Park Plaza

Allegation investigated: Staff do not respond to resident's health related requests for help in a timely manner Staff do not follow doctor's orders for medication administration Staff do not follow doctor's orders regarding ambulation assistance Staff dropped medication on the floor and still distribute it to residents Staff do not treat resident with respect Staff do not remove trash from residents' room in a timely manner

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on June 2, 2026. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Kurt Knauer. LPA explained the reason for the visit. This Department has investigated the complaint alleging that staff do not respond to resident's health related requests for help in a timely manner. Regarding the allegation the following was revealed: During the investigation LPA reviewed the Physician Report dated April 17, 2025, for Resident 1 (R1). Per Physician Report, R1's primary diagnosis is listed as Diabetes Type 2, R1 is able to follow instructions and is not at risk if allowed direct access to personal and grooming hygiene items. Per Physician Report, R1 is able to administer and store own medications, able to administer own injections and is able to perform own glucose testing. During the interviews with residents, Resident 1 (R1) reported that staff assist them with their glucose monitoring and give them orange juice if needed. Per R2 and R3, staff will assist them if they ask for help. CONTINUED ON LIC9099-C... Unsubstantiated Regarding the allegation that staff do not follow doctor's orders for medication administration, the following was revealed: During the investigation LPA reviewed the Park Plaza Care Plan dated June 4, 2026 for R1. Per Care Plan, R1 requires assistance with blood glucose checks and requires assistance with insulin injections. LPA reviewed the Medication Administration Record (MAR) dated August 2026 for R1. Per MAR, R1 was being administer their medications as prescribed. During the interviews with residents, R1 reported that they are being administer their medications as prescribed. Per R2 and R3, they manage their own medications and/or stated that they get their medications as prescribed. During the interviews with staff, Staff 1 (S1)-S3 reported that the medications and insulin are given as prescribed and/or stated that staff are following the Doctor's order for prescribed medications. Regarding the allegation that staff do not follow doctor's orders regarding ambulation assistance, the following was revealed: During the investigation LPA reviewed the Park Plaza Care Plan for R1. Per Care Plan under Escorts it states, aide to check and ensure R1 goes to all meals...may require escorting during times of weakness. During the interviews with residents, R1 reported that staff assist them to go to the dining room for their meals. R2 and R3 reported that staff will assist if they asks for help. During the interviews with staff, S1 reported that R1 had intermittent weakness and staff was escorting them for their meals and activities. S2 stated that staff was following the Doctor's order to assist the resident to go from their bedroom to the dining room. Per S3, if a resident needs assistance to ambulate to the dining room or about the facility it is part of their Care Plan. Regarding the allegation that staff dropped medication on the floor and still distribute it to residents, the following was revealed: During the investigation LPA reviewed the in-service training on passing Medications dated August 11 and 12, 2026. During the interviews with residents, R1 reported that they have never seen staff dropped the medications and still distribute it to them. R1 stated that staff are pretty professional. Per R2 and R3, they have never seen staff dropped the medications on the floor and/or stated that if staff dropped a medication that they will destroy it. During the interviews with staff, S1-S3 reported that if staff dropped a medication that the protocol is to discard the medication and give the resident a new one. CONTINUED ON LIC9099-C... Regarding the allegation that staff do not treat resident with respect, the following was revealed: LPA reviewed the staff training on Resident Rights dated February 26, 2026. Per Resident Rights it states, to be accorded dignity in your personal relationship with staff, residents and other persons. During the interviews with residents, R1 reported that staff treat them with respect. Per R2 and R3, staff are so respectful and very helpful and/or stated that they treat them like a queen. During the interviews with staff, S1-S3 reported that staff treat the residents with respect, respect their Personal Rights and/or respect the residents' privacy. Regarding the allegation that staff do not remove trash from residents' room in a timely manner, the following was revealed: During the investigation LPA reviewed the Housekeeping schedule dated July 22, 2026. Per Housekeeping schedule, staff clean R1's bedroom every Thursday. During the initial visit on June 9, 2026, and subsequent visit on August 19, 2026, LPA tour R1's bedroom and observed that the trash cans were empty and the bedroom was clean and sanitary. During the interviews with residents, R1 reported that their bedroom gets clean one time per week and stated that staff remove the trash on time. During the interviews with staff, S1-S3 reported that staff empty the residents' trash twice per day and/or stated that staff remove the residents' trash in a timely manner. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with ED Knauer, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 19, 2026 · control 22-AS-20260602091919

Allegation investigated: Staff did not seek medical attention in a timely manner resulting in resident passing away. Staff did not observe changes in resident's condition.

