Complaint Investigation Report

LPA review of R1’s records revealed that R1’s medical assessment (LIC602A) dated 6/11/2025 states R1 is able to leave the facility unsupervised (considering physical and cognitive abilities). Interviews and police incident report reveal that on 9/12/2025 an employee of a commercial business approximately 0.7 mile from this facility called police when R1 entered the business and appeared confused. Police took R1 to a facility they previously lived at, the facility was able to assist police in contacting R1’s family, and R1’s family returned them to this facility the same day. Interviews revealed that on a day in March 2026 R1 left the facility unattended, when staff noticed R1 missing from the facility they went looking for them and found R1 on the sidewalk east of the facility approximately two houses down. Interviews revealed no knowledge of a third incident where R1 left the facility unattended. A review of reports received from the facility by Community Care Licensing (CCL) revealed the facility has not submitted reports for either of the two listed incidents. The Licensee states they have not documented either of these incidents.

An appraisal/needs and services plan for R1 dated 6/20/2025 does not mention any risks, non-risks or interest to R1 in leaving the facility unsupervised. A reappraisal dated 12/25/2025 states R1 is ambulatory and very independent; that all staff are to orient R1 to time, place and situation; and that all staff are to take R1 for a short walk. Staff interviews revealed that they do not think R1 is able to find their way back to the facility if they leave and the reason R1 needs to be oriented to time, place, and situation is because are confused at times. The Licensee states that R1’s primary care physician was made aware by family of the incident that happened on 9/12/2025, but that no staff notified the physician or requested an updated medical assessment. The Licensee states the physician has not been made aware of the incident that occurred in March 2026 and they do not know why they have not updated the appraisal/needs and services plan to reflect R1’s interest in leaving the facility unassisted and risk of elopement.

During the initial LPA visit on 3/11/2026 LPA requested the Licensee obtain an updated medical assessment from the physician and update R1's reappraisal. As of today's visit the Licensee has an updated medical assessment dated 4/30/2026 indicating that R1 is not able to leave the facility unsupervised and needs safety assistance. R1's reappraisal was updated with a date of 3/13/2026 stating staff are expected to increase visual checks of R1 and report increased wandering to the physician.