Complaint Investigation Report

Staff reported R1 was back inside facility by 9:10pm. Based on interview and record review, it was revealed that R1 was absent without supervision for approximately 15 minutes. It was further revealed through interview that R1 eloped due to inadequate supervision in that staff was given a break without adequate coverage to ensure R1's safety and whereabouts. No injuries resulted from this elopement event. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation: Staff did not properly report incidents involving a client. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, R1 eloped from facility on 8-2-2025. Incident was not reported as required immediately to Administrator or within 48 hours to regional center as required by their applicable laws and regulations. Incident was reported to Licensing department within regulatory time frames. Incident report submitted by facility regarding this incident stated: "The incident was not reported to administration or VMRC (regional center)." As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation: Staff did not ensure the facility grounds are properly secured. LPA conducted interviews, record reviews, and facility observation as noted above. Based on interviews and record reviews, it was revealed that on 8-2-2025, R1 eloped from facility and found in a neighbor's yard fully disrobed. It was further revealed that R1 was without supervision for approximately 15 minutes. On 8-27-2025, LPA observed multiple fenced boards down with neighbor's yard exposed and accessible on left side of facility's property. LPA observed unfilled pool located on neighbor's property. It was further observed that this area of the facility is accessible to residents in care. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Citations are issued under Title 22, Division 6 and noted on LIC 9099D. An immediate civil penalty in the amount of $1000 is issued as a result of absence of supervision occurrence. An exit interview was held with lead staff Jill Lahman as administrator designee departed prior to the completion of this report, and gave permission for lead staff to sign in her absence. LIC 811 and appeal rights provided.