Incident investigation·January 22, 2026

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit regarding an incident report submitted to Licensing concerning Resident #1 (R1) being observed leaving the facility unassisted. According to the incident report, staff observed R1 walking on the sidewalk outside of the community. Staff escorted R1 back to the facility. The report further stated that R1 exited the facility through the back gate and was not immediately observed by staff. During today’s visit, LPA met with Resident Care Director Venca Avivi, who confirmed that R1 left the facility. Venca reported that R1 is physically capable of leaving the facility; however, per physician’s orders, R1 is not permitted to leave unassisted due to physical limitations, not cognitive impairment. Venca stated that R1 was taken to urgent care by R1’s daughter and was diagnosed with a urinary tract infection (UTI), which may have contributed to the incident. Facility staff reported there are currently no concerns regarding R1. The facility will continue to monitor R1 closely and document any changes in condition. LPA obtained and reviewed R1’s current physician’s report. At this time, no further review is required. During the visit, LPA also identified concerns regarding the facility Administrator on record, Eden Tolentino. According to Eden, her designated back-up Administrator is Chad Jones, who resides in Kentucky when Eden is not present at the facility. LPA spoke with Eden via telephone. Eden reported she has not been physically present at the facility since January 05, 2026, and stated that Chad Jones has been present full time. ( See LIC809C) LPA requested submission of an updated LIC 308 (Designation of Administrative Responsibility) and LIC 501 (Personnel Report), reflecting the days and hours the Administrator is working at the facility. At this time, there is no full-time Administrator physically present at the facility. Eden reported she is fulfilling the Administrator licensing requirements. LPA will follow up with Eden and Chad regarding the requested documentation. An exit interview was conducted, and a copy of this report was provided to Venca Avivi.