Complaint Investigation Report

Law enforcement deputies arrived at the elopement location and recognized the subject as C1 who had previously been located at the same location from an elopement in August 2023. During follow up at the facility by Law Enforcement on 06/29/2024 after C1’s elopement, it was reported that C1 was allegedly able to leave the residence because one facility Staff member was asleep and the other was watching their cell phone and not paying attention to their surroundings. A subsequent UIR reported by the facility to the Department on 07/01/2024 stated that Staff did not know that C1 had eloped from the facility until returned by Law Enforcement. The documented facility "line of sight requirement" for C1 states that Law Enforcement must be contacted if C1 is unsupervised and out of sight of Staff. Law Enforcement was not contacted at any time by Staff during the elopement of C1. LPA was informed by the Licensee that the same employee was on duty during the elopement by C1 in August 2023 and the recent elopement on 6/29/2024. C1 stated to Law Enforcement that they were almost hit by car during elopement on 06/29/2024.

On 07/09/2024, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility unannounced to conduct an initial complaint visit. The LPA conducted a physical tour to make sure the auditory alarm systems in place in the facility were in working order. The LPA also requested and received documents pertinent to the complaint allegation. The Tri-Counties Regional Center (TCRC) Resident Placement Information, dated 02/25/2019, indicates that C1 has a propensity for wandering/AWOL behavior that requires constant redirection to keep the client and others safe. The Functional Capability Assessment for C1 dated 04/29/2024 indicates C1 is required to have "Line of Sight" supervision that has a protocol to inform Law Enforcement. The TCRC Individualized Program Plan (IPP) for C1 states that C1 needs a high level of care and close supervision throughout the day. C1 requires proximity of support to avoid elopement. The current auditory alarm system in place on doors that exit the facility was observed to be in sufficient working order and appropriate level of noise. The facility has a documented Behavioral Consulting Missing Person’s Plan/Elopement Plan for C1, updated as of May 2023, that provides a protocol for Staff when C1 leaves without supervision and is in sight of Staff, or when C1 leaves without supervision and is out of sight of Staff. Through interview with facility Staff, Law Enforcement, and record review, LPA learned that C1 has a documented history of wandering behavior/elopement known by the facility and Staff on duty during the elopement of C1 on 06/29/2024. C1 has a current documented facility Missing Person’s Plan/Elopement Plan that was not followed by facility Staff.

Based on the information obtained, there was sufficient evidence to show Staff did not provide adequate care and supervision to a client. Therefore, the allegation is deemed Substantiated at this time. Contd. 9099-C