Complaint Investigation Report

According to staff interviews and care records from San Diego Regional Center (SDRC), C1 was diagnosed with Mild Intellectual Disability and was not able to safely leave the facility unassisted. Per C1’s SDRC Client Placement Referral, a document in licensee’s possession, C1 had one elopement incident prior to moving-in to Abigail’s Home IV in May 2022. Staff interviews showed C1 eloped on a few occasions during their first year living at the facility, requiring police involvement for some. C1’s exit-seeking behavior then mostly subsided, until the two (2) days leading up to the current incident in question, during which time C1 was yelling/cursing at staff, punching walls, throwing objects, and stating that they wanted to leave.

Staff interviews and police records generally aligned to show: On the afternoon of 01/27/2025, Staff #1 (S1) and Staff #2 (S2) transported C1, Client #2 (C2), Client #3 (C3), and Client #4 (C4) via passenger van to a medical office. Once parked, S2 walked/escorted C4 inside the medical office for their doctor’s appointment and remained with them. Meanwhile, S1 stayed in the vehicle with C1, C2, and C3. About an hour later, C1 began punching/kicking the seat of C2 and yelling. Seeking to minimize the impact of these behaviors, S1 walked/escorted C2 and C3 into the medical office so that they could be left with S2. However, in the process S1 left C1 alone inside the vehicle. (The doctor’s office was roughly fifty yards from where the vehicle was parked, but due to a bend/turn was also not in direct line-of-sight of the vehicle.)

Once inside the medical office, S1 and S2 spent several minutes conversing. Staff accounts of how long S1 was away from the vehicle (and C1) ranged from “five to ten minutes” to “eight to ten minutes." When S1 returned to the vehicle, C1 was no longer there. Staff searched the parking lot and nearby premises for about twenty minutes, then called 911 around 5:45 PM. Chula Vista Police Department (CVPD) conducted a full search for C1, employing public announcements and air support. Shortly after 8:30 PM, C1 approached Southwestern College Police Department (SDCPD) personnel to ask them for help getting home. C1 had traveled around 5.4 miles on foot by the time they were found. C1 was unharmed and uninjured, and facility staff went to collect C1 and bring them back to the facility.