The complaint alleged that resident #1 (R1) left the facility on 06/14/24 at 10:00 pm. On 06/24/24, the department conducted a record review during an unannounced visit, examining the night-shift resident's two-hour check documentation list. On May 20, 2026, the department conducted a records review of resident R1. R1 was admitted to the facility on 05/03/2023. The department's review of the physicians' reports dated 01/15/2024 and 06/06/2025 indicates that R1 was able to leave the facility unassisted. On 06/16/2024, R1 was not present at the facility at 8 pm, 10 pm, 12 am, 2 am, and 4 am. On 06/17/2024, the facility contacted the Riverside Police Department and learned that R1 had been admitted to Riverside Community Hospital and was discharged on 06/20/2024.

On May 20, 2026, the department interviewed the facility's administrator, who denied the allegations. The administrator explained that some residents are allowed to leave the facility on their own and can return at any time. The facility maintains a sign-in and sign-out sheet for residents. In R1's case,they also noted that R1 could leave the facility unassisted. S4 also stated that R1 does not typically leave the facility for more than a day.

The facility has house rules that residents must follow, including notifying on-duty staff and signing in and out when leaving. The facility operates as an open facility, meaning it is not locked, and residents can come and go as they please.

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The department also interviewed eight residents (R1-R8), all of whom denied that the facility lacks supervision. They acknowledged that, as it is an open facility, they have the right to come and go as they please, provided they sign in and out. However, some residents occasionally leave without signing out. Additionally, the department interviewed R1, who also denied being missing. R1 stated that they do not remember certain events, recalling only their hospitalization. On May 20, 2026, the department's review of the Unusual Incident Report dated 06/17/2024, which was reported to the Community Care Licensing.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore, the allegation is Unsubstantiated.

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The complaint alleged that the facility staff did not follow protocol. On May 20, 2026, the department interviewed Administrator A1, who denied the allegation and stated that they followed protocol by immediately calling the police and by sending an unusual incident report to licensing. At the same time, the department interviewed four staff members (S1-S4), all of whom denied the allegation and stated they would notify the police within 24 hours if they didn’t find the residents. In the case of R1, S4 called the police and later learned that R1 had been admitted to the Riverside Community Hospital.

Additionally, the department interviewed eight residents (R1-R8), all of whom denied ever being missing for a day; they also stated they only go to the small store a block away. R1 also stated that R1 had not been missing; R1 only goes to the store sometimes. On 06/16/2024, R1 was not present at the facility at 8 pm, 10 pm, 12 am, 2 am, and 4 am.

The department records reviewed indicated that, on 06/17/2024, the facility contacted the Riverside Police Department and later learned that R1 had been admitted to Riverside Community Hospital on the same date. On 06/17/2024, the Community Care Licensing department received an unusual Incident Report from the facility regarding R1's disappearance. R1 was later found to be admitted to the Riverside Community Hospital.

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No deficiencies were cited.

An exit interview was conducted. A copy of this report was provided to Administrator Shalabi Jamal.