Complaint Investigation Report
It was alleged that the staff did not adequately supervise resident resulting in resident (R1) wandering away from the facility.
Based on review of the police report records, it’s noted that R1 was found about 0.2 miles away from the facility running through the parking lot of the shopping center.
On 01/30/2025, staff members and the Licensee were interviewed. Based on staff interview 2 staff were working during the time of the incident. It was stated that on 01/23/2025 R1 left the facility from his/her side door and jumped the fence to go to a sandwich shop across the street of the facility.
2 out of 2 staff stated that they were cleaning and assisting other residents when R1 exited the facility. When staff noticed R1 was missing, staff went to look outside and saw an employee of the sandwich shop waving them down to come there.
The Licensee stated that R1’s new behavior of leaving the facility began in the beginning of January 2025. Licensee states that they were addressing the behavior by talking to the doctor, following up with R1’s case manager, and they were waiting for R1’s insurance to approve a 1:1 staff. Licensee states that R1’s bedroom door does not have door alarms but stated a plan to buy door alarms for his/her room due to his/her exit-seeking behavior. Licensee also stated a plan to replace the battery for the door alarm at the front door to help notify staff when someone opens the doors.
Based on interview with resident (R1), it was stated that he/she likes to leave the facility at least twice a week to go across the street by him/herself, without staff supervision.
The review of R1’s records indicates that R1 is not able to leave the facility unassisted.
On 01/30/2025, LPA observed that R1’s bedroom is located right next to the front door entrance of the facility. The front door alarm was not operable. R1’s private bedroom has a sliding door which leads to the side of the facility. R1’s sliding door had a door alarm, but the door alarm was not operable. Page 2 of 3.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction