Complaint·May 15, 2025

The investigation revealed the following: Allegation #1- Staff denied a resident access to their personal belongings. It is alleged that the resident was not allowed access to their personal belongings such as clothing, pictures, and snacks while living at the facility. On 05/15/25, the department interviewed staff (S1-S4), and residents (R1-R5) from 10:00am-2:00pm about the allegation. 4 of 4 staff denied the allegation that Staff denied a resident access to their personal belongings. All staff (S1-S4) stated that they have never denied any resident access to their own belongings. They further state that all residents in the facility have full access to all of their personal items and are never denied access to them. The department interviewed residents (R1-R5) about the allegation and 3