complaint·November 12, 2025

Allegation: Staff administered medication to the resident without consent. Based on interviews, record reviews, and documentation obtained during the investigation, there is insufficient evidence to support the allegation that staff administered medication to a resident without consent. Medication Administration Records (MARs), physician orders, and resident records were reviewed and showed no discrepancies or indications of unauthorized medication administration. Interviews with staff and residents revealed consistent procedures for obtaining consent before administering medications, in accordance with physician orders and facility policy. Although the allegation may have been made in good faith, there was no direct evidence or witness statements confirming that staff administered medication to any resident without consent. Therefore, the allegation is determined to be unsubstantiated . Allegation: Staff are not properly trained. Based on interviews, record reviews, and documentation obtained during the investigation, there is insufficient evidence to support the allegation that staff are not properly trained. Staff training records, personnel files, and required certification documentation were reviewed and found to be current and in compliance with Title 22 regulations and facility policy. Interviews with staff confirmed they had received training appropriate to their assigned duties, including ongoing in-service and annual training. Although the allegation may have been made in good faith, there was no evidence to indicate that staff lacked the necessary training to perform their responsibilities. Therefore, the allegation is determined to be unsubstantiated . Report continues on LIC 9099 C2... Allegation: Staff are not following infection control practices. Based on interviews, observations, and record reviews conducted during the investigation, there is insufficient evidence to support the allegation that staff are not following infection control practices. Observations during the inspection showed staff adhering to proper infection control procedures, including the use of personal protective equipment (PPE), proper hand hygiene, and sanitation practices consistent with facility policies and Title 22 regulations. Interviews with staff confirmed that they had received infection control training and understood the required protocols. Review of training records and facility policies indicated that infection control practices are regularly reviewed and reinforced. Although the allegation may have been made in good faith, no evidence or observation confirmed that the staff failed to follow infection control practices. Therefore, the allegation is determined to be unsubstantiated . Allegation: Facility is overcharging the resident in care. Based on interviews, record reviews, and documentation obtained during the investigation, there is insufficient evidence to support the allegation that the facility is overcharging the resident in care. A review of resident financial records, admission agreements, and billing statements showed that charges were consistent with the agreed-upon rates and services outlined in the resident’s contract. Interviews with facility staff and residents (or responsible parties) confirmed that fees and billing practices were explained and documented in accordance with regulatory and facility requirements. No discrepancies or unauthorized charges were identified during the investigation. Although the allegation may have been made in good faith, there was no evidence to substantiate claims of overcharging. Therefore, the allegation is determined to be unsubstantiated. Report continues on LIC 9099C3... Allegation: Staff do not ensure residents are provided with activities. Based on interviews, observations, and record reviews conducted during the investigation, there is insufficient evidence to support the allegation that staff do not ensure residents are provided with activities. Review of the facility’s activity calendar, resident participation logs, and staff schedules confirmed that planned activities are offered on a regular basis in accordance with Title 22 requirements and facility policy. Interviews with residents and staff indicated that a variety of activities are available, including group and individual options, and residents are encouraged—but not required—to participate. Observations during the visit also confirmed that activities were being conducted and residents were engaged. Although the allegation may have been made in good faith, there was no evidence to indicate that staff failed to provide or encourage resident participation in activities. Therefore, the allegation is determined to be unsubstantiated. Allegation: Staff do not provide adequate food service. Based on interviews, observations, and record reviews conducted during the investigation, there is insufficient evidence to support the allegation that staff do not provide adequate food service to residents. Meal service was observed during the visit, and food was found to be properly prepared, well-portioned, and served at appropriate temperatures. The facility’s menu was reviewed and found to meet residents’ nutritional needs in accordance with Title 22 regulations and physician or dietician recommendations. Interviews with residents and staff indicated that meals are provided on schedule, with alternative options available for those with dietary restrictions or preferences. Review of food supply records and storage areas confirmed that the facility maintains an adequate quantity and quality of food. Although the allegation may have been made in good faith, there was no evidence to indicate that staff failed to provide adequate food service. Therefore, the allegation is determined to be unsubstantiated. Report continues on LIC 9099C4... Allegation: Facility is not in good repair Based on observations, interviews, and record reviews conducted during the investigation, there is insufficient evidence to support the allegation that the facility is not in good repair. During the inspection, the physical plant, resident rooms, common areas, and outdoor spaces were observed to be clean, safe, and well-maintained. No health or safety hazards were identified, and all fixtures, furnishings, and equipment appeared to be in proper working condition. Interviews with residents and staff indicated no ongoing maintenance concerns, and review of maintenance logs showed that repair requests are addressed in a timely manner. Although the allegation may have been made in good faith, there was no evidence to indicate that the facility failed to maintain the premises in good repair. Therefore, the allegation is determined to be unsubstantiated. Allegation: Facility has pests. Based on observations, interviews, and record reviews conducted during the investigation, there is insufficient evidence to support the allegation that the facility has pests. During the inspection, all indoor and outdoor areas—including resident rooms, kitchen, dining area, and storage spaces—were observed to be clean and free of any signs of pest activity. Interviews with staff and residents revealed no recent reports or sightings of pests. Review of pest control service records confirmed that the facility maintains a regular pest control contract and receives routine inspections and treatments as needed. Although the allegation may have been made in good faith, there was no evidence to indicate the presence of pests at the facility. Therefore, the allegation is determined to be unsubstantiated. Report continue on LIC 9099C5... Allegation: Staff do not securely store residents' personal items. Based on interviews, observations, and record reviews conducted during the investigation, there is insufficient evidence to support the allegation that staff do not securely store residents’ personal items. During the inspection, residents’ rooms and storage areas were observed, and personal belongings appeared to be properly stored. Lockable storage options were available to residents who wished to secure their valuables. Interviews with residents and staff indicated that residents are encouraged to keep personal items in their designated areas and that the facility has policies in place to safeguard residents’ belongings. Review of records revealed no reports or complaints of missing or mishandled items. Although the allegation may have been made in good faith, there was no evidence to indicate that staff failed to securely store residents’ personal items. Therefore, the allegation is determined to be unsubstantiated. Based upon interviews conducted and records reviewed, LPA has investigated the above allegations and found that it is Unsubstantiated. A finding that the complaint allegation/s are Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview is conducted, and a copy of this report is provided.