Complaint Investigation Report

R1’s medical report indicated that R1 was admitted to the hospital on 10/30/2025 at around 2:30 a.m. Report indicated that on the day R1 left the facility, R1 arrived at the hospital via ambulance with pain and swelling in the right elbow. Report states that R1 was able to recall experiencing a fall and hitting their head on a tree. The medical report states that R1 was diagnosed with a right humeral fracture per x-ray impressions conducted when admitted to the hospital on 10/30/2025. Police interrogation of the nurse on shift during R1’s hospital care stated that R1 sustained the humeral fracture after falling when walking in the community. Information also provided by the police indicated that facility filed a missing person report at 9:00 a.m.

Based on interviews, facility staff did not conduct proper checks on R1 which resulted in R1 eloping and walking outside of the facility unassisted and without anyone noticing. Records also show that R1 fell and sustained a fracture during the time they were missing from the facility. The elements reviewed during the investigation, corroborate the allegation that staff neglect resulted in resident eloping and sustaining a fracture.

The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated . California Code of Regulations (Title 22), is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided.

***Immediate Civil Penalties are issued today in the amount of $500 due to neglect/lack of supervision that resulted in resident sustaining a fracture and for Repeat Violation of Section 87468.2(a)(4). At this time, an Enhanced Civil Penalty (ECP) determination in reference to Health and Safety Code 1569.49(f) is pending and may be assessed at a later date.***