complaint·March 11, 2022

The investigation revealed the following; Allegation: Resident eloped from facility. Based on interviews conducted and record reviews, LPA discovered that R1 was discharged from LAC-USC on 3/7/22 and transferred to Pasadena Villa Senior Living (PVSL). R1 was admitted to PVSL on 3/7/22, at approximately 2:45pm (Note: R1 was not a resident of PVSL prior to 3/7/22). Shortly after being admitted to PVSL, R1 is observed (in surveillance video at 4:17pm) leaving the facility through the front door without staff supervision. Facility staff did not witness R1 leaving the facility and it wasn't until later, while conducting room checks when staff discovered R1 had eloped. A missing person's report was filed with the Pasadena Police Department on the evening of 3/8/22 and R1 was found by Officers a few blocks away from the facility on the morning of 3/9/22, at approximately 9:30am. R1 has not returned to PVSL and is currently staying with family. Per the physician's report dated 3/1/22, R1 is not able to leave the facility unassisted. R1 eloping from the facility poses an immediate health and safety risk to R1. Based on LPA’s observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is 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. The investigation revealed the following; Allegation: Facility did not report resident missing. Based on interviews conducted and record reviews, LPA discovered that R1 was discharged from LAC-USC on 3/7/22 and transferred to Pasadena Villa Senior Living (PVSL). R1 was admitted to PVSL on 3/7/22, at approximately 2:45pm (Note: R1 was not a resident of PVSL prior to 3/7/22). Shortly after being admitted to PVSL, R1 is observed (in surveillance video at 4:17pm) leaving the facility through the front door without staff supervision. Facility staff did not witness R1 leaving the facility and it wasn't until later, while conducting room checks when staff discovered R1 had eloped. On 3/7/22, the Responsible Party / Family Member of R1 was notified by the Assistant Administrator that R1 had eloped from the facility. There was a discussion between the Responsible Party / Family Member and the Assistant Administrator that only one person would need to file the missing person’s report and the Responsible Party / Family Member stated that she would be filing the missing person’s report for R1. A missing person's report was filed with the Pasadena Police Department on the evening of 3/8/22 and R1 was found by Officers a few blocks away from the facility on the morning of 3/9/22, at approximately 9:30am. R1 has not returned to PVSL and is currently staying with family. Based on interviews conducted, LPA learned that there was an understanding between Facility Staff and the Responsible Party / Family Member of R1 on who would be filing the missing person's report to Law Enforcement therefore facility is not in violation for not reporting R1 missing to Law Enforcement. 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 and a copy of this report was provided to the Assistant Administrator.