complaint·August 24, 2023

Regarding Allegation #1 : Staff allowed resident to wander from facility resulting in a fracture. This complaint alleges resident R1 left the facility memory care unit and sustained an injury in the facility parking lot. On 11/23/2022 received and reviewed the department’s Investigation Branch (IB) Investigator Edward Hector report. The investigators report states: During the investigation I obtained and reviewed medical records. I interviewed the R1, R1 son and facility administrator and facility staff. All information and interviews confirm that R1 was assigned to secure and locked memory care unit. R1 absconded from the memory care unit and was later found outside in the parking lot of nearby facility with an ankle injury. R1 did not explain how R1 escaped the memory unit and staff have no information on how R1 got out without any alarms going off. There is sufficient evidence to support the allegation of lack of supervision”. Regarding Allegation #2 : Staff abandoned resident. This complaint alleges that the facility refused to allow R1 to return to the facility after a hospital visit. On 08/23/2023 LPA Calderon interviewed A1 Veronica Gomez and A2 Peggy Clark. A1 and A2 expressed that A1 went to the hospital to evaluate R1. A1 and A2 expressed that R1 had been very aggressive with staff and other residents striking staff and residents. A1 and A2 expressed that A1 evaluated R1 and R1 was very aggressive at the hospital. A1 and A2 expressed that due to R1 being very aggressive with staff R1 was not allowed to return to the facility. On 08/17/2023 LPA Calderon interviewed A1(Gomez) for complaint. A1 (Gomez) expressed that R1 was taken to the hospital for R1 left ankle injury after leaving the memory care unit and being found in the facility parking lot. A1 (Gomez) expressed that A1 went to the hospital to evaluate. A1 (Gomez) expressed that R1 was combative with A1, urinated on the floor and needed more care than the facility could provide. A1 (Gomez) expressed that R1 was moved to Saint Edna’s in the city of Santa Ana for further care and never returned to the facility. A1 (Gomez) expressed that the facility would never abandon a resident in the hospital without evaluating a resident for additional medical care and informing R1 family. On 07/10/2023 LPA Calderon interviewed S1-S4 for complaint. S1-S4 expressed that R1 was found in the facility parking lot with a left ankle injury. S1-S4 expressed that it is normal for staff to evaluate a resident that is taken to the hospital for further care prior to the resident being returned to the facility. S1-S4 expressed that they have no knowledge as to why R1 was not returned to the facility. On 02/08/2023 LPA Calderon interviewed R2-R13 for complaint. 12 out of 12 residents expressed that staff would not abandon them at a hospital. On 10/03/2022 LPA Calderon reviewed South Coast Medical Center report (09/17/2022). “R1 was diagnosed with health issues”. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) “staff allowed resident to wander from facility resulting in a fracture” “staff abandoned resident” is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Administrator Peggy Clark (A1).