complaint·August 25, 2025

Lack of supervision resulting in a resident eloping from the facility. On the allegation that lack of supervision resulted in a resident (R1) eloping the facility, it is the concern of the RP that R1 was found wandering the streets on 08/19/2025, was picked up by Los Angeles Fire Department and transferred to a medical facility for observation and care. LPA Urena interviewed the RP, and the interview revealed that R1 stated that they have left the board and care facility at least three (3) prior times and the staff usually finds them, and R1 goes back with staff. The Administrator’s interview revealed that they were aware that R1 had eloped the facility, and that they had not reported the incident to the Community Care Licensing Division (CCL) because the Social Worker for R1 had contacted them within 48 hours. The Administrator stated that R1 had eloped on Thursday 08/21/2025. The LPA interviewed the staff (S1) and S1 stated that R1 had eloped on Tuesday (08/19/2025). The staff stated that they noticed that R1 had eloped the facility on 08/19/2025 between 6:00 p.m. and 7:00p.m., was not sure of the specific time, but knew it was before dinner. S1 did not see R1 leave the facility. S1 stated that they were assisting another resident, and after they finished assisting the other resident, they realized that R1 was gone. Per S1, R1 exited the facility through the side gate, which the R1 knows how to deactivate the signal system. S1 stated that R1 has attempted to elope before, but they usually catch R1 and stop them by redirecting R1 back to the facility. Furthermore, S1 stated that they informed the Administrator right away after they noticed that R1 was gone and could not find them. LPA was able to obtain the contact number for the SW and reached out to them. Per the SW, they are not R1’s SW, they work for a health care center where R1 was previously admitted. Record review of LIC 602 (Physician’s Report) reveals that R1 cannot leave the facility unassisted. Based on the information obtained through interviews and record review, the allegation that staff’s lack of supervision resulted in R1 eloping from the facility, is deemed to be Substantiated at this time. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiency may result in civil penalties. Citations were issued. Exit interview was conducted with Amy Vetinyan, the Administrator's acquaintance due to the Administrator being unavailable via person or telephone. The Administrator allowed the staff to sign off on the report. A copy of the report and Appeal Rights were issued.