Facility Evaluation Report

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met Rachael Robert, Resident Care Coordinator (RCC). LPA stated the reason for the inspection was to follow up on an incident report recently submitted to the Department involving resident (R1) who eloped from the community on May 26, 2026 (10:53 am).

The RCC explained that (R1) was able to exit the facility through the front entrance without being observed by staff because the concierge staff had to cover for a care staff who had called out for work around 7:20 am after the morning shift began. At the time (R1) exited the building, the concierge staff was attending to residents at the other end of Hall #1, which is away from the front entrance. The RCC added that (R1) began pushing on the front door and then walked away from the door when the alarm was triggered; however, when the alarm stopped, (R1) walked back to the front entrance, exiting to the parking lot. The RCC stated she and staff immediately searched within the facility but were unable to locate (R1), who wasn't able to be seen on the cameras.

At 11:00 am, the RCC and a Med-Tech drove in separate cars to search for (R1) in the nearby area, but were not able to locate them. Around 11:15 am, the local police were contacted and at 12:14 pm, (R1) was returned to the community after being found in a nearby neighborhood. The incident report notes (R1) returned without any "injuries, pain, distress or change in condition."

The RCC stated that following the incident, maintenance staff checked the front door to ensure the door doesn't unlock before 15-20 seconds of the alarm sounding. The RCC indicated that staff will be instructed today (3:15 pm) on how the timing works on the egress door unlocking after the alarm sounds.