complaint·December 18, 2025

Interviews were conducted with the Administrator and Staff S1 and Staff S2. In regards to the allegation Staff did not report resident's incident to appropriate parties, based on interviews conducted and information gathered LPA did receive Special Incident Report (SIR) dated 05/12/25 which states that at 9:15PM 05/11/25 Client C1 left the facility to go to a friends house and would return later. Following day 05/12/25 C1 had not returned back to the facility. Report was made to Law Enforcement on 05/12/25 at 3:30PM Case #25-2841 and Case Manager from VA and Conservator for Client C1 were informed. Staff interviewed all stated that Special Incident Report (SIR) was sent on 05/12/25 to Licensing and that Case Manager from VA was notified. 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. In regards to the allegation Staff failed to take action on change of condition, based on interviews conducted and information gathered it was revealed upon observation of Medication Log from the VA dated 04/23/2025 that there was no physician's order for Clonozepam and therefore was not on the Medication list. MAR's Log also for the month of 05/25 did not have Clonozepam on the list of medications. Client's C2-C6 all are with the VA and stated the staff does a great job assisting them on VA appointments and transportation and that they have received all doses of their medication and it has always gone smoothly. Client's C7- C9 said they are assisted with all their medications and it has always gone smoothly. Stated staff are great and also assist with food service and any other needs they may have. Staff all stated that Client C1 was admitted on 03/19/25 and had never been prescribed Clonozepam. All said that Client C1 had not refused taking any medication. Physician's Report under listed medications does not have Clonozepam listed, All staff stated that Client C1 never had a change in condition. It should be noted that Client C1 no longer resides at the facility as of 05/11/25. 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 with Administrator Maria Jacobo conducted and copies of the report provided..