complaint·July 21, 2025

Interviews with staff and outside sources revealed that R1 had a diagnosis of major neurocognitive impairment and had limited verbal skills, however, medical and assessment records for R1 were not available during the investigation. Interviews with staff and outside sources revealed that R1 received outside transportation to and from appointments and R1 was not accompanied. The Licensee stated that R1’s responsible party had made an agreement with the transportation service to have the driver walk R1 to the facility’s front door, however the Department was unable to confirm this information. Interviews with the Licensee and outside sources revealed that on 3/26/2025, R1 had a medical appointment in the morning. Interviews with the Licensee and review of the incident report received on 4/3/2025 revealed that R1 was picked up from the facility by the transportation service at around 8:30am. Interviews with the Licensee revealed that R1 was supposed to return to the facility sometime around 2:00pm, however R1 did not return to the facility at that time. Information obtained during interviews was unclear if facility staff were notified by R1’s responsible party when R1 was on their way back to the facility via the transportation service. Sometime around 3:00pm, the Licensee called R1’s responsible party stating that R1 had not returned to the facility. Interviews with the Licensee revealed that R1’s responsible party called law enforcement to report R1 missing and both the Licensee and R1’s responsible party called the transportation service. According to Licensee and outside sources, the transportation service stated that R1 had been walked to the front door and entered the facility sometime between 2:30pm and 3:00pm. However, the Licensee stated staff claimed that R1 did not enter the facility following the appointment. The Licensee stated that the driver dropped R1 off at the front gate and R1 walked away from the property without supervision. While the details of how R1 was dropped off after R1's appointment are unclear, both the Licensee and outside sources confirmed that R1 walked away from the facility property without supervision. Interviews with the Licensee and outside sources confirmed that R1 was discovered to be at an address in the neighborhood by an outside individual, who contacted local law enforcement and paramedics at approximately 3:40pm. R1 was returned to the facility by law enforcement at approximately 5:30pm. The Department has investigated the above-mentioned allegation and based on interviews and record review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency was cited for lack of supervision and noted on the attached LIC9099-D page. Additionally, a civil penalty in the amount of $500 for lack of supervision was assessed and noted on an LIC421IM form. An exit interview was conducted with Licensee Natalia Verdugo, whose signature below confirms receipt of a copy of this report, the LIC421IM, and the Licensee Appeal Rights (LIC9058 3/22).