complaint·December 5, 2025

Adult, threw Resident 1 (R1) to the ground, causing R1 to sustain a black eye. On another occasion, it was reported that this same family member pinched either Resident 2 (R2) or Resident 3 (R3), causing both residents to bleed. It was also reported that residents were forced to bathe and shower in cold water. There were no times, dates or any witnesses identified to corroborate these allegations. Investigation to these allegations are as follows · On April 24, 2025, LPA Cava made a ten day visit to conduct the Health and Safety check. Interview with the administrator between 12:50pm to 1:50pm reveal that there are only four (4) residents living in the home at this time. Administrator states only her and her husband/Staff 1 (S1) are live in staff. Administrator also confirm a family member resides in the home. Review of the facility Personnel Summary via the Licensing Information System (LIS) reveal that all three individuals, including hired staff, Staff 2 (S2), have fingerprint clearance, and are all associated. Additional interviews held with the four (4) of four residents held between 1:50pm to 2:50pm confirm that their needs are met. · On April 25, 2025, this complaint was referred to IB and accepted as an assignment. · On May 14, 2025, IB Investigators Douglas Real and Michele Salant conducted their investigation at the facility and conducted interviews with Administrator, residents and hospice personnel between 1:00pm to 2:00pm · The administrator denied any physical abuse, corporal punishment of facility residents or not providing safe and healthful environment to the residents. These residents reveal their needs are met and express no concerns with staff regarding physical abuse and/or corporal punishment. A hospice nurse who was present at the facility during the day of their investigation expressed no concerns of any personal rights violation, nor received any reports from the residents concerning facility staff. · On September 11, 2025, LPA Cava conducted another complaint (control # 31-AS-20250820130352), with similar allegations of personal rights. LPA interviewed the administrator and one (1) of one staff member, Staff 2 (S2), who both deny these allegations. Interviews with three (3) of three residents also deny any personal rights violation, stating staff are respectful, polite and attentive to their needs. · On December 5, 2025, between 8:30am to 10:30am, additional interviews were made with the Administrator and one (1) of one staff. Between 10:30am and 12:00pm, interviews with four (4) of four residents remain consistent with questions asked by LPA Cava on September 11, 2025. Based on the information obtained, there was insufficient evidence to corroborate the Personal Rights allegation. Therefore, investigation is deemed Unsubstantiated at this time. Licensee allowed Staff and other non-employees to be present without Criminal Record Clearances. In regard to this allegation, it was reported that there is a staff member and another individual, who is not an employe, present at the facility without a criminal record clearance. The individual who is not an employee is identified as the Licensee’s family member. Investigation to this allegation is as follows: · On April 23, 2025, LPA Cava reviewed and printed out the facility personnel report summary. · On April 24, 2025, LPA made a ten-day visit. Interviews with both the administrator and Staff 1 (S1) confirm there are two live-in staff working in the facility. Both confirm that their family members live in the home. A review of the facility personnel summary report per Licensing Information System (LIS) confirmed all three individuals, including Staff 2 (S2), have fingerprint clearance, and association to this facility. · On this December 4, 2025, LPA confirmed that the administrator, S1, S2 and the administrator's family are still involved in facility operation, and are still all associated to the facility. Based on the information obtained, it could not be proven that there is a staff on a non-employee present at the facility without a Criminal Record Clearance. Therefore, the allegation is deemed Unsubstantiated at this time. Facility operated over capacity In regard to this allegation, it was reported that the facility is providing care and supervision to six (6) residents, when it is only licensed for a capacity of four (4). The additional two residents would be hidden in the closet or staff room when the Licensing Agency were to show. Investigation into this allegation is as follows: · On April 24, 2025, LPA made a ten day visit to conduct the Health and Safety check. Interview with the administrator reveal there are only four (4) residents living in the home at this time. LPA conducted a physical inspection to ensure compliance with regulation. The facility is a two story building, with five (5) bedrooms. Three (3) bedrooms are designated for residents. Two of these rooms are private, and one is shared. There is one staff room, occupied by the licensee’s family member on the first floor, and one staff room on the second floor, occupied by the administrator. Closets were checked in all rooms. Closet spaces were observed to be small to hide any person. · On September 11, 2025, in conjunction to a complaint (control # 31-AS-20250820130352), with a similar allegation, LPA Cava also conducted a required annual visit. A physical plant inspection on that date remains