complaint·August 15, 2025

The facility staff searched the entire building and drove around the streets but could not find R1. Staff contacted the police to file a report the same day. The administrator noted that R1 was found by the police on 8/6/25 approximately 4pm and is temporarily in a rehabilitation facility. Based on information gathered, R1 had gone missing in the past while out with another resident. Staff had not observed any changes in R1 and stated that R1 usually does not leave the facility. Staff are aware that R1 cannot leave the facility unassisted and did not know why R1 left without informing anyone. LPA reviewed R1’s physician’s report, and it indicated that the resident is not able to leave the facility unassisted. Residents interviewed stated that the staff monitor who enters and leaves the premises. Four (4) residents who can leave the facility will sign out when or if they do, and one, who cannot leave the facility unassisted, only goes out in the community with a staff member. Based on interviews conducted and record review, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Correction was reviewed and developed with the administrator. A copy of this report and appeal rights were provided.