Complaint Investigation Report

On January 28, March 21 and April 1, 2025, the Department interviewed staff S1-S11. Staff S1-S3 and S8 stated they are unaware of any incidents of residents eloping from the facility. Staff S4, S6 and S7 stated they are aware of an elopement that occurred when R1 jumped over a fence. (This elopement is being investigated under a separate complaint investigation: 26-AS-20220913094545). Staff S5, S9-S11 stated they are aware that R1 eloped from the facility on 2 different occasions but don’t know the details. Staff S1-S11, stated they have not seen a resident running in the streets naked.

Staff S6 stated the was an elopement that occurred on May 29, 2023, where R1 trespassed onto a neighbor’s property at 11:50am. S6 stated this elopement occurred without staff supervision.

The Department interviewed residents R1-R4. All residents interviewed were unable to provide answers to LPA's questions. Residents interviewed had behaviors such as, but not limited to; not talking or responding to questions LPAs posed/ continuing to watch/play on their iPad/television.

Licensing Program Analyst Manuel Monter interviewed ADM. ADM stated she wasn’t at the facility when the elopement occurred on May 29, 2023. ADM stated she only knows what was reported to her and what was written on the incident report. ADM stated the facility did implement changes outlined in the incident report.

On April 1, 2025, LPA Manuel Monter interviewed witnesses W1 and W2. W1 stated he/she has not observed residents eloping from the facility. W2 stated he/she is aware of incidents were R1 eloped from the facility a few years ago but couldn’t provide details. W1 and W2 stated they have not seen residents running in the street naked.