On December 23, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Assisted Living Director Christina Gonzalez was present and assisted on today's visit. During the course of the investigation, the Department inspected the facility, interviewed staff, and obtained and reviewed resident records. Regarding the allegation that staff did not seek medical attention in a timely manner resulting in residents passing away, the following has been concluded: Resident #1 (R1) was admitted to the facility on July 29, 2023. Per R1’s Physician Report dated July 26, 2023, R1 had a primary diagnosis of Mild Cognitive Impairment; was non-ambulatory; was unable to manage her own treatment/medication; was confused/disoriented at times; and was unable to leave the facility unassisted. Per the facility’s charting notes, R1 had documented falls on September 17, 2023, November 9, 2023, and November 21, 2023. CONTINUED ON LIC9099-C Substantiated Per the facility’s charting notes dated November 21, 2023, R1 had an unwitnessed fall in her bedroom. R1 was found on the floor at approximately 3:40 AM by a facility staff and was put back in her bed after not observing any injuries and R1 denying any pain. However, it was also noted that R1 was unable to explain what happened. The facility notified R1's Responsible Party via telephone. At 1:53 PM, approximately ten hours after the fall, R1’s Responsible Party came to visit and observed R1 was not behaving like herself. 9-1-1 was then called and R1 was transported to the hospital for further treatment. R1 was admitted to the hospital with a diagnosis of an intracranial hemorrhage and R1 remained in the hospital from November 21, 2023, to November 30, 2023. R1 passed away at the hospital on November 30, 2023. Per R1’s certificate of death, the listed causes of death are non-traumatic intracranial hemorrhage and hypertension. The Department conducted four staff interviews. Staff interviews conducted confirmed that R1 was placed back in her bed after sustaining her unwitnessed fall on November 21, 2023, and that 9-1-1 was not immediately called. Staff interviews also confirmed that there was a delay in calling 9-1-1 for R1 after her fall on November 21, 2023, due to R1 not complaining of any pain or declining medical attention. However, per R1’s Physician Report dated July 26, 2023, R1 was unable to manage her own treatment and was confused/disoriented at times. Therefore, R1 was unable to decide if medical attention was necessary and there should not have been a delay in approximately ten hours for 9-1-1 to be called for R1 after sustaining an unwitnessed fall. Regarding the allegation that, staff did not observe changes in resident’s condition, the following has been concluded: Based on a review of R1’s records, the Department observed that there were there were no re-assessments on file for R1 after she had three documented falls at the facility on September 17, 2023, November 9, 2023, or November 21, 2023, to determine if there was a change in condition or if more supervision was necessary. There were also no records to support that R1 was evaluated by her Primary Care Physician during this period to determine if the resident was at a high risk for falls. Furthermore, there were no documented fall prevention techniques in place despite R1 having three falls between September 17, 2023, and November 21, 2023. Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegations that, staff did not seek medical attention in a timely manner resulting in resident passing away and that staff did not observe changes in residents’ conditions. The preponderance of evidence standards has been met; therefore, the above allegations are SUBSTANTIATED. CONTINUED ON LIC9099-C See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed in the amount of $500.00. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division. An exit interview was conducted with Assisted Living Director Christina Gonzalez. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Dec 23, 2025 · control 22-AS-20251010214134

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Dec 24, 2025

87465 Incidental Medical and Dental Care: (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis ... This requirement was not evidenced by: Based on interviews and records reviewed, the licensee did not immediately call 9-1-1 after Resident #1 (R1) sustained an unwitnessed fall on November 21, 2023. Facility staff called 9-1-1 approximately ten hours after the fall. This posed an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Dec 23, 2025

