Complaint Investigation Report

It was later revealed through record reviews that R1 did not return to the facility and admitted to the hospital after her absence without leave (AWOL), and later admitted to another licensed care home. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D. An immediate civil penalty in the amount of $1000 is issued in addition to the citation due to absence of supervision a repeat violation of Section 80078(a) within a 12-month period.

Allegation: Facility did not report incident to CCL (Community Care Licensing). LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was determined that R1 exited facility in July 2024 and later admitted to the hospital as a result. Record reviews further revealed that an incident report for this event was not received by community care licensing. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D.

Allegation: Insufficient Staffing. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was determined that in July 2024, R1 exited facility and continued to walk away from facility despite redirection attempts. It was further determined that staff on duty was unable to follow R1 for supervision and lost sight of R1 resulting in an absence of supervision. It was further revealed through interviews that at the time of the event, facility had one staff on duty temporarily as a scheduled one-on-one staff member assigned to R1 was late to arrive. Due to only one staff on duty, R1 was unable to be supervised during her absence without leave (AWOL) event, resulting in a lack of appropriate staffing and absence of supervision. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D.

Allegation: Personal rights were violated.LPA conducted interviews and record reviews as noted above. Based on interviews, it was revealed that on at least one occasion during an outing R1 was given access to a staff member’s private residence for purposes of using the restroom. It was further revealed through interviews that R1 was, as a result of this event, placed in an unfamiliar environment with access to various supplies presenting a potential risk to health and safety. The preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.