Incident investigation·April 16, 2026

On 04/16/2026 at 10:15 AM, Licensing Program Analyst (LPA) A. Gomez conducted a case management as a result of a self reported incident on 3/24/2026. LPA met with Sr General Manager, Abbie Apolinario and explained the purpose of the visit. It was reported that on 3/20/2026 at approximately 4:19PM R1 was found outside in the facility parking lot and stated that they were going for a walk. Staff were notified and redirected R1 inside. LPA reviewed R1s careplan and physicians report prior to the incident and observed that R1 did have a dementia diagnosis however their physicians report stated that they could leave unassisted. LPA observed that R1's careplan also did not note that R1 required assistance leaving. However Sr General Manager, Abbie Apolinario and Resident Care Director (RCD) Kimari Pinkney were both aware of R1's seemingly declining cognitive abilities and had requested an updated 602. LPA advised facility that in the future if there is conflicting information observed on residents physicians reports they should call and verify the information with the doctor right away. R1 no longer resides at the facility. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.