complaint·August 1, 2023

residents in care. Per AD 61 residents can leave the facility unassisted, 22 residents have a diagnosis of dementia and none of the residents are bedridden. During interviews with residents, it was reported that hiring more staff would be beneficial for both caregivers and residents. It was reported via interviews that hiring more staff would be beneficial because residents would have better care and supervision and/or that because the residents require a lot of care and attention. Records reviewed by LPA Ramirez included the Unusual Incident/Injury Report (UIIR) dated 05/02/22 for Resident 1 (R1). Per UIIR R1 pushed the door, started running and left the facility. During interviews with staff, it was reported that no one followed R1 but that a caregiver noted which direction R1 went. Per UIIR R1 left the facility unassisted on 05/01/22 at 11:49 AM. During the investigation LPA reviewed documents including the Physician Report (LIC602A) dated 04/29/22 for Resident 1 (R1). Per Physician Report R1 is not Able to Leave Facility Unassisted. Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: facility is operating understaffed is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with facility representative and a copy of this report along with the Appeal Rights were provided at the time of this visit.