complaint·October 31, 2023

The investigation revealed the following: Regarding allegations: Resident wandered from the facility due to lack of staff supervision and Resident sustained a fall resulting from lack of staff supervision. It is alleged R1 exited the residential care facility unsupervised and subsequently fell 3 blocks north of the location and was later transported to the hospital. Documents reviewed revealed; On 3/5/23 Pasadena Police Department officers responded to a report of an individual who had fallen on the sidewalk, upon responding the individual was identify as R1 and per protocol transported to the emergency room at Huntington Hospital for an evaluation. Incident report dated 3/7/23 notes R1 left the facility on 3/5/23 at 5:16pm and was taken to the hospital due to a fall. Physician’s report dated 2/2/23 notes R1 has dementia and cannot leave the facility unassisted. Hospital discharge dated 3/5/23 notes R1 was evaluated for brain and cervical trauma and was discharge back to the facility on 3/6/23. On 3/6/23, S2 was given a warning with a (3) three-day suspension for “danger of resident going out the front desk door”. LPA attempted to interview R1 however due to cognitive skills was not able to obtain information. Interviews with staff determined the incident did happen and corroborated that R1 fell down upon leaving the facility unassisted. Per S2, forgot to turn switch to lock the front door and did not notice when R1 left the facility. Upon caregivers inquiring S2 reviewed video footage and saw R1 leave the facility, notify other staff and went out looking for R1. S2 noticed people and police officers assisting R1, who was on the floor, and was transported to the hospital. Based on LPAs interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Virginia Garcia and a copy of this report, LIC 9099D, and appeal rights were provided.