Incident investigation·January 26, 2026

Licensing Program Analyst (LPA) Garrett Haner-Tomasko conducted a case management – incident visit to the facility along with personnel from Tri-Counties Regional Center (TCRC). LPA met with Administrator Deborah Cole and explained the purpose of the visit. The Department received an incident report regarding a resident found on the ground in the backyard of the facility by staff. The Department also received photos of injuries that occurred to the resident’s face, elbow, knee and toes possibly due to this incident. During the visit, LPA and TCRC personnel checked on the resident’s wellness and toured the facility. Staff are not sure how the resident got outside, the resident was last checked at 3:40am in their room and at approximately 6:50am during shift change the resident was found outside in the backyard. Staff check on residents approximately every two hours throughout the night and state this resident does often ask staff to leave their room when they do their checks. After the incident, staff implemented additional precautions for the resident’s safety; placing a floor mat with alarm next to the bed and a pressure bed alarm to alert staff of the residents attempt to get out of bed without assistance between staff checks, conducting extra checks on the resident, and a meeting was conducted between TCRC personnel, the facility administrator and residents responsible person to discuss additional safety measures. The resident states they like this facility and the staff that care for them. They do not recall falling recently. LPA and TCRC personnel provided technical assistance to the facility administrator and licensee on reporting requirements and additional safety measures that can be taken to keep the resident safe. During this visit no deficiencies were cited, but the LPA may return at a later date if citations are warranted. Exit interview conducted, report signed, and report provided to the Administrator.