Incident investigation·April 8, 2026

On 04/08/2026, Licensing Program Analyst (LPA) Aziz Faizi conducted an unannounced case management visit to the facility to follow up on an Unusual Incident/Injury Report (LIC 624) submitted by the facility reporting an incident involving Resident 1 (R1). LPA met with Executive Director, Marie Hill who was informed of the purpose of the visit. The LIC 624 reported the following information. On 04/03/2026, At approximately 6:20 pm staff received a call that R1 was found outside at the church located near the facility. Staff immediately went outside to check and upon arrival resident was observed outside of the facility. Staff redirected R1 back inside the facility after multiple attempts. Executive Director was interviewed and reported the following information. The doors of the facility are kept closed and were checked in the morning and in the afternoon before residents were allowed to be in the East wing of the facility and found to be secured. There were concerns of the residents according to the Executive Director. During LPA’s observations LPA found that there were doors and gates that lead to the outside were secured and gates have an alarm that can be heard inside the facility, however according to S1 they stated that they did not hear any alarm go off the day of the incident. During the visit LPA was shown video footage by Executive Director that disclosed that R1 had pulled the door open and left the facility. Staff were not aware of R1 leaving the facility. Additional maintenance and witnesses were interviewed but did not disclose any additional information. During today's visit, LPA toured the facility did not observe any immediate health and safety concerns. Based on interviews and video footage a citation including with proof of correction has been issued. Additionally an alarm system will be installed by 04/24/2026 at the east side exit door. An exit interview was conducted, and a copy of this report, LIC 809-D, were reviewed and provided to Administrator, Marie Hill