Complaint Investigation Report

9099C-1.. Allegation: Staff allowed residents in care to leave the facility without staff supervision. The allegation states there were two incidents where (2) clients were lost and later found by the staff. About 9 months ago, client (C1) was relocated an hour later at the Dollar Tree (7313 Greenback Ln) shopping center. About 6 months ago, client (C2) was located at the Kentucky Fried Chicken restaurant about a mile away. Both residents had to cross a busy road (Sylvan Road).

LPA reviewed the information report submitted to regional center for an incident occurring on January 11, 2025, where client (C1), who was visiting from a related facility, stated they wanted to go to another location (this facility location) to participate in gardening activities. The report notes staff drove (C1), there at 9:45 am and checked on (C1) every 5-10 minutes, but at 10:30 am, could not locate (C1). The report documents that staff searched extensively for (C1), called and texted their mom and the administrator located them at 10:50 am, 20 minutes later, near a business (7801 Greenback Lane) on Greenback Lane.

Interviews with the Administrator and Licensee indicated that (C1) would not go to the Dollar Tree by themselves, which was determined to be 5 blocks further from the business where (C1) was located at.

(S1) stated they are "not sure" if they were at the facility on January 11, 2025, when (C1) became very upset and verbally stated they wanted to leave but explained (C1’s) mom found (C1) from their tracking device/cell phone- through a "community safe" program and that (C1) was found crossing the street.

LPA reviewed the information report submitted to the regional center on May 25, 2025, involving client (C2) who left the facility that day around 10:00 am. The report notes staff “noticed (C2) was no longer sitting in the facility and staff immediately informed all other staff on duty and searched the immediate grounds and inside the facility.” The report indicates that several staff left the facility to look for (C2) who was found a few blocks away, unharmed.

Staff (S1) confirmed they were on duty when (C2), left, and confirmed (C2) eloped only once. (S1) explained that client (C2), walks pretty fast and was asked to wait but (C2) didn't. (S1) stated that (C2) was "found by the corner" by the house manager and did not go to the Dollar Tree, which was the other direction. (S1) indicated that (C2) shouldn't leave the facility without assistance, as a best practice. Staff (S2) confirmed they were "off duty" when (C2) eloped from the facility.