Complaint Investigation Report

SIR three states on 05/25/2026 at approximately 4:45 AM staff discovered that C1 had exited the building through an emergency door in another residents room. Interview with Administrator stated that all three times C1 eloped, they eloped from the same emergency exit door and prior to C1’s elopement, C1 would deactivate the doors alarm system. Per C1’s physician’s report dated 3/25/2026, C1 is unable to leave the facility unassisted. Per C1’s admission agreement on page 13 and 14 under current behavioral concerns it outlines elopement and agitation with behavior triggers for elopement being transition times and working with new staff. On page 14 it states under Safety/Risk Management Needs that C1 needs oversight due to elopement.

Based on LPAs observations and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Division 6, Chapter1 is being cited on the attached LIC 9099D. Appeal rights given.