Complaint Investigation Report

The allegation is that staff did not supervise resident R1, resulting in R1 trespassing onto neighbor's property.

On 02/20/2026, LPA interviewed Administrator (ADM) Fay Cacdac. ADM stated on 02/07/2026, Saturday, around 5:10PM, after resident R1 had snack in dining room and was walking back to his/her bedroom. Suddenly R1 rushed to the main door and exited. ADM stated two staff (S1, S2) followed R1 immediately to redirect him/her to get on facility VAN and offered R1 an outing to get something he/she likes. ADM stated R1 got on the facility VAN but then suddenly got off the facility VAN and ran to neighbor house. ADM stated two staff followed R1 immediately to the neighbor house. The two staff offered R1 cookies and redirected R1 returned to the facility. ADM stated before and on 02/07/2026, R1 had 2:1 caregivers Monday to Friday from 3:00PM to 7:00PM, and Saturday, Sunday from 9:00AM to 5:00PM.

ADM stated after the incident, R1 has 2:1 caregivers from 11:00AM to 7:00PM on Saturday, from 10:30AM to 6:30PM on Sunday., and Monday to Friday from 3:00PM to 7:00PM. ADM stated except R1's 2:1 caregivers, R1 also has 1:1 caregiver for 8 hours from Monday to Friday and 1:1 caregiver for 14 hours on Saturday and Sunday. ADM stated the facility has exit door alarms setup for 24 X 7.

LPA interviewed 3 staff (S3, S4, S5). 3 Out of 3 staff stated on 02/07/2026, R1 exited the facility and went to the neighbor house. 3 Out of 3 staff confirmed 2 facility staff followed R1 immediately to the neighbor house and redirected R1 back to the facility. 3 Out of 3 staff stated R1 does not behave aggressively and R1 does not hit or hurt others.

Based on review of R1's progress notes, on 02/07/2026, R1 exited the facility and went to the neighbor house. Two staff followed R1 immediately to the neighbor house and redirected R1 back to the facility.

Based on the review of incident reported dated 02/07/2026, on 02/10/2026, R1 went to neighbor house and two staff followed him/her immediately. The two staff redirected R1 back to the facility. No one hurt or obtained injuries. R1 rang the neighbor doorbell but did not enter the neighbor house.

Based on the review of the email log, the facility nurse and Board Certified Behavior Analyst (BCBA) reviewed and discussed on R1's medication regarding R1's behavior.