Incident investigation·November 13, 2023

Licensing Program Analyst (LPA) Olson conducted a Case Management - Incident visit to issue deficiencies on an elopement the facility self-reported. LPA and met with Audie Sherberg, Administrator and explained the purpose of the visit. CCL received an incident report on 10/30/23 stating that on 10/28/23 Staff discovered Resident 1 (R1) was missing from Memory Care around 6:55 pm and could not locate them. Staff called 911 and conducted a search throughout the community, outside the community and surrounding areas. At around 7:21 pm Santa Maria Police Department called to say R1 was found and was taken to the hospital for evaluation. Resident was found on the corner of Rose and Suey Rd. and the paramedics were called because R1 fell. A CT was done and R1 was admitted for a Brain Bleed. LPA received a call/voicemail from the Garden House Director on Sunday 10/29/23 at 9:02 am explaining what happened. Administrator called LPA Monday 10/30/23 and stated R1 was on blood thinners which lead to the brain bleed, was doing well and no longer in the ICU and will be coming back to the facility soon. Administrator stated they are not sure how R1 got out of the double locked doors of the home and the locked fence. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). An immediate $500 civil penalty was assessed due to the resident being injured during their elopement. An exit interview was conducted, a copy of the report, Civil Penalty, and appeal rights were issued.