complaint·April 14, 2026

Report Continue LIC 9099… It was alleged that staff failed to provide proper care and supervision to a resident having suicidal ideation. LPA reviewed a sample of eight (8) resident files and gathered various documents, including but not limited to: the staff roster with contact information, resident roster, resident admission agreements, physician reports, care plans, narrative charting, progress notes, and communication log. In addition, the LPA interviewed the Executive Director (ED), seven (7) staff members, and eight (8) residents. All seven staff members stated that if a resident expresses any suicidal ideation, they are trained to ask leading questions, help redirect the resident to understand their thoughts better, and immediately report the situation to the ED or director, who would then contact the Union City Police Department. All eight (8) residents interviewed stated that staff provides appropriate care and supervision whenever residents express—or if they were ever to express—suicidal ideation to staff or anyone else. One resident (R1) clarified, “I do not have any suicidal ideation thoughts. I called the crisis team to talk, but I never mentioned that. I am mad that people keep on asking.” R1 stated, “staff do their round check and check in with me every hour”. Report Continue on LIC 9099c1... Report continue on LIC 9099c1... Allegation: Staff failed to accord privacy to the residents in care- unsubstantiated During the investigation, the Licensing Program Analyst (LPA) conducted interviews with the Executive Director (ED), six (6) staff members, and eight (8) residents. The investigation focused on the allegation that staff failed to respect residents’ privacy or provide adequate privacy for them. The LPA also reviewed relevant facility documents, including staff schedules, resident records, care plans, and policy and procedure manuals regarding resident privacy. During interviews, all eight residents stated that staff consistently provide privacy during personal care activities, such as bathing, dressing, and medical treatment. Several residents mentioned that staff always knock before entering their rooms and ensure doors and curtains are closed when privacy is needed. Residents also reported that staff respect their privacy when they are talking on the phone, ensuring conversations remain private and uninterrupted. No residents interviewed reported concerns about their privacy or described any incidents in which privacy was not respected. R1 stated, “They give me privacy, staff are always there in the med room”. Both staff and residents consistently reported that privacy is maintained during care. Based on the preponderance of evidence, the allegations are unsubstantiated. No deficiencies were cited regarding this allegation. An exit interview is conducted, and a copy of this report is provided.