Complaint·May 25, 2021

In regards to the allegation "Staff failed to supervise resident resulting in resident wandering away from facility" it was alleged that the facility staff did not supervise R1 enough which resulted in R1 leaving the facility and going missing. Review of R1's document reveal that R1 has a medical diagnosis that requires staff supervise and monitor R1. Interviews with staff show that on 5/2/21 R1 left the facility without the knowledge of staff and did not return. On 5/8/21 R1 was admitted to Lakewood Regional Hospital and would not be returning to this facility. LPA confirmed that R1 was admitted on 5/8/21 and released to a skilled nursing facility on 5/12/21. From this investigation it was revealed that staff failed to provide supervision to R1 resulting in R1 wandering away from the facility and being admitted into a hospital. Based on LPAs 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 & Chapter number), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator along with the Appeals Rights. (5) of (5) staff interviewed deny the allegation. (2) of (2) residents interviewed could not corroborate the allegation. Documents from R1's file show that R1 does not have an emergency contact information of any family member on file. R1's file shows that R1 is responsible for themselves as well. interviews conducted do show that Assistant Administrator Darolyn "Dee" Azevedo did contact a family member of R1 on 5/5/21 to notify of the incident even though R1's files do not show that family members information. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Assistant Administrator / Darolyn "Dee" Azevedo and a hard copy of this report was provided.