Complaint Investigation Report

(Page 2) Report continued from LIC 9099...

On 12/02/2024 the Department received a complaint regarding the following allegation Staff are not providing adequate supervision for residents in care. On 12/06/2024 LPA Brian Balisi conducted the initial 10-day complaint visit. At approx. 12:40pm, LPA conducted a physical plant tour, interviewed one (1) staff, and the Administrator, reviewed and obtained copies of pertinent documentation relevant to the investigation. On 3/13/2025 at 11:25 a.m. LPA Mosley conducted a telephonic interview with Witness #1 (W1) who provided Ring video footage of the incident. On 4/15/2025 starting at 5:07p.m. – 5:40p.m. LPA Mosley conducted three (3) telephonic interviews with staff.

During today’s visit, at 9:50 a.m. LPAs conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations. Starting at 9:37 a.m. LPAs conducted an interview with (1) staff and Administrator, brief file review and obtained copies of pertinent documents relevant to the investigation.

On the allegation Staff are not providing adequate supervision for residents in care it is the concern of the reporting party (RP) that the facility staff did not adequately supervise Resident #1 (R1), who was left unattended in the community, leading to intervention by local law enforcement. To investigate this complaint, LPAs conducted in person interviews with two (2) staff and the Administrator, telephonic interviews with three (3) staff and W1,reviewed documents and video footage relevant to the investigation. Video footage obtained revealed that the incident occurred on 11/29/2025 at 13:16:20 PST – 13:17:27 PST where R1 is at the front door of a neighboring home unattended by staff. From the video footage there were no staff in sight. Interview with staff revealed that R1 had eloped and was unsupervised by staff. R1 returned to the facility by police escort. Interview with the Administrator revealed that R1had eloped without staff knowledge and returned by police escort. Interview with W1 revealed that R1 was out in the community without any staff supervision. Record review revealed that R1 requires one to one supervision 24 hours a day. Based on interviews, video footage, and file review there is sufficient evidence to support the allegation occurred. Therefore, the allegation Staff are not providing adequate supervision for residents in care is deemed substantiated at this time.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and / or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. Report was reviewed. A copy and appeal rights were issued.