complaint·July 11, 2024

into the neighbors' yards and collecting dried leaves, fallen flowers, rocks, twigs and going into neighbors trash cans and taking out discarded items such vases and picking up discarded furniture and taking it back to the facility. Resident #1 elopes very fast from the facility in bare feet and without the staff's knowledge. Resident #1 sustained a foot injury as a result of wandering around barefooted. Per interviews conducted with the Administrator, Resident #1 would elope for only a few minutes before staff realizes that Resident #1 is gone and they will look for her and bring her back. Upon inquiry about auditory devices on all 5 outside exiting doors, the Administrator admitted they used to have them on the doors but they were removed. Per statement received from Witness #1, they have observed Resident #1 alone on multiple occasions , wandering around in the neighborhood collecting leaves, rocks, flowers and un-escorted. Per review of Resident #1's file, the physician has determined that Resident #1 is not able to leave the facility unassisted. Per interview with Witness #2, they arrived at the facility on 7/9/24 for a visit and saw Resident #1 rummaging through the trash cans placed outside the facility with staff close by re-directing the resident. Resident #1 was observed with dirty nails and matted hair. Per interviews conducted, Resident #1 refuses to shower and refuses to have the injured foot treated. Witness #2 also believes that Resident #1 may have also shoved a staff. Per the Administrator, due to this unusual behavior, she has had a discussion with Resident #1's conservator and social worker and they all agreed that Resident #1 be sent to the hospital to be assessed for possible infection and medication adjustment. Resident was taken to the emergency room by the Administrator on 7/10/24 and was still hospitalized as of today's visit. Witness #2 confirmed that upon discharge, arrangements have been made to relocate Resident #1 to the facility's sister facility. Based on the interviews conducted and file review, there is sufficient evidence to support to the allegation that staff do not provide adequate care and supervision to a resident. Deficiencies cited under Health and Safety Code, Title 22, Division 6, Chapter 3.2 Exit interview was conducted, Appeals Rights discussed and a copy was provided.