complaint·July 5, 2023

Allegation: Staff did not prevent resident from wandering from facility During the course of this investigation, LPAs interviewed the Administrator, S1 and reviewed R1's file and obtained relevant documentation pertaining to this allegation. Interview with the Administrator and S1 revealed R1 moved to this facility in November 2022. Interviews with staff revealed that R1 could not leave the facility unassisted due to head trauma. LPAs were also informed that R1 did not have a history nor showed signs of wondering out. Moreover, interviews with the Administrator and S1 confirmed that on 06/25/23 around 12:30pm, R1 went missing. Staff did not realize R1 was missing until 1:00pm. Once staff realized R1 was not at the facility, staff conducted a search within this facility to locate R1. The search was unsuccessful as R1 was nowhere within this facility. In addition, LPAs were informed that an incident report was submitted to LA County at 11:30pm, and on 06/26/23, the Administrator contacted the Police Department to file a Missing Person's Report. Lastly, LPAs were informed that on 06/28/23 at 11:45am, S1 observed R1 walking across the street from the facility. S1 immediately assisted R1 back to the facility. Although, R1 refused to go to an Emergency Room, 911 was requested by the Administrator and R1 was taken to the hospital and released on a following morning (06/29/23). Based on information obtained from records review and interviews, the above allegation is deemed Substantiated. Allegation: Staff did not notify authorities that resident was missing It was reported that on 06/25/23, R1 went missing from the facility and did not return until 06/28/23. Although, interview with the Administrator revealed that the LA County and the Police Department were immediately notified regarding R1's elopement, LPA reviewed Incident Reports submitted to the Regional Office and did not observe a copy of R1's incident on file. Based on interviews and record reviews, the above allegation is deemed Substantiated. Deficiencies documented on 9099D. Exit interview conducted, appeal rights explained and copy of this report signed and delivered.