Incident investigation·January 29, 2026

On 01/29/2026 at 12:00 PM, Licensing Program Analysts (LPA), Ardalan Gharachorloo arrived unannounced to conduct a case management visit in response to an incident report received on 01/27/2026. LPA met with Health services director, Vernica Herrera and explained the purpose for the visit. On 01/23/2026 at approximately 8:30 PM, LPA interviewed S1 who stated that staff heard a door alarm wile immediately checked the nearby exit and stairwell but did not observe anyone exiting the building. A headcount of residents was initiated, during which it which discovered R1 was not in her room. Staff continued to search and promptly located R1 outside the building walking toward the parking lot with a family member of another resident. R1 was safely redirected back to the facility. No injuries were observed or reported, and the responsible party was notified of the incident. S1 stated that "R1 was redirected back to the building with a staff member immediately after leaving". LPA reviewed R1's file. No deficiencies cited during the visit. Exit interview conducted and a copy of the report provided.