Complaint·December 20, 2024

Allegation: Staff allowed resident in care to leave the facility without supervision. It is being alleged that R1 left the facility unassisted and was later found wandering the streets. On 12/20/24 between 10am- 11am LPA conducted an interview with Executive Director(ED) Suzette Johnson. Per ED Johnson, she was told that R1 informed staff that R1s partner would be coming by to pick R1 up, and R1 proceeded to make their way into the community. Per ED, the facility has procedures in place for when a resident is requesting to go out into the community. The reception desk will check August health to determine if a resident is able to go out without supervision, if a resident is not allowed, the resident is redirected. On 12/20/24 between 10am- 11am LPA conducted interviews with staff 1-staff 4 (S1-S4) reading the allegation. Of those interviewed, 4 of 4 staff denied the allegation and reported there is always a staff member at the front desk to ensure that residents who cannot leave the facility unassisted do not make their way out into the community. Per S1, residents who cannot leave the facility unassisted have an asterisk next to their name in the computer. On 12/20/24, between 11am-12:30pm, LPA conducted interviews with residents #2-3 (R2-R3). Of those interviewed, 2 of 2 residents denied the allegation and reported being unable to leave the facility unassisted. On 12/20/24 between 12:30pm-12:24pm LPA conducted interview with R1 regarding the allegation. R1 stated during the interview they walked right out the front door of the facility, unassisted by staff. On 12/20/24 LPA reviewed incident report sent to CCLD on 12/13/24. On 12/20/24 LPA conducted a records review for R1 and observed the physicians report, dated 09/13/24, which indicates resident has wandering behaviors and is unable to leave the facility unassisted. On 12/20/24 LPA reviewed Needs and Services plan, dated 09/13/24, which indicates that R1 had a wander guard device. On 12/20/24 LPA reviewed facility resident sign out sheet. Per the sheet, R1 was signed out by their responsible party on 12/11/24 at 10 am. On 12/20/24 LPA conducted interview with Witness 1 (W1), responsible party for R1. Per W1, they arrived to the facility around 1pm when it was determined R1 was out in the community and R1 was found at around 3pm. Based on LPAs observations, interviews and record reviews, 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. Exit interview conducted, appeal rights explained, and a copy of this report was provided.