Plan of correction: The Assisted Living Director stated that they will conduct an in-service training course with all staff regarding the facility’s fall policy to ensure that staff seek immediately medical attention for residents after sustaining falls as necessary. The Assisted Living Director agreed to provide LPA proof of training via email or fax by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Dec 24, 2025

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. ... This requirement was not evidenced by: Based on interviews and records reviewed, the licensee did not reassess Resident #1 (R1) to determine if there was a change in condition or more supervision was necessary, despite having three falls at the facility This posed an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Dec 23, 2025

Plan of correction: The Assisted Living Director stated that they will conduct an in-service training course with all facility staff regarding observing changes in residents’ conditions. The Executive Director agreed to provide LPA proof of the training via email or fax by POC date.

Type of visit: Required - 1 Year

On December 17, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Benjamin Davis was present and assisted on today's visit. LPA observed that Benjamin Davis has a valid Administrator certificate which expires on December 12, 2026. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for one hundred and fifteen residents, of which thirty six may be ambulatory, seventy three may be non-ambulatory, five may be bedridden, and has a hospice waiver for eight. The facility is a three story building with a central outdoor plaza. The building consist of resident apartments, with bathrooms located in suite, a dining hall, a commercial kitchen, multiple activity rooms, multiple storage rooms, multiple laundry rooms, a fitness center, a beauty salon, a medication room, and staff offices. LPA, accompanied by the ED, conducted a tour of the exterior portions of the facility. LPA observed the See Something, Say Something (PUB 475) poster mounted on the wall by the entryway of the facility. LPA inspected resident apartments in each floor. LPA observed resident apartments to be clear of any hazards. LPA observed resident apartments to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. Resident beds had clean linens and blankets. LPA observed additional linens to be stored in the laundry rooms. LPA inspected the bathrooms in each of the residents apartments and observed them to be clean. Bathrooms were equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 110.1 and 117.8 degrees Fahrenheit. LPA additionally tested the call system alarms in resident apartment and they tested operational. CONTINUED ON LIC809-C LPA inspected the commercial kitchen and observed it to be clean. LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. LPA observed knives and sharps to be inaccessible to residents. LPA observed fire extinguishers to be mounted on the walls in each floor and fire extinguishers were observed to be charged and serviced as of March 20, 2025. LPA observed the facility passed their most recent fire inspection visit conducted on November 3, 2025, which consisted of testing the smoke detectors, carbon monoxide detectors, and fire sprinklers. LPA observed the facility conducted their most recent emergency disaster drill on October 16, 2025. LPA observed the facility has a three day emergency food and water supply kept in a storage room on the third floor. LPA observed chemicals and toxins to be stored in a locked storage rooms inaccessible to residents in care. The facility has a medication room located on the second floor. The centrally stored medications are kept in locked medication carts. LPA observed a First Aid kits stored in the medication room and it had all the required components. LPA inspected all other common areas such as the dining room, activity rooms, beauty salon, fitness center, and observed them to be clear of any hazards. LPA, accompanied by the ED, conducted a tour of the exterior portion of the facility. LPA observed exterior to be clear of any obstructions or hazards. LPA observed a shaded outdoor seating area with furniture for resident use. There are no bodies of water on the premises. LPA reviewed nine resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed residents’ medication and medication administration records. LPA reviewed nine staff files. All staff are background cleared and associated to the facility. Based on today's observations, no deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Executive Director Benjamin Davis and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 17, 2025

Allegation investigated: Lack of care and supervision resulted in resident sustaining a fall with injuries. Staff did not seek timely medication attention for resident after sustaining fall.

