complaint·October 29, 2024

The investigation revealed the following: Regarding allegation: Facility staff did not provide adequate supervision resulting in a resident eloping from the facility. It is alleged a resident with dementia went missing for several hours. On 9/27/24 around 12:30pm R1 left the facility unattended with another resident. R1 did not return to the facility. Per administrator the facility’s policy is 24 hours to report the resident missing. Med-tech checked for R1 the morning of 9/28/24, R1 was not found. Med-tech contacted Pasadena police department to file a missing person report. A few hours later administrator was informed by Pasadena police department that they responded to a call for a person that seem to be confused around Del Mar and San Marino. Once the description was matched administrator and another staff went to pick up R1 around 11:00am from the area and returned R1 to the facility. No medical assessment was conducted. Interviews conducted with staff revealed R1 seems forgetful. However, staff believe R1 does not have dementia. Per staff, they know that R1 should not leave the facility unattended and when they see R1 in the lobby they redirect R1 to either R1’s room or dining room. LPA was unable to obtained information regarding the incident as R1 did not recall the incident. R2 who left the facility with R1 stated that when they were out R1 wanted to go for a walk, and they parted ways. Documents review revealed, two physician’s reports were obtained by LPA for R1; physician’s report dated: 8/21/23 notes R1’s has dementia and cannot leave the facility unattended. Physician’s report also dated: 8/21/23 obtained at the facility notes R1 has mild cognitive impairment and cannot leave the facility unattended. Medication sheet for September notes R1 is taking a medication prescribed for cognitive impairment. Therefore, the allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. *Immediate $500 Civil penalties were assessed due to lack of care and supervision.* Exit interview was conducted with Lydia Pabion and a copy of this report, LIC 9099D, and appeal rights were provided.