complaint·March 22, 2023

The investigation revealed the following: Regarding the allegation… Resident wandered away from the facility due to lack of supervision. It’s being alleged a resident walked out of the facility unsupervised and remains missing. LPA Agard interviewed 2 out of 16 staff in total. 2 out of 2 were able to confirm the allegation. S1 states, “R1 left and never came back. We called the police the same day. We’ve called the hospital. Every 2-3 days we call the police to get updates but still nothing. R1 didn’t say anything or sign out. They are independent in the community.” S2 states, “that day when staff checked, R1 wasn’t there. We checked everywhere. We waited a few hours to make sure because our residents go out. We called hospitals, the police department and so far, we haven’t heard anything. The police can’t even find them. During interviews with residents, LPA interviewed 5 out of 54 residents in total. 2 out of 4 confirmed the allegation. R1 was unavailable for an interview. R2 states, “I only know that they said were going to “Alvarado near MacArthur Park.” R3 states, “I’m not sure, the last time they eloped was about a year ago. They found them in some place called Alvarado near a park. R4-5 were unable to speak on the allegation. During a record, LPA reviewed R1’s physician report dated 01/01/2022 which indicates resident is unable to leave the facility unassisted. LPA reviewed R1’s resident appraisal dated 06/01/2022 which indicates residents need for special observation/ night supervision and help with moving about the facility. LPA reviewed R1’s needs and services plan dated 01/01/2022. Under the section functioning skills, it states: “R1 needs support with activities of daily living, is not able to go outside and needs assistance with medical and financial management. Based on the interviews with staff, residents and a record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is (are) found to be Substantiated . California Code of Regulations, Title 22 Division (6) and Chapter (8) are being cited on the attached LIC9099-D. An exit interview was conducted, and a hard copy was provided with appeal rights. See LIC 9009-D on the next page