complaint·September 9, 2025

Facility Supervisor (S2) and Administrator, Chukwudi “Patrick” Ikiseh (S3), both acknowledged that it was facility policy for the front door alarm to remain activated at all times, but it had not been turned on the night of the incident. S2 and S3 also admitted that the alarm was old, and staff sometimes forgot to use it, leaving the facility unsecure. Review of R1’s medical records confirmed that as a result of leaving the facility unsupervised, R1 sustained multiple serious injuries, including fractures to the cervical spine, nasal bone, nasal septum, and orbital roof, as well as facial bruising, resulting in hospitalization. Medical records and death certificate record further confirmed that R1’s injuries, combined with advanced dementia and lack of food and fluid intake, contributed to R1’s death on 5/8/2025. The evidence shows the facility did not ensure to provide proper supervision and security, which directly led to R1’s injuries, resulting in hospitalization and eventual death. Therefore, the allegation is SUBSTANTIATED. **************************************************************************************************************************** Allegation - Lack of supervision resulted in resident eloping from facility: The investigation into this allegation consisted of interviews and record reviews. On 4/30/2025, a resident (R1) was found outside in the roadway after leaving the facility unsupervised. Witness (W1) and police reports confirmed the facility’s front door was open when they arrived at the facility, and staff on duty, S1, admitted she had not checked on residents because she was “very tired.” Responding Police Officer (W2) confirmed S1 was asleep behind a locked garage door when W2 entered the facility. Supervisor (S2) and Administrator Chukwudi “Patrick” Ikiseh (S3) both acknowledged that facility protocol required the front door alarm to be turned on at all times, but it was not activated the night of the incident. S2 and S3 also admitted there was no system in place to document when the alarm was turned on or off, and staff sometimes forgot to use it. Interview with S3, suspected that R1 likely spent 30 to 45 minutes outside unsupervised before being found. Because the alarm was not activated and staff did not provide the expected supervision, R1 was able to leave the facility unnoticed, resulting in R1 being found injured in the street. The evidence demonstrates that the facility did not follow its own safety protocols, directly leading to R1’s elopement. Therefore, the allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. {9099-2} Deficiencies are being cited from the California Code of Regulations (CCR) and/or the Health and Safety Code. Immediate Civil Penalty is being assessed in the amount of $1000.00. At this time enhanced civil penalty assessments are under review and additional civil penalties may be assessed pursuant to Health and Safety Code 1569.49. An exit interview was conducted with S2 over the phone and a plan of corrections and appeal process were discussed. A copy of this report and appeal rights were provided. {9099-3}