complaint·November 19, 2024

Review of an incident report submitted by the facility to the Department on 11/18/2024 revealed that on 11/16/2024, Resident 1 (R1) left the facility on an outing. Interviews with R1 revealed that R1 told staff of R1's planned outing and staff knew that R1 would be away from the facility. Review of the incident report revealed that R1 notified Staff 1 (S1) that R1 would be returning to the facility at approximately 9:00pm. Interviews with R1 and the incident report revealed that R1 returned to the facility at approximately 9:00pm and there was no staff present at the facility to allow R1 entry into the facility. Interviews with R1 revealed that R1 attempted to get in contact with facility staff and management via telephone with no response. R1 was able to get in contact with one of the facility's management team (S2) and informed S2 that there was no one available to allow R1 entry into the facility. Interviews with R1 also revealed that R1 contacted law enforcement who arrived at the facility to assist R1. Interviews with residents and staff revealed that a staff member arrived at facility and R1 was allowed entry into the facility sometime after 10:00pm. Review of staff schedules for November 2024 revealed that staff were assigned to work two different schedules, one from 7:00am to 6:00pm and the other from 9:00am to 8:00pm. Interviews with staff and facility management revealed that a staff member was supposed to be at the facility overnight and would get up to assist residents as needed. Those interviews also revealed that the overnight staff was not required to be awake and was not paid for the hours where staff were responsible for the overnight supervision of residents. Residents denied that staff were present at the facility overnight and stated during interviews that staff did not provide assistance to residents overnight from approximately 8:00pm in the evening to approximately 7:00am in the morning. Interviews with staff and residents revealed that there are no staff present at the facility on the weekends from approximately 8:00pm to 6:00am. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency for lack of supervision is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. Additionally, a civil penalty in the amount of $500 was assessed for lack of supervision and noted on the attached LIC421IM form. An exit interview was conducted with Administrator Lynn Drummond via telephone and Caregiver Rommel Abedoza, whose signature below confirms receipt of a copy of this report, the LIC421IM, and the Licensee Appeal Rights (LIC9058 3/22).