complaint·January 16, 2024

The investigation consisted of the following: Regarding allegation: Resident eloped from facility. It is alleged R1 was lost during the summer of 2022 and picked up by police. Interviews conducted revealed the following: Administrator stated R1 is not a wander and does not leave the facility unattended. Interview with staff revealed R1 has not left the facility unattended, due to R1’s sight tends to wander inside the facility. However, with redirection R1 finds way back to where R1 needs to go. Interview with R1 revealed, R1 does not leave the facility and does not feel comfortable leaving due to R1’s sight not being great and not knowing the area. Interviews with other residents revealed those that are able to leave the facility unattended do. Upon leaving the facility they notify the staff and when they return they let staff know they are back. Documents reviewed revealed: Incident Report dated 7/4/22 notes R1 went out with another resident on 7/2/22 and did not return to the facility, due to a disagreement between the two residents. The following day R1 continue to be out of the facility. Facility staff proceeded to call hospitals and Pasadena Police Department. It was found R1 was taken to the hospital due to sustaining a fall. R1’s responsible party was notified, who requested R1 not go out due to R1 not being familiar with the area. Physician’s report dated 5/6/22 notes R1 cannot leave the facility unassisted due to visual impairment. Although R1 left the facility with another resident. R1 was not assisted by a staff or responsible party. Therefore, allegation of resident eloping is substantiated. Based on LPAs interviews and record review which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to absence of supervision. Refer to LIC 421IM*** Exit interview was conducted with Maria Razo and a copy of this report, LIC 9099D, and appeal rights were provided. The investigation revealed the following: Regarding allegations: Facility abandoned resident at hospital. It is alleged hospital has attempted several times to call facility and was not able to communicate for discharge. During file review conducted on 2/14/23 there were only 2 residents that went out to the hospital during the time of the allegations and per the allegations only R1 meet the criteria for allegations. Interviews conducted revealed: Administrator maintains a group chat to communicate with care staff regarding sending or discharge of residents to and from hospital. Phone lines have been working. Interviews with residents revealed to not have heard of residents having difficulties returning to the facility upon discharge. Interviews with staff revealed staff are aware when residents go and return form the hospital and keep a chat that notifies each other when a resident is being discharge back to the facility. As well as reception staff respond and are notified by the hospital when a resident is being discharge back to the facility. Documents reviewed for R1, reveal R1 has gone out to the hospital twice, on 1/17/23 and on 2/3/23 for the same health complaint. Huntington Hospital Medical Records subpoena for R1’s visit on 2/3/23 revealed no notes that determined facility was not responding hospital for discharge noted. R1 was discharge back to the facility on 2/8/23. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Maria Razo and a copy of this report was provided.