complaint·March 15, 2025

During the physical plant tour, LPA observed that all residents were clean, well-groomed and did not show signs of physical abuse. Record review revealed that R1 has a history of self-harming behavior. A review of the Department’s Incident Report records did not show that resident had any wandering incidents or physical incidents with staff. During interviews with staff, all staff stated R1 has never had a physical altercation with them or know of any other staff that has harassed or hit R1. During interviews with residents, all residents stated staff do not harass or hit them. Based on observations, interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation will remain UNSUBSTANTIATED at this time. ---Staff did not treat resident with dignity and respect. It was alleged that facility staff are evil people. To investigate the allegation, on 03/13/2024 LPA Rosaura Valenzuela interviewed staff from 10:45a.m. to 11:15a.m. and reviewed facility documents from 11:30a.m. to 12:00p.m. On 03/15/2025, LPA interviewed three (03) additional staff from 11:00a.m. – 12:30p.m. and six (06) residents from around 1:00p.m. to 2:30p.m. Records revealed that R1 has a history of multiple psychiatric hospitalizations. During interviews with staff, all staff stated they treat all residents with dignity and respect. During interviews with residents, all residents stated staff treat them with dignity and respect. LPA was unable to interview R1 as they were not in the facility at the time of the visit. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation will remain UNSUBSTANTIATED at this time. --- Due to lack of supervision resident wandered away from facility. It was alleged that R1 eloped from the facility. To investigate the allegation, on 03/13/2024 LPA Rosaura Valenzuela interviewed staff from 10:45a.m. to 11:15a.m. and reviewed facility documents from 11:30a.m. to 12:00p.m. On 03/15/2025, LPA Duguma conducted a physical plant tour and requested documents at around 9:30a.m., interviewed three (03) additional staff from 11:00a.m. – 12:30p.m. and six (06) residents from around 1:00p.m. to 2:30p.m. A review of the facility logbook shows that R1 left the facility without signing out. (CONT. on LIC9099-C) A review of R1’s Physician’s Report revealed that resident is able to leave the facility unassisted. A review of the Department’s Incident Report records did not show that resident had any wandering incidents. During interviews with staff, Staff #1 (S1) stated Residents are free to come and go as they please. S1 added on 2/19/24, R1 left the facility and did not use the sign out book. After 24 hours had passed, S1 contacted the Glendale Police Department and filed a missing person's report. S1 stated R1 returned to the facility on 3/04/24. All other staff stated to their knowledge, R1 is able to leave the facility unassisted. LPA was unable to interview R1 as they were not in the facility at the time of the visit. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation will remain UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.