Complaint Investigation Report

Physician’s Report (LIC 602) for client C1 dated 12/27/2021 states that client is “not able to leave facility unassisted” and ISP dated 8/1/2021 states “increase of insomnia with elopement behavior during the night”. Administrator and staff stated that there are 2 staff scheduled to work overnight (NOC shift) and on 6/6 and 6/13/2022 there were only 1 staff working at the facility. Due to facility not having the appropriated staffing during NOC shift, client C1 eloped both days and facility contacted 911 due to not having staff available to supervise client. (see copy of docs on file, confidential name list, LIC 9099-D)

Based on documentation review and interviews for the case of client C1, Department is able to prove that C1 eloped on 6/6/2022 and 6/13/2022 and facility failed to supervise client C1 due to not having adequate staff to meet C1’s needs.

According with complaint allegations “Resident eloped from facility.”; “Facility does not have adequate staff to meet clients’ needs.” there were related observations made during visit. Based on LPAs' observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.