dated 04/15/2026. The physician’s report indicated that R1 is unable to leave the facility unassisted. LPA informed the Administrator that they were recently cited for a violation of Health and Safety Code section 1569.312(a) on 04/08/2026. LPA informed the Administrator that since this is their second (2nd) violation of this licensing regulation within a twelve (12) month period a civil penalty in the amount of $250 is being assessed on today’s date (05/05/2026) for a repeat violation. Based on the interviews conducted, evidence submitted, and file review, there is sufficient evidence to support to the allegation of “Staff did not prevent resident in care from leaving the facility without supervision.” Therefore, the allegation is deemed Substantiated at this time.

The following deficiency was cited and civil penalty assessed (Refer to LIC 9099D). Exit interview was conducted, a copy of the report and appeal rights were provided.