Complaint·August 10, 2023

R1 said R1 has turned off the alarm on this door. Dayoan, S1, S2, and S3 said R2 sometimes tries to leave the facility to go to church. R2 said R2 goes to church alone. R2’s LIC 602 indicates that R2 cannot leave the facility unassisted. In interviews, Dayoan said she did not know where R1 was discharged after being hospitalized. Dayoan said R1 was discharged on July 2, 2023. Dayoan could not provide any discharge paperwork from this hospital visit. Dayoan said R1 was hospitalized after leaving the facility without authorization and asking a neighbor to call emergency services. R1’s sibling said they unintentionally ran into R1 on the street around this time. R1 corroborated the sibling’s account of their run-in on the street. R1’s sibling said R1 was not accompanied by staff at the time. R1 said that after being discharged from the hospital, R1 was given a bus pass. R1 said R1 stayed at a friend’s house for one night, and spent multiple other days living on the street. R1’s ACRC service coordinator said ACRC was notified of R1’s general whereabouts by R1’s sibling after their contact with R1. Dayoan said R1 returned to the facility after being discharged a second time from a different hospital. LPA Moleski reviewed discharge paperwork from this hospital dated July 5, 2023 which show R1 was returned to Dayoan’s facility. R1’s LIC 602 indicates that R1 cannot leave the facility unassisted. R1’s ACRC service coordinator said ACRC has received calls from other community members notifying ACRC that R1 was out in the community. LPA Moleski reviewed a handwritten statement written by S2. In this statement, S2 described an incident that occurred on July 11, 2023, around 5 p.m. S2 wrote that S2 was out walking with R1 when R1 got onto a bus. S2 wrote that S2 did not have bus fare. R1 left on the bus unaccompanied, according to S2’s statement. R1 corroborated the events described in S2’s statement. Dayoan said she filed a missing person report with the local police department after this incident. LPA Moleski reviewed a missing person report regarding R1 dated July 11, 2023. Dayoan said R1 was returned to the facility that same day, around 10 p.m. R1 said R1 called Dayoan and was picked up that same day, around 10 p.m. The department has determined the following as it relates to the allegation that staff are not properly supervising residents in care resulting in residents wandering from the facility: [continued on 9099-C] Based on interviews with Dayoan, S1, S3, R1, R2, R1’s sibling, and R1’s ACRC service coordinator, and based on review of resident records and facility records, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is being cited per 22 CCR Section 87411(a). An exit interview was held with Dayoan. Appeal rights and a copy of this report were left with Dayoan.