Complaint Investigation Report

During today’s visit, the LPA and the LVN conducted a brief safety check tour at 1:33PM, and no immediate concerns were observed. The following was then determined:

Allegation: “Resident wandered away from the facility due to lack of care and supervision from staff.”

It was reported that on 08/01/2025, Resident #1 (R1) wandered away from their Assisted Living Facility and was discovered by a bystander who contacted the Los Angeles Police Department (LAPD). Los Angeles Fire Department (LAFD) arrived on scene at 8:16PM and transported R1 to St Joseph’s Hospital for further evaluation. Interviews with eight (8) out of ten (10) staff revealed that the facility’s protocol for a missing resident or elopement includes immediate notification of all Supervisors and the Med-Tech in charge. Staff are expected to conduct a room-to-room and facility grounds search. If the resident cannot be located, the Supervisors and Med-Tech are responsible for notifying law enforcement and the resident’s family. The reception desk is equipped with an “elopement book,” which contained photos and names of residents who are not permitted to leave the facility unassisted, per their Physician’s Report. Staff reported that identifying which residents can and cannot leave the facility unassisted was “general knowledge.” Staff #1 (S1) stated they were unable to identify which residents had clearance to exit the facility unassisted and had initiated the inquiry independently. S1 also expressed the belief that other staff were similarly uninformed unless they sought out the information.

Staff #2 (S2) reported that an Agency staff worked the evening reception shift on 08/01/2025 and had previously assisted the facility in the past. The facility’s perimeter is secured against outside access; however, individuals inside the facility can exit freely. When a perimeter door is opened, reception staff are alerted through an auditory alarm, a visual blinking light, and TV monitors that focus on the open door.