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 ensure that facility fences were repaired. 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.

The above substantiated allegations of similar nature were already investigated and cited in complaint #27-AS-20250819124925, as a result no citations issued today. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights provided.