Complaint·May 12, 2026

Regarding allegation: Resident went AWOL while in care of staff resulting in nasal fracture and multiple injuries. It Is alleged that on 09/13/25 Resident #1 (R1) left the facility unattended, sustained a fall that resulted in a nasal fracture and bruises, subsequently being hospitalized. The investigation revealed the following: Interview conducted with Licensee revealed, licensee was called by Burbank Police Department and was notified that R1 was found and had gone missing from the facility. A caregiver from a registry agency was brought in to cover the shift. Based on interview with registry staff on 11/13/25, they stated they were not aware that the door alarm was not on. Caregiving agency staff stated they assisted R1 to sit in the living room as they assisted other residents and did not know R1 had walked out of the facility. When caregiving agency staff looked for R1 inside and outside the facility for 15 minutes, they received a phone call from the Fire Department, notifying them of R1’s hospitalization. Per caregiving agency staff, it was the responsibility of the previous shift staff to set the door alarm because caregiving agency staff did not know how to operate them. Per documents reviewed Physician’s report dated: 10/02/23 notes of dementia for R1. Incident report (SIR) dated: 9/14/25 submitted to the Department notes that on 09/13/25, a Caregiving Agency staff was called to provide care during the night shift, as facility’s evening shift staff had called out sick. SIR also notes, R1 had walked a distance from the facility and fell. A neighbor called 911, and R1 was taken to the hospital. Per Hospital Admissions Record dated: 09/13/25, R1 was admitted to the hospital on 09/13/25 after R1 sustained a ground level fall and was brought in by Emergency Responders (EMS). R1 was admitted to the hospital with an open fracture of nasal bone. Based on the information obtained, a Caregiving agency staff was covering the night shift on 09/13/25, during this shift R1 left the facility unattended, sustained a fall that resulted in an open nasal bone fracture. Therefore, the allegation is substantiated. Based on interviews and review of records obtained, 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, are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustaining an open nasal fracture while in care. Refer to LIC 421IM*** The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49 (f); if the department determines the serious bodily injury was due to neglect. Exit interview conducted and a copy of this report, LIC9099D, and appeal rights were provided.