Incident investigation·April 20, 2026

Licensing Program Analyst (LPA) Daiquiri Boyd made an unannounced visit to the facility to discuss an Incident Report submitted to the Department. Staff at the home called Administrator (AD) Teresa Long, who arrived at the home a short time later. LPA explained to AD that I was there to discuss the incident that was reported on 1/5/26 with resident (R1) (See Confidential Names list on LIC811). AD pulled up a video of the night of the incident. The video showed R1 coming out of one of the reisdent's rooms sliding glass door at 19:59 pm (and approach the side fence. R1 then climbed over the fence and into the neighbors property, which was in the front of the neighbor's side fence, where he walked away from the home. Staff on duty never heard an alarm go off and didn't realize he was not in the home. At the 8 pm medication pass, it was realized that the resident was not in the home. Administrator was then notified and as protocol was followed. Licensee has added extra fence boards to the fence. There is no longer a place for residents to place their foot to hop over easily. Staff now take R1 out of the facility on regular walks every day to help him to not feel so restless. No deficiencies were issued on this day.