Complaint Investigation Report

Regarding the allegation that facility staff did not allow resident to use the bathroom: it was alleged that Client #1 (C1) asked staff to go to the bathroom and staff denied C1’s request, told C1 they did not need to go, and told C1 to go back to their room. LPA inspected the facility, conducted health and safety checks on all four clients, and observed no health and safety issues. LPA reviewed an audio recording in which C1 asks to use the bathroom and facility staff deny C1’s request and tell C1 to go back to their room. LPA interviewed AD and two staff who denied the allegation, stating that C1 had already used the bathroom, C1 had urinated themselves in the living room, facility staff were cleaning up the living room and told C1 to wait in their room, and as soon as the staff was done, they took C1 to the bathroom where C1 did not need to use the restroom. LPA interviewed four clients and did not obtain additional information corroborating the allegation. Although C1 was later provided assistance in using the bathroom, the information corroborated that facility staff did deny C1’s request to use the bathroom.

Regarding the allegation that lack of supervision resulted in resident eloping: it was alleged that C1 eloped from the facility, was gone all day, and was found one mile away from the facility. LPA inspected the facility, conducted health and safety checks on all four clients, and observed no health and safety issues. LPA interviewed AD who admitted the allegation, stating that during this incident there were two staff present at the facility attending to various tasks, C1 left the facility without their notice, when staff noticed C1 missing the police were called and a search for C1 was initiated, and C1 was found by the police at a local grocery store. LPA reviewed a facility incident report stating that on April 5, 2024, around 10:00AM, staff noticed that C1 was not present at the facility, the police were called and a search initiated, C1 was found by police at about 10:50AM at a grocery store about a quarter of a mile away, and C1 did not need any medical treatment. LPA interviewed four clients and did not obtain any additional information corroborating the allegation. The information obtained corroborated the allegation.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.