Complaint Investigation Report

LPA conducted (3) staff interviews which revealed R1 experienced wandering behaviors and experienced a fall occurring after 3 am when R1 got up at night to go to the restroom. All (3) staff interviewed confirmed staff are on call at night and there is no awake staff. Records review revealed physician's report identifying R1 with Condition #1 (C1). There was no readmission appraisal or plan of care on file for R1.

According to California Code of Regulations (CCR) Title 22, person's identified with C1 in facilities with (16) residents or less require at least (1) awake staff at night. Therefore, based on interviews and records review the allegation is substantiated. The preponderance of the evidence standard has been met and CCR Title 22 regulation is being cited on the attached LIC9099-D. An exit interview was conducted where this and attached reports including appeal rights were reviewed and provided.