Incident investigation·April 2, 2026

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management Incident visit at 11:31AM. The LPA met with Med-Tech Claudia Perez and explained the reason for the visit. The Administrator was unavailable during today’s visit and participated via telephone call. Entrance interview conducted. On 03/27/2026, the Department was notified of Resident #1 (R1) who was unattended at a related facility. The LPA contacted Administrator Amber Leigh via telephone call who stated that R1 left the facility on 03/23/2026, was independent, and able to provide their own transportation. The Administrator provided documents which indicated R1 was non-ambulatory, able to leave the facility unassisted, and unable to manage or have access to medications. During today’s visit, the LPA contacted the Administrator at 11:47AM. Beginning at 12:02PM the LPA and Med-Tech conducted a physical plant tour and reviewed R1’s medications. No immediate concerns were observed. The Administrator confirmed with the Med-Tech on shift on 03/23/2026 that R1 left the facility without notice and medications were not checked out to them. R1 then returned to the facility on 03/28/2026 and was immediately placed on a psychiatric hold due to aggressive behavior. Med-Tech Claudia Perez stated that they contacted R1 on 03/24/2026 and were unable to receive a clear answer on R1’s return to the facility and notified R1's physician. Report Continued on LIC 809-C The Administrator stated that going forward the facility will ensure that all appropriate parties are notified including law enforcement, responsible parties, and physicians if a resident is unable to be contacted, located, and does not return to the facility. The LPA also discussed reporting requirements with the Administrator as the Department has not received any Unusual Incident Reports since 04/16/2025. The Administrator stated they have faxed their reports and the LPA advised providing them through email. The Administrator agreed. Due to the Administrator’s unavailability, they have designated Med-Tech Claudia Perez to sign today’s report. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.