Incident investigation·June 17, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following receipt of (2) incident reports on June 10, 2025. LPA met with staff, Sofia Minor. Geoff Curtis, Assistant Administrator, arrived at 3:45 pm. Also present were LPA and Assistant Administrator discussed each incident report, as follows: On June 7, 2025 (9:45 am), resident (R1) left the facility, unattended, after threatening to leave for the last week. (R1's) physician's report notes that (R1) has a diagnosis of Dementia and Aphasia and cannot leave the facility unattended. Staff at the facility attempted to redirect (R1) but were not able to on June 7, 2025, as resident was very agitated. Staff immediately contacted senior management to notify then that (R1) had left the facility unattended. The police and placement agency were also contacted and the police located (R1) twenty minutes later, at a bowling alley two miles away. The Licensee met with (R1) and (2) police officers, and attempted to redirect resident back to the facility, but resident refused to return. On June 7, 2025, resident (R2) arrived to the facility at 4:13 pm. At 5:46 pm that day, (R2) left the facility, unassisted and refused any re-directions efforts. (R2) suffers from Mild Cognitive Impairment due to a Traumatic Brain Injury. (R2's) responsible person, the placement agency and police were all contacted. Staff had recently received training on re-direction techniques. Both residents were admitted for a short, two week stay and were accustomed to being un-housed for many years. Staff attempted to follow each resident to the end of the street court where the residents became verbally aggressive. LPA discussed preventative measures on going forward when licensed medical professionals are completing the LIC602. Exit interview. Copy of report provided.