Incident investigation·April 16, 2026

At approximately 1:00 PM Licensing Program Analyst (LPA) Star Stevenson arrived unannounced on a case management visit regarding a self-reported Unusual Incident Report (LIC624) received by the Department on 04/10/2026 in which a resident (R1) was able to open a memory care window in their room on the night of 04/09/2026 and place their walking device over an approximately 12" high by 15" wide concrete ledge and exit the building where they were later found by the security staff at the facilities guard shack inside the perimeter of Paradise Valley Estates. LPA notes that immediate notifications were made to R1’s Primary Care Physician (PCP), who was asked to evaluate R1 for consideration of medication changes related to sundowning and exit seeking behaviors. In addition, the spouse of R1 was immediately notified, with spouse of R1 noted to agree to the request of R1’s PCP to potentially adjust behavior medicines for R1. LPA obtained documents, made observations and conducted interviews around the inner-facility elopement of R1. It was revealed through the Physician Assessment (LIC602) and care note review that R1 can be “confused”, has known “wandering behavior” and “sundowning behavior”, requires “constant supervision” and is able to “ambulate without assistance”. It was also revealed through interview of S1 that R1 exited from their private apartment where they can be alone and it was from this apartment that R1 was able to push in a locking clamp of their ground level window and exit their apartment without staff initially knowing. Continued on LIC809C Continued for LIC809 Review of documents and interviews obtained during today's case management visit indicate staff moved quickly to remedy this potential danger for memory care residents and by the next morning Management and Communication/IT staff had placed an order for window alert alarms for all Memory Care resident room windows. In addition, interview with S1 revealed that a motion room sensor was placed in R1's room the night of the inner-facility elopement. (see photos of window sensor and room motion alarm) No deficiencies are cited. Report was reviewed with Assisted Living Manager whose signature here denotes receipt.