Complaint·October 7, 2025

Regarding allegation: Staff did not provide adequate supervision to prevent residents from eloping. It is alleged that a resident was missing since 07/20/2025. As of the date of submitting the complaint report to CCLD, the resident (R1) had not returned and was missing. It is alleged that R1 had recently shown to be having issues with cognitive decline and had been hospitalized twice. It is alleged that facility should have provided supervision to prevent R1 from eloping. The investigation revealed that record review indicated the R1 left facility on 07/20/2025 at approximately 11:00 AM. LPA interview with residents revealed that four (4) out of seven (7) residents were aware of a resident missing from the community. However, residents did not personally know R1. Residents became aware of R1 missing from other residents’ comments. LPA interview with staff revealed that six (6) out of six (6) staff were aware of R1 missing. Records reviewed revealed that based on R1’s physicians report dated 04/29/2025, R1 was not able to leave facility unassisted. Staff 1 (S1) stated that R1’s physician report dated 04/29/2025 indicated that R1’s inability to leave facility was because of physical condition and not because of mental disability. S1 provided a physician’s progress note dated 07/22/2025 indicating to the effect of R1’s physical limitation as the reason to not leave the facility unassisted. R1 returned safely to facility on 07/23/2025. On 07/29/2025, R1 was reassessed, and a new physician report was issued indicating R1 risk for elopement. Based upon the investigation, resident and staff interviews, document review, and LPA observations, the licensee did not ensure to follow physicians report to not allow R1 from leaving facility without adequate supervision even for reason of physical condition and not mental. Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC-9099D. Exit interview held with Director of Health Services Milca Osorio. A copy of the report and appeal rights were provided.