On November 18, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Executive Director Benjamin Davis and explained the reason for the visit. During the course of the investigation, LPA inspected the facility, interviewed staff and residents, obtained and reviewed resident records. Regarding the allegation that, lack of care and supervision resulted in resident sustaining a fall with injuries, the following has been concluded: Resident #1 (R1) was admitted to the facility on June 5, 2025. Per R1’s Physician’s report dated May 20, 2025, R1 is diagnosed with Mild Cognitive Impairment and had a medical history of skin cancer, eye disease, heart disease, seizure disorder, and had a pacemaker. R1 is ambulatory; able to follow instructions; able to leave the facility unassisted; able to bathe self; able to dress/groom self; able to dine independently; able to care for own toileting needs; and is able to manage own cash resources. CONTINUED ON LIC9099-C Unsubstantiated Per R1’s care plan dated September 10, 2025, R1 has a diagnosis of mild cognitive impairment, congestive heart failure, atrial fibrillation, obstructive airway disease, and had a pacemaker. R1 was receiving assistance with medication, required escorts to all meals and activities of choice, and wears a wander guard for safety. Per R1’s charting notes dated September 19, 2025, R1 had an unwitnessed fall in his apartment and was found by staff on the floor around 7:30 AM. R1 was transported to the hospital for his injuries and was admitted for syncope and collapse. R1 remained in the hospital from September 19, 2025, to October 5, 2025. R1 returned to the facility on October 5, 2025, after being discharged from the hospital and was admitted under hospice with a primary diagnosis of end stage heart failure. R1 passed away on October 5, 2025. Per R1’s certificate of death, the listed causes of death are cardiopulmonary arrest and congestive heart failure. Based on a review of R1’s records, there were no records that indicated R1 was a fall risk and there were no records indicating that R1 has any previous recorded falls at the facility. Additionally, R1 did not require hourly checks by staff. LPA conducted six staff interviews. Six out of the six staff interviews conducted confirmed that the fall on September 19, 2025, was R1’s first fall while at the facility. The staff interviews conducted also denied R1 being considered a fall risk. Furthermore, it was revealed during staff interviews that R1 was provided with a call pendant upon move in which he could press to call for assistance from staff. However, R1 was not wearing his call pendant on the morning of September 19, 2025, and staff later found R1’s call pendant in his kitchen cabinet. Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. Regarding the allegation that, staff did not seek timely medication attention for resident after sustaining fall, the following has been concluded: LPA reviewed R1’s charting notes dated September 19, 2025, which stated that R1 had an unwitnessed fall in his apartment and was found by staff on the floor around 7:30 AM. The charting notes stated that Staff #4 (S4) found R1 on the floor and that Staff #1 (S1) called 911 to seek medical attention for R1. LPA conducted an interview with both S1 and S4. Both staff interviewed denied the allegation and denied any delay in seeking medical attention for R1 after he was discovered on the floor. LPA reviewed S1’s personal cell phone call log and observed 911 was called at 7:37 AM on September 19, 2025, which is approximately seven minutes after R1 was discovered on the floor by staff. CONTINUED ON LIC9099-C Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Benjamin Davis and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 22-AS-20250919150730

Type of visit: Case Management - Incident

On July 14, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management Incident inspection. LPA is following up on a self reported incident report that was submitted to the Orange County Regional Office on July 2, 2025. The incident report described Resident #1 (R1) missing personal belongings such as her gold cross necklace and gold ring. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Benjamin Davis was present and assisted LPA on today's inspection. On today's visit, LPA, accompanied by the AD conducted a tour of the physical plant. LPA observed the facility to be clear of any obstructions or hazards. LPA obtained pertinent document for R1 such as her Identification page, Admission Agreement, Personal Property inventory, and most recent Physician's Report. LPA additionally conducted one resident interview and one staff interview. Based on the information gathered during the inspection, no deficiencies are being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with Executive Director Benjamin Davis and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 14, 2025

Type of visit: Case Management - Incident

On May 30, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the follow to conduct a Case Management Incident inspection. LPA is following up on an incident report that received by the Orange County Regional Office on May 15, 2025. The incident report was dated March 10, 2025 and described a medication error for Resident #1 (R1). LPA was greeted and granted entry into the facility by staff after explaining the purpose for today's visit. Executive Director (ED) Benjamin Davis was present and assisted LPA with the inspection. On today's visit, LPA, accompanied by the ED, conducted a tour of the facility. LPA observed the facility to be clear of any obstructions or hazards. LPA observed residents participating in various activities such as painting and reading. LPA additionally reviewed pertinent documents for R1. LPA also conducted interviews with R1 and two staff. Based on the observations made during today's visit and the information gathered, a deficiency is being cited on the attached 809-D. An exit interview was conducted with Executive Director (ED) Benjamin Davis. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, May 30, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(5)(A) · Plan of correction due date: Jun 13, 2025

