Complaint·May 5, 2023

The investigation revealed the following: 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 immediate Civil Penalty of $500.00 is being issued today, due to the lack of supervision resulting in R1 leaving the facility and being hospitalized. Refer to LIC 421IM* Facility was informed that a civil penalty may be assessed based on health and safety code 1569.49 (e)or (f), or 1548 (e) or (f), 1568.0822(e) or (f)." An exit interview was conducted. Appeal rights were provided and discussed. A copy of this report was provided as well.