Complaint Investigation Report

9099C-1.. Resident (R1) moved to the facility on March 17, 2025 with a primary diagnosis of Alzheimer's Dementia. The Physician's Report notes that (R1) could be confused/disoriented, exhibits wandering/sundowning behaviors and is an "elopement risk". Additionally the report notes (R1) is ambulatory, not able to leave the facility unassisted, and requires assistance with bathing and medications.

Allegation: Staff are locking resident in their room. The allegation states there is a resident (R1) who is locked in their room after hours to prevent them from leaving the facility since throughout the day the resident would attempt to elope.

The Administrator stated prior staff (S2) placed a lock on (R1's) door for approximately a week and he was not aware of this as (S2) did not tell him. The administrator explained it was (S2's) job to check on (R1) at night", stating "(S2) would sleep through" (R1) getting up, exiting through the front door, and not get up when the "alarm went off" and "(S1) would have to go after (R1)". After (S1) left the facility, (S2) put a lock on (R1's) bedroom door at night". The administrator stated he removed the knob to turn the lock and disabled the locking mechanism, over a year ago, when he found out about this as (S2) quit.

Resident (R1) was asked if there was ever a lock on their bedroom door and was not able to articulate well and provide an answer, but appeared pleasantly confused. (R1's) family member stated she was not aware of a lock ever being on (R1's) door and (R1) did not say anything to her about it.

LPA observed the door knob on (R1's) door, and all other resident doors, to not have a locking mechanism in place when inspected on April 21, 2026 or on May 19, 2026.

Based on information obtained, the allegation is found to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page.