Incident investigation·November 12, 2025

On November 12, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case- management visit in relation to an incident that occurred on 10/24/25. LPA met with Assistant Administrator, Gabriel Mendoza and explained the purpose of the visit. The Licensee reported on 10/23/24, Resident 1 (R1) left the facility without signing out and did not come back overnight. On 10/24/25 at around 8:45am, the facility received a call from R1 stating that he/she is at Peninsula Medical Center due to rapid heart rate. During the visit, LPA reviewed R1's file, reviewed documentation and interviewed the assistant administrator. According to the assistant administrator, both him and the administrator observed R1 outside the facility between 9am-10am and R1 stated he/she was going to a doctor's appointment. According to the assistant administrator, sometimes R1 makes his/her own appointments and staff are unaware of R1's appointments unless the facility scheduled them. Staff are unaware if R1 actually went to the doctors. Based on R1's physician's report dated 6/13/25, R1 is not allowed to leave the facility unassisted. Based on documentation reviewed, there was an endorsement from the med-tech to the NOC shift caregivers that R1 is out. In addition, there was a text message sent to a group chat at 10:35pm by PM med-tech stating if R1 does not return back to the facility by 12am to call the police. The NOC shift caregivers have access to the phone so they were aware of the text message. There was no documentation provided to show that the police were called. According to the assistant administrator, PM Shift and NOC conduct safety checks every 2 hours so they would have been aware if R1 was not at the facility. Assistant administrator is unsure if NOC shift caregivers called 911 and if they did, why it was not documented. Further investigation is required. Report is reviewed with the assistant administrator and a copy is provided.