the same as what was observed on April 24, 2025. · On December 5, 2025, between 12:00pm and 1:00pm, LPA conducted another physical plant inspection. Both the first and second stories of the building were checked. All five bedrooms, three bathrooms and common areas checked. LPA did not observe a licensee providing care and supervision over their capacity. Based on the information obtained, it could not be proven that the facility is operating over capacity. Therefore, the allegation is deemed Unsubstantiated at this time. Facility Staff did not ensure food served was of the quality necessary to meet the needs of the residents In regard to the allegation, it was reported that residents are being served expired food. There were no witnesses identified to corroborate this allegation. Investigation into this allegation is as follows: · On April 24, 2025, LPA made a ten-day visit to conduct the Health and Safety check. Inspection of the facility kitchen/food service area was inconsistent to the allegation, as no expired foods were observed. Perishable food items in the refrigerator were observed to be freshly dated and sealed. Non-perishable/Canned foods were stocked and maintained in the pantry. Interviews with four (4) of four residents had no concerns with food service at the time. · On September 11, 2025, in conjunction to a complaint (control # 31-AS-20250820130352), with a similar allegation, LPA Cava also conducted a required annual. A physical plant inspection of the facility kitchen and food service area on that date remains the same as what was observed on April 24, 2025. · On this date December 5, 2025, between 12:00pm and 1:00pm, LPA conducted another physical plant inspection and observed the facility kitchen/food service area. LPA observed perishable food refrigerated, properly sealed and labeled. Non-perishable foods were sealed and to date. Nothing was observed spoiled or expired during the visit. Observation of food revealed nothing was exposed to contamination. Based on the information obtained, it could not be proven that staff did not ensure food served was of the quality necessary to meet the needs of the residents. Therefore, the allegation is deemed Unsubstantiated at this time. Facility Staff did not provide managed incontinence care necessary to meet resident’s needs: In regard to the allegation it was reported that residents are not taken to the bathroom when needed, and if they would urinate on themselves, administrator and staff would yell at them. There were no witnesses identified to corroborate with this allegation. Investigation is as follows: · On April 24, 2025, LPA made a ten day visit to conduct the Health and Safety check. Interviews with four (4) of four residents at the time do not corroborate with the allegation. These residents expressed their needs to be met, and had no complaints regarding their care and supervision. · On May 14, 2025, IB Investigators Real and Michele Salant conducted interviews with four (4) of four residents. These residents deny the allegation and confirm that their needs are being met. Investigators also interviewed a hospice nurse who was present. The hospice nurse stated no complaints of neglect reported to them by the residents. · On December 5, 2025, between 10:30am and 12:00pm, another interview was held with four (4) of four residents. Interviews with these residents remain consistent with previous interviews, and confirm their needs are being met. Based on the information obtained, it could not be proven that staff did not provide incontinent care necessary to meet resident's needs. Therefore, the allegation is deemed Unsubstantiated at this time. Facility Licensee made false/misleading statements to Resident family member(s) when reporting an incident In regard to this allegation, R1 sustained a black eye due to a personal rights violation from staff. It was reported to R1’s family that the black eye was caused by a fall. There were no witnesses to corroborate the personal rights violation. R1’s family also could not confirm the incident to R1. Investigation is as follows: · On May 14, 2025, IB Investigators Real and Michele Salant conducted interviews with four (4) of the four residents who deny allegations of personal rights. These residents reveal their needs are met and express no concerns with staff. Investigators also interviewed a hospice nurse who was present. The hospice nurse expressed no concerns about any personal rights violation, nor received any reports from the residents of their personal rights being violated. · On September 11, 2025, LPA Cava conducted another complaint (control # 31-AS-20250820130352), with similar allegations of personal rights. LPA interviewed the administrator and staff, who deny these allegations. Interviews with three (3) of three residents also deny any personal rights violation. · On December 5, 2025 between 8:30am and 10:30am, another interview was held with administrator and one (1) of one staff. Between 10:30am and 12:00pm, interviews with four (4) of four residents were interviewed. These interviews with the administrator, staff and the four residents remain consistent with questions asked by LPA Cava on September 11, 2025. Based on the information obtained, it could not be proven that the Licensee made false/misleading statements to Resident family member(s) when reporting an incident. Therefore, the allegation is deemed Unsubstantiated at this time.