complaint·October 3, 2024

The investigation revealed the following: In regards to the allegation: “Staff did not adequately supervise resident in care resulting in resident wandering from the facility.” It is alleged that R1 was wandering into the traffic and put herself in harm’s way. Interviews with S1-S2 corroborated the allegation. S1 stated that the incident happened early evening on 09/30/2024. S1 indicated that R1 was admitted to the facility recently. S1 stated that what she thinks happened was that R1 went out the back gate and the alarm did not go off. S1 showed LPA how the back gate’s alarm work and it involved 4 steps to secure the gate. S1 indicated that someone must have missed a step or two in locking it, hence the alarm failed to go off. LPA observed that the back gate leads to a driveway towards the main road next to the freeway. Interviews with W1-W2 also corroborated the allegation. W1 stated that she drove around to help in locating R1 and was handed over to her by the authorities and W1 took R1 back to the facility. W1 indicated that she did not observe injury on R1. W2 stated that she called the facility and 911 to report that a resident was walking next to the freeway. Interviewed staff stated that they conducted a body check and assessed R1 as soon as she returned to the facility. LPA interviewed R1 who cannot recall the incident. Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provid ed to Lisa Gomez, Administrator along with the Appeals Rights.