Facility Evaluation Report

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) James Arp. Note, LPA did step out for lunch from 12pm-1pm.

Community Care Licensing received an Incident Report on 12/05/25 in which it was reported that Resident #1 (R1) had eloped from the facility during the night and had been located by police approximately a block away from the facility, and taken to the hospital. Per the report, R1 sustained a laceration to the head, which was treated at the hospital. R1's responsible party and primary care physician were notified of the incident. LPA had also received a verbal report via phone call by ED Arp same day, where additional details regarding the incident were shared. Per the verbal report, R1 had a Diagnosis of Dementia and that exterior door alarms had failed, thus not notifying staff. Additionally, per ED Arp, the security guard that was supposed to be at the front entrance where R1 passed as they left the property was not at their post, and thus did not see R1 wander away either.

During today's visit, LPA conducted a health and safety visit with R1 and provided consultation with ED Arp. The facility has moved R1 to the secured Memory Care unit post hospital discharge. The facility is working on updating/repairing their exterior door alarm systems and adding additional alarms to them. Additionally, the facility has increased staff presence at the front entrance to ensure someone is present at all times. The facility plans to implement trackable devices for at-risk residents for wandering/elopement in the coming months.