complaint·November 18, 2025

The investigation consisted of; review of requested/obtained documents; staff roster, client roster, R1’s face sheet, R1 placement agency contact, R1’s physician report dated 09/09/2025, R1’s medical/health summary dated 08/19/2021, a court ordered examination/competency evaluation dated 03/02/2015, R1’s third party caregivers. Review of R1’s court order dated 04/09/2015. Interviews with staff, residents and witnesses and LPA observations. NOTE: Due to the displacement of individuals from 2025 Eaton Fires, The facility, has been housing residents on an emergency basis, including R1. Regarding the allegation: Staff is sleeping in the same room as a resident . It is alleged that a facility staff person is sleeping in the resident’s room. Five (5) out five (5) staff denied the allegation. Staff interviewed stated that no facility staff person is sleeping in a residents’ room. Staff interviewed stated the R1 is a placement from the Eaton Fire and is a temporary resident since 01/08/25. Three (3) of four (4) witnesses interviewed stated R1 has a court order that was issued in April 2015. The court order allows R1 to be placed in a behavioral facility with constant 1:1 staff supervision that is provided to R1 on 24-hour basis for seven (7) days a week. R1’s placement agency placed R1 in the facility on 01/08/25, as a result of being displaced due to the Eaton Fires and informed the facility administrator of the details of R1’s court order. According to W1, R1 needs continuous and constant 1:1 staff supervision, therefore, per the court order, R1 is assigned two third party caregivers (W2, W3). W2 provides care and supervision to R1 for 24 hours/ 6 days per week and W3 provides care and supervision to R1 for 24 hours/1 day per week. R1’s placement agency assigned W2, W3 a bed in R1’s room to monitor and provide support to R1’s due to R1s behaviors issues. Based on records reviewed, interviews conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Administrator Kim Commodore and a copy of LIC 9099, LIC 9099C were provided to Administrator Kim Commodore.