Complaint Investigation Report
415601126-7-20-2023-14-AS-CSMH-CU2T73-20230724142805
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
SF COASTAL AC/SC , 851 TRAEGER AVE., SUITE 360
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/14/2023 and conducted by Evaluator Komal Charitra
COMPLAINT CONTROL NUMBER: 14-AS-20230714123226
Staff did not prevent resident from eloping
On July 20, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Operations Specialist, Kathleen Calobeer and explained the purpose of the visit.
Regarding the allegation that staff did not prevent resident from eloping, according to the reporting party, on July 12, 2023, Resident 1 (R1) left the facility unassisted. The reporting party indicated, that he/she called the facility to confirm that R1 had no restrictions to leaving the facility. According to the concierge, he/she confirmed R1 lives in assisted living and there are no restrictions in R1's file restricting him/her on leaving unassisted.
During the investigation, LPA reviewed R1's file and interviewed staff. Based on R1's file, R1 has a secondary diagnosis of dementia and is unable to leave the facility unassisted. According to staff interviewed, R1 leaves the facility after signing out and staff do not accompany or redirect him/her. In addition, it was indicated by staff interviewed that this has not been the first time R1 left the facility unassisted. Furthermore, based on observations, LPA observed a resident service plan binder on the front desk that indicate whether each resident is able to leave the facility unassisted or not. R1's service plan was observed to indicate R1 is unable to leave the facility unassisted.
Therefore, the allegation staff did not prevent resident from eloping is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.
Report is reviewed with Operations Specialist and a copy is provided with appeal rights.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction