complaint·September 11, 2023

On both dates the alarm rang when the exit was pushed and after pushing for 10 seconds the door opened. LPA observed as staff responded to the delayed egress alarm within three to five seconds. During the course of the interviews AD stated that the alarms get tested once a month. Per AD staff redirect residents who cannot leave unassisted, and staff try to provide what the residents need in order to de-escalate the situation. However, records reviewed by LPA Ramirez included the Unusual Incident/Injury Reports (UIIRs) dated 05/02/22 for Resident 1 (R1), dated 09/17/22 for R2 and dated 06/19/23 for R3. Per UIIRs R1 eloped from the facility on 05/01/22, R2 eloped from the facility on 09/17/22 and R3 eloped from the facility on 06/18/23. The facility neglected the residents’ care and supervision as it was unsafe for all three residents to leave the facility unassisted. Even though the facility has security systems, the security systems have proved inadequate as evidence by multiple residents eloping from the facility unsupervised. 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 has inadequate security systems 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 AD Santos and a copy of this report along with the Appeal Rights were provided at the time of this visit.