complaint·August 9, 2024

On 12/7/2023, R1 eloped from the facility around 0930 hours. A review of Union City Police report indicates that the staff told police R1 possibly exited the facility through dining area sliding door. The police said that there were sensors on all of the doors that would ring when opened. However, the sensor was turned off on the sliding door in the dining area, and the backyard gate was open. R1 was found deceased by the railroad tracks. R1’s date of death as indicated in the death certificate is listed as “December 7, 2023 unknown hours.” The death certificate indicates “blunt injuries” as the cause of death, place of injury is “railroad track ballast in Union City” and description how injury occurred is “pedestrian struck by train.” R1’s 2023 Physician’s Report (PR) indicates R1 has Alzheimer’s Disease, confused and has wandering and sundowning behaviors with able to leave facility unassisted listed as “yes.” However, R1's 2022 Physician's Report (PR) from same treating physician indicates same diagnosis and behavior with able to leave facility unassisted as “no.” On 5/2/2024, LPA interviewed R1’s doctor regarding the two PRs. R1’s doctor stated that “….but considering R1 had dementia, R1 should not leave the facility unassisted.” Based on interviews and record reviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Sec 87705(b)(2) is being cited on the attached LIC 9099D. A Non Compliance Conference (NCC) is scheduled for August 15, 2024 to discuss plans of correction. Civil penalty determination related to serious bodily injury is pending. A copy of this report was provided to Bacani and Appeal Rights was provided.