87456(a)(5)(A) Incidental Medical and Dental Care: (a) A plan for incidental medical..care shall be developed by each facility..(5)Facility staff.. may assist persons with self-administration as needed...(A)Medications.. authorized by the person's physician. This was not evidenced by: Based on observation, interviews, and records reviewed, the facility failed to administer the medication to Resident #1 as prescribed. This poses/posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: The staff involved was provided an in service training regarding the proper administration of medications. The staff involved also voluntary resigned from the position a month later. POC cleared at time of visit.

Type of visit: Required - 1 Year

On 12/14/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Debbie Marroquin/RRD. LPA explained the purpose of today’s visit. The facility is licensed to serve (115) elderly adults ages 60 and above, of which (73) can be non-ambulatory and (5) Bedridden on 1st and 2nd floor. The facility has an approved hospice waiver for (8). The facility is located on a residential neighborhood it consists of a three level structure, The facility has common areas which include, a dining area, tech room, hair salon, fitness center and a library. LPA Iniguez and the Administrator toured the physical plant. There was a gated pool at the premises. No obstructions on the premises. LPA inspected a total of (7) bedrooms and (7) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 115.6°F to 117.4°F, and the room temperature ranged from 76°F to 78°F. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 10/17/24. A review of (5) residents' service files and (4) staff personnel files was performed. LPA reviewed (3) Medication Administration Records (MARs) and found no discrepancies. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was provide to LPA. Facility Annual Fees are not current, LPA provided notice to administrator regarding fees. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -See D page for details. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Debbie Marroquin / RRD.the state’s words, verbatim · CDSS document, Dec 14, 2024

Allegation investigated: Staff did not provide adequate supervision resulting in resident wandering away from facility

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to continue the investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility, interviewed Administrator as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegation that staff did not provide adequate supervision resulting in resident wandering away from facility, the investigation revealed the following: Resident 1 (R1) admitted into the facility on 03/31/2023 with a diagnosis of hypothyroidism. On 04/24/2023, Resident was discovered in the facility parking lot at approximately 3:00 AM after the exit door alarm had triggered. Resident was brought back into the facility with no injuries noted. Physician report dated 03/27/2023 indicated no cognitive impairment and resident is able to leave the facility unassisted. Based on interviews conducted and record review, the allegation is deemed unfounded, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to facility representative. Unfoundedthe state’s words, verbatim · CDSS document, Oct 10, 2024 · control 22-AS-20230426155340

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to follow up on an incident report submitted to the department on May 14, 2024 by Assisted Living Director (ALD), Christina Gonzalez. The purpose of this visit is for a case management incident where a client eloped from the facility on May 10, 2024 and was found by Orange Police Department (PD) on a nearby street. LPA requested resident file and evening staffing roster for May 10, 2024. LPA interviewed resident (R1) to ensure she was okay. Resident did not recall PD finding her and stated she, "took off by herself on a long walk." Reviewing R1's file she is unable to leave the facility unassisted but is able to walk around the building. R1 usually has a friend with her or is in an activity walking during the day but the incident took place in the evening around 7:15pm. The concierge did not see R1 leave the facility. ALD took the call from PD and the son happened to be entering facility at the same time. LPA interviewed S1,S2, S3 and ALD. On November 13, 2023 ALD noted a change in condition with R1. On April 10, 2024 NP with Senior Doc stated R1 is, "incapable of making an informed decision..because of the patient's condition, which includes dementia." Prior to the incident R1 did not have exit seeking behavior and checks in with concierge whenever she walks outdoors. Based on LPA observations and interviews there was adequate staffing, with two medical technicians, three aides and the ALD. After the incident ALD spoke with the son and agreed to use a wander guard for R1. ALD is initiating a care plan meeting for R1 to move to Memory Care due to the progression of cognitive decline. Currently they are awaiting urinalysis results to determine if there are other underlying issues. An exit interview was conducted with RRD Debbie Marroquin and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, May 24, 2024