Incident investigation·December 19, 2024

Licensing Program Analysts (LPAs) Marcella Tarin and Kenneth Madrigal conducted an unannounced Case Management visit to follow up on two incident reports involving two elopements. LPAs met with Administrator Candace Bolin and explained the purpose of the visit. On 12/11/2024, the Department received an Incident Report regarding resident R1 eloping from the facility on 12/08/2024. R1 was returned back to the facility by local police and was unharmed during the elopement. On 12/18/2024, the Department received a second Incident Report regarding resident R2 eloping from the facility on 12/15/2024. R1 was returned to the facility by local police and was unharmed during the elopement. LPAs toured the interior and exterior of the facility and inspected the alarm panel in the Garden House Medroom for 13 alarmed exit doors in the facility. 13 out of 13 doors were alarmed, with all buttons on the panel indicating that the doors were alarmed. LPAs inspected Garden House Door #1 and Stairwell Exit Door #3, and Garden House Gate. LPAs interviewed 3 staff, and attempted to interview 2 residents during visit. LPAs requested R1 and R2's needs/service plan, R1 and R2's physician's report, staffing roster for 12/08/2024 and 12/15/2024, maintenance service records, a copy of security video footage and resident roster. Due to insufficient information, this investigation requires additional review. This report was reviewed with Administrator Candace Bolin and a signed copy of the report was provided.