Complaint·May 19, 2025

It was alleged that the staff did not adequately supervise resident resulting in resident (R1) wandering away from the facility. Based on review of the police report records, it’s noted that R1 was found about 0.2 miles away from the facility running through the parking lot of the shopping center. On 01/30/2025, staff members and the Licensee were interviewed. Based on staff interview 2 staff were working during the time of the incident. It was stated that on 01/23/2025 R1 left the facility from his/her side door and jumped the fence to go to a sandwich shop across the street of the facility. 2 out of 2 staff stated that they were cleaning and assisting other residents when R1 exited the facility. When staff noticed R1 was missing, staff went to look outside and saw an employee of the sandwich shop waving them down to come there. The Licensee stated that R1’s new behavior of leaving the facility began in the beginning of January 2025. Licensee states that they were addressing the behavior by talking to the doctor, following up with R1’s case manager, and they were waiting for R1’s insurance to approve a 1:1 staff. Licensee states that R1’s bedroom door does not have door alarms but stated a plan to buy door alarms for his/her room due to his/her exit-seeking behavior. Licensee also stated a plan to replace the battery for the door alarm at the front door to help notify staff when someone opens the doors. Based on interview with resident (R1), it was stated that he/she likes to leave the facility at least twice a week to go across the street by him/herself, without staff supervision. The review of R1’s records indicates that R1 is not able to leave the facility unassisted. On 01/30/2025, LPA observed that R1’s bedroom is located right next to the front door entrance of the facility. The front door alarm was not operable. R1’s private bedroom has a sliding door which leads to the side of the facility. R1’s sliding door had a door alarm, but the door alarm was not operable. Page 2 of 3. The Department has investigated the above allegation. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency was cited per California Code of Regulation, Title 22. This report was reviewed with Licensee Marie Pendar and a copy of the report and appeal rights were provided. Page 3 of 3. Based on review of the police report, 2 witnesses stated to have observed staff hit R1. Witness (W1) stated to have observed one of the staff swing at R1 but was not sure which of the staff hit R1. It was stated that the incident happened in front of the facility. Witness (W2) stated to have observed of the staff hit R1 multiple times to get into the facility. Resident (R1) was interviewed. Based on interview, R1 denied staff pushing and hitting him/her. R1 did not have any complaints about staff’s treatment towards him/her. The 2 staff members who were part of alleged incident were interviewed. Based on staff interview, 2 out of 2 staff denied pushing and hitting R1. Staff stated a moment while walking back to the facility where the staff was yelling at R1 to “stop” before crossing the crosswalk as there was a bus coming. Staff denied touching R1 while walking back to the facility and before entering the facility. Based on review of the police report, on 01/23/2025, there were no bruises or marks on R1’s body. It was noted that R1 did not seem fearful of the staff. Based on LPA’s observation on 01/30/2025, there were no bruises or marks on R1’s body. R1 did not observe to seem fearful of the staff. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated, meaning that although the allegation is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee, Marie Pendar and a copy of the report was provided. Page 2 of 2.