complaint·December 17, 2025

R1’s physician’s report noted R1 was depressed but was not suicidal. The physician determined that R1 could leave the facility without supervision. About five months after admission R1 was overheard talking with a suicide prevention hotline. The facility staff contacted R1’s responsible party who was unavailable to assist in obtaining an assessment of R1's needs. The facility contacted the Psychiatric Emergency Response Team (PERT), and after the PERT assessment R1 was transported to a hospital for evaluation. Two days after the PERT assessment the resident was released from the hospital without being admitted for in-patient psychiatric services. The discharge documentation had a note signed by the physician stating R1 “is not suicidal”. Twenty-five days later R! was brought into the facility accompanied by an outside individual who reported that R1 was walking into traffic. The following day facility staff conducted a Suicide Risk Assessment regarding R1. Although R1 denied being suicidal, or having a plan, R1’s behavior of walking in the street without an apparent concern for their safety was noted. After the assessment, and noting the very concerning behavior, facility staff determined that a one-to-one companion was needed to keep R1 safe. An email was sent on a Monday to inform R1’s responsible party of the requirement for a one-to-one companion. Facility staff told R1’s responsible party that they had until Friday to hire a companion. On Wednesday facility staff hired a companion. Interviews revealed that the facility’s practice would be to use facility staff as one-to-one companions until outside staff could be secured. R1 is responsible for the cost of these services. It was alleged that facility staff obtained outside services for the resident without prior authorization. Residential Care Facilities for the Elderly (RCFE) are required to follow Title 22, Division 6 Chapter 8 regulations. Section 87466-Observation of the Resident states that “the licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.” A review of the admission agreement signed by R1’s responsible party states that “the community will revaluate resident’s needs to determine which service level is appropriate... The fee charged will be based upon the Service Level provided.” The community determined that R1 needed additional services and arranged for those serviced to be provided. Not the admission agreement, nor the RCFE regulations require that prior authorization is required. This allegation is Unsubstantiated. It was further alleged that facility staff did not properly supervise the resident. The investigation revealed that R1’s initial physician’s report stated that R1 could leave the facility without supervision. Until the incident when R1 was found to be acting unsafe in traffic, the facility had no reason to supervise R1 outside of the community. This allegation is Unsubstantiated. It was further alleged that facility staff did not get resident appraisal updated. The investigation revealed that the day after the incident where R1 was unsafe in traffic, a Suicide Risk Assessment was completed to address the area of concern regarding R1. This allegation is Unsubstantiated. Based on the evidence obtained during the complaint investigation, the above allegations are UNSUBSTANTIATED, meaning the preponderance of evidence standard was not met to prove a violation occurred. An exit interview was conducted with Jennifer Ortega, Executive Director; a copy of this report and Licensee's Rights (LIC9058) were provided.