complaint·December 23, 2024

The liquor store manager confirmed seeing R1 walking outside of the facility the night of incident. Staff interviewed reported last seeing R1 at around 8 PM and did not see them again until approximately 9:20 PM when R1 was brought back by an unknown stranger. Staff had failed to notice R1 was missing during this time. One of two staff on duty that day admitted staff often turn off the auditory alarm to the emergency exit door located in the building and confirmed the alarm to the door was turned off at the time of R1’s elopement. One of two staff interviewed reported it being difficult to hear alarms due to the noise levels and location of R1’s bedroom. The facility is not approved for a locked perimeter exterior, however, two of two staff interviewed reported observing other staff propping the gates open for easy access in and out of the facility. R1’s family arrived at the facility at approximately 9:30 PM. Upon arriving R1’s family stated R1 had major bruising to their face, chest, hands and arms in addition to having a front right tooth completely knocked out, left front tooth loose and bottom teeth sore and cracked. After consulting with R1’s hospice nurse, 9-1-1 was called. R1 was taken to UCI Medical Center due to the severity of injuries sustained where they were admitted at 11:14 PM and diagnosed with bruising to the chin, tooth avulsion and maxillary ridge fracture of the mouth, blunt trauma to the torso, organ injury and cardiac contusion and a skull fracture. A meeting was held with facility management and R1’s family where it was disclosed that R1 had actually fallen outside of the facility grounds and an unknown man had brought them back to the facility despite initially saying the fall occurred at the facility. Two of two staff confirmed lying to R1’s family and that they were pressured to do so by the facility management. R1’s family reported management admitted to lying regarding the circumstances of R1’s fall during their meeting. Therefore, based on interviews conducted and records reviewed, the preponderance of evidence has been met. The allegations that staff did not provide adequate supervision resulting in resident wandering away from facility and causing resident to sustain multiple fractures and injuries; Staff did not provide resident’s authorized representative with the correct information of incident; Staff do not respond to facility alarm; and Staff does not securely lock facility's exterior gate has been Substantiated. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f) An exit interview was conducted, and a copy of this report, 9099-D Page, and appeal rights was left at the facility.