Based on an interview with a witness (W1), on 11/14/2025, residents R1 has been known to have methamphetamine in their possession and has distributed methamphetamine to R2. Interviews revealed that within one week of moving into this facility, R1 displayed behaviors consistent with drug use. R1 went on outings, and returned to the facility erratic, grinding their teeth, swearing, and having red eyes. According to one facility staff member, R1 would return to the facility appearing high on drugs and bringing back “crystal rock.” Staff interviews confirmed they had not seen R1 with drugs but seen R1 with a “pipe.”

Records for R1 show a history of substance abuse. R1’s Medical Assessment dated 8/15/2025 documented that R1 was diagnosed with substance abuse disorder and polysubstance self-abuse. The assessment also stated that R1 was able to leave the facility unassisted. R1’s Needs and Services Plan dated 8/13/2025 did not include a plan for how the facility would manage or address R1’s illegal substance abuse. R1’s court documents dated 8/12/2025 showed R1 had a scheduled court appearance for unlawful possession of methamphetamine, criminal threats, and felony-level elder abuse.

Facility daily notes from 10/10/2025 to 11/11/2025 were also reviewed. On 11/10/2025. R1 told staff that they went to buy drugs and said they had shared the drugs with other residents in care. On 11/11/2025, staff documented that R1 was giving methamphetamine to other residents around 3:00 AM. It was also noted that R1 and R2 left the facility at around 3:30 AM.

Police records dated 11/12/2025 further confirm concerns of drug use. Officers responded to the facility after receiving a report that a resident was possessing and distributing methamphetamine. Staff on duty reported that R1 admitted to using methamphetamine and giving it to two other residents. During a search of R1’s bedroom, officers found burnt foil and a plastic blue straw, which are commonly used to ingest drugs such as methamphetamine, heroin, or fentanyl. R1 was taken into custody for possession of drug paraphernalia and stated that they used the foil and straw to smoke drugs.

The facility’s house rules state that possession of illegal drugs is prohibited. However, records and interviews show that R1 continued to leave the facility, obtain drugs, return to the facility while under the influence, and share drugs with other residents.

Based on the interviews, records reviewed, and police report, the allegation that residents had access to illegal drugs due to neglect and lack of supervision is substantiated.

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Interview with witness, W1, who reported that on 11/10/2025, an unnamed resident in care eloped from the facility. W1 further stated that 2 facility staff left the facility for approximately 20 minutes to look for the resident, leaving the facility without any staff present. On the same day, another resident (R4) eloped from the facility at approximately 11:35 AM. W1 reported that facility staff did not report that R4 was missing to law enforcement. On 11/12/2025, R4 was located at a location approximately seven miles away from the facility.

Interview with a resident’s family member stated they received a call from a facility staff informing them that R2 had eloped from the facility without supervision. Interviews and record reviews revealed that R2 was unable to leave the facility without assistance.

Review of facility notes revealed that on 10/11/2025 confirmed that R1 had shared drugs with R2 and other residents in care. The facility notes also revealed that on 11/11/2025, R1 and R2 left the facility at around 3:30 AM and R2 returned to the facility at around 4:00 AM.

Police records from the Elk Grove Police Department were also reviewed. According to Summary Report #25-004128, on 06/20/2025, Officer responded to the facility after resident R3 was reported missing at approximately 10:00 AM. after leaving the facility.

Additional information was obtained during another complaint investigation conducted on 12/17/2025 (Complaint# 27-AS-20251208152635). During that investigation, interviews and record reviews revealed that resident R3 had another elopement incident on 12/15/2025. Staff on duty reported that on the morning of 12/15/2025, during breakfast, R3 became angry. Staff stated that she was the only staff member on duty at the time. While taking the garbage outside, staff observed R3 outside on the sidewalk. Staff stated that R3 walked past her and continued walking down the street. Staff attempted to verbally redirect R3 but was unsuccessful. Staff then instructed another resident, R5, to follow R3 while she returned inside the facility to contact the administrator, Bulou Matamadua, to report the incident. Staff reported that the administrator instructed her to call 911. Staff stated that law enforcement eventually located R3. Record reviews for R3 revealed that R3 was assessed as unable to leave the facility without assistance and required staff supervision, including supervision when using the bathroom.

Based on interviews and record reviews, multiple residents who were assessed as unable to leave the facility without assistance were able to exit the facility without staff supervision. Additionally, there were incidents where the facility was left without staff present, and in one case, staff instructed another resident to follow an eloping resident instead of directly supervising the resident. Based on the evidence obtained during the investigation, the allegation that staff did not prevent residents from eloping from the facility is substantiated.

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