Complaint Investigation Report

Allegation- Staff does not provide adequate supervision to residents in care. -Substantiated

The Department conducted record review, interviewed staff and residents to investigate this allegation. Record review indicated that resident, R1, left the facility and AWOL on 06/23/24 around 8.30am and was found by law enforcement 0.5 miles away from facility in their wheelchair. R1 was transferred to nearby hospital for 51/50 and facility was notified by law enforcement around 10 am that they found R1 on street unattended and unsupervised. Staff interviews indicated that staff saw R1 sitting outside the facility around 8.30am on 06/23/24 but did not provide adequate care and supervision resulting R1 leaving the facility unattended. Record review indicated that R1's physician's report, dated 10/27/23, indicates that resident has diagnosis of stroke and cannot leave the facility unassisted. Although no injuries resulted from R1’s AWOL, R1 was unable to leave the facility unassisted. Facility staff did not provide care and supervision to R1 resulting in R1 leaving the facility unassisted therefore this allegation was found to be Substantiated.

Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted, appeal rights and copy of report was provided.