Complaint·January 12, 2024

This is an amended report. Santa Barbara Police Department (SBPD). Guerra stated he was unsure whether it was an officer from SBPD but was certain it was a representative from SBPD. Guerra further stated R1 was taken to the local hospital for evaluation. Record review revealed the hospital evaluation determined R1 sustained a skin tear and brain bleed as a result of the hospital evaluation. Medical records specify R1 sustained bilateral subdural hematomas. Guerra stated R1 did not return to the facility after R1's elopement. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that due to lack of supervision R1 eloped from the facility; therefore, the above allegation is deemed SUBSTANTIATED at this time. The following deficiencies were observed (See LIC 9099-D.) and cited from the CA Code of Regulations, Title 22 Regulations. A civil penalty of $500 is assessed due to R1 sustaining an injury as a result of a deficiency. Exit interview conducted. A copy of the report and civil penalty was issued at the time of the visit along with appeal rights. This is an amended report. During today’s visit, SRCD stated a Service Plan Meeting was scheduled on 9/16/2021 upon R1’s admission into the facility. Record review indicated R1’s Service Plan was updated on 9/29/2022 and 12/22/2022. SRCD further stated a Service Plan Meeting was scheduled to be held with R1’s responsible party on 2/14/2023. SRCD stated the Service Plan Meeting scheduled to be held on 2/14/2023 was to address changes of condition, emergency contact information, medication records, resident’s weight and current status, resident’s level of care and fall risk, interventions, latest Physician’s Report, Service Plan, and an open discussion regarding service and care. The Service Plan Meeting would include any/all hospitalizations, incidents, and elopements. SRCD stated he scheduled the Service Plan Meeting on or about 2/7/2023 and notified R1’s responsible party of the meeting prior to 2/7/2023. Based on interviews conducted and records reviewed, LPA determined that the facility updated R1’s service plan after residing in the facility for a year, and then following the third found on floor incident. Additionally, although the Service Plan Meeting on 2/14/2023 did not come to fruition due to R1 moving out of the facility, SRCD Guerra addressed the resident’s change of condition following one additional found of floor incident by scheduling the Service Plan Meeting with R1’s responsible party. Therefore, the allegation that staff did not address a resident’s change of condition is deemed Unsubstantiated at this time. Exit interview conducted. Report issued at the time of the visit.