Complaint Investigation Report

On March 10, 2025, the Department received an incident report for resident R1. The incident report stated the following: “On Saturday, 03/08/25 at approximately 2:40pm, R1, requested to take a nap in his/her bedroom…At 2:48pm, R1 opened the sliding door in his/her bedroom which leads to the back yard (R1 has one door/exit in his/her bedroom that leads to the backyard, while the other door/exit leads to the hallway inside the home). R1 then opened the side gate in the back yard and walked to the driveway in front of the house. At 2:49pm, a staff that was in the kitchen looked through the kitchen window and saw R1 outside and immediately redirected R1 back into the house. R1 went back into his/her bedroom and tucked him/herself back into bed. At 3:02pm, R1 opened the same sliding door in his/her bedroom which exits to the back yard and walked to the front yard via the side gate. At 3:05pm, staff went to his/her bedroom and noticed R1 was not in his/her bed. Staff walked throughout the house and checked all rooms and R1 was not in any of the rooms. They also checked the back yard and R1 was not there. Staff then walked to the front yard and saw R1 on the sidewalk of the next-door neighbor’s home. Staff immediately brought R1 back into the home…There were five staff on shift during the time of this incident…No injuries were sustained during this incident.”

On March 14 & 17, 2025, Licensing Program Analyst Manuel Monter interviewed Witness W1 and W2. Both Witnesses interviewed stated that on March 8, 2025, he/she observed resident R1 walking in the street, unsupervised. W1 stated W2 ran to the care home and informed the staff that R1 was outside the home, unsupervised. Witness W1 stated there was also an incident where resident R2 was observed outside his/her home on December 30, 2024.

On March 19, 2025, Licensing Program Analyst Manuel Monter interviewed staff S1-S3 regarding resident R1's elopement on March 8, 2025. All staff interviewed stated they were working on March 8, 2025. S1 stated R1 had initially made an attempt to elope, but staff redirected him/her. S1 stated the second attempt, R1 did leave the facility. S1 stated he/she noticed that R1's room was quite and noticed R1 was gone. S1 stated staff searched the home. S1 stated as he/she was headed towards the street, a neighbor had told him/her that one of the residents was alone and wandering. S1 stated he/she and S3 brought R1 back to the home.

Staff S2 stated he/she was supervising the residents when Staff S1 told him/her that R1 wasn't found in the home. S2 stated R1 was found outside the home by S1. Page 2 Out of 4.