Complaint Investigation Report

LPA interviewed C1, who stated that C1 independently walks through the neighborhood every day and that facility staff have never accompanied or supervised C1 during these walks. LPA also interviewed Client 2 (C2), who corroborated C1’s statement and confirmed that C1 regularly leaves the facility and walks through the neighborhood without staff supervision.

LPA interviewed Witness 1 (W1), who stated that W1 observed C1 walking alone in the neighborhood on July 14, 2026. W1 stated that no facility staff member was present or accompanying C1 at that time.

LPA reviewed C1’s Physician’s Report, which states that C1 is not permitted to leave the facility unassisted. LPA also reviewed C1’s Appraisal/Needs and Services Plan, which states that C1 requires another person to remain nearby while C1 is walking to prevent injury in all settings. The records establish that C1 requires supervision when walking outside the facility and cannot safely leave the facility independently.

Although S1 believed that C1 was permitted to leave the facility unassisted when remaining near the facility, C1’s Physician’s Report and Appraisal/Needs and Services Plan clearly identify C1’s supervision needs. Statements obtained from S1, C1, C2, and W1 consistently established that C1 regularly left the facility and walked through the neighborhood without the required staff supervision.

Based on interviews conducted and records reviewed, the Department determined that facility staff failed to provide C1 with the supervision required by C1’s Physician’s Report and Appraisal/Needs and Services Plan. Therefore, the allegation that “Staff does not provide adequate supervision resulting in resident wandering from facility” is Substantiated, meaning that the preponderance of evidence standard has been .

The facility is being cited under Title 22, Division 6, Chapter 1, California Code of Regulations, Section 85078(a)(1), Responsibility for Providing Care and Supervision.

An exit interview was conducted with Licensee Mitra Dixon. A copy of this report, the Appeal Rights, and the LIC 811, Confidential Names List, were provided at the conclusion of the visit.