Incident investigation·October 9, 2025

Licensing Program Analyst (LPA) Michael Tea conducted a case management incident visit to follow up on an incident report received by Community Care Licensing Division (CCLD) on Oct 8, 2025, submitted by Health and Wellness Director (HWD) Suzette Paige. LPA was greeted and allowed entrance into the facility by Executive Director (ED) John Goodwin. LPA explained the reason for the visit. The department received an incident report regarding elopements of a memory care resident, Resident 1 (R1) that happened on October 1, 2025 and October 7, 2025. During the visit, LPA and ED Goodwin toured the facility and inspected Clare Bridge Memory Care unit and R1's room. LPA conducted a health and safety check on R1 and observed no health and safety issues. Based on LPA's observation and review of records, despite R1 having a diagnosis of Alzheimer's, R1 is very cognitive, high functioning and very alert. LPA toured and observed the rest of the facility and found no health and safety issues. LPA requested and reviewed copies of R1’s resident file. LPA Tea spoke to staff and management regarding R1's care and the elopements. One of the delayed egress on the doors in the memory care unit in which R1 has exited out of, has an alert that is not loud enough for staff to hear. The alert does go to the front desk and 2nd floor of the facility, and staff has caught the alerts in time during each elopement. Currently the facility has fixed the annunciator alert for the delayed egress in the memory care unit to be more audible and louder and added additional siren alert as of yesterday, Oct 8, 2025. R1 is very quick and can run fast but each elopement they were able to bring him back to the facility within in a short matter of time, no more than 20 mins and less than a mile away from the facility. The facility did follow elopement protocols and contacted local law enforcement. They contacted the family and R1's primary care physician. Facility was was able to redirect him to the facility and ensure that he (Report continued on LIC809-C) was safe. Facility management believes R1 needs a higher level of care. With proper mitigation, the facility has been keeping a close observation on R1 and since the last elopement the facility has had the family hire a one to one personal caregiver from 7:00 AM to 7:00 PM for R1. After the hours of the personal caregiver, the facility has assigned a facility caregiver staff to be with R1 till bedtime and monitoring throughout the night. Based on the observations made during today’s inspection, no deficiencies are being cited at this time. An exit interview was conducted with Executive Director John Goodwin and Health and Wellness Director Suzette Paige and a copy of this report was provided at exit.