1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 | Former facility Staff (S1) reported that they saw R1 go to dinner on 05/31/2025 between approximately 1700 hours to 1800 hours. S1 took her hour long break, and returned to conduct room checks. Between approximately 1900 hours and 2000 hours, S1 looked for R1 but could not find him, so she notified former Administrator Aria Alaghemand.
S2 marked that R1 did not receive his evening medication that occurs at 2000 hours on 05/31/2025. S2 failed to report the incident and was terminated. Administrator did not notify law enforcement that R1 was AWOL until 1543 hours on 06/01/2025, although he learned about his AWOL on 05/31/2005 at approximately 2237 hours.
R1 should have been reported missing “immediately.” R1’s physician report noted that R1 is to not leave the facility unassisted. Chief Operating Officer Madison Fetyko reported that the facility staff did not follow proper policy and procedures.
Therefore, the allegation is substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency was cited on a 809-D page, on 6/03/2025 during a case management visit regarding the same incident.
The facility Administrator was informed that an additional civil penalty was pending review during the 6/3/2025 case management visit and may be assessed according to Health and Safety Code § 1569.49(e). Once a civil penalty has been determined, the Department will return at a future date to assess civil penalty.
Exit interview conducted and report provided. Appeals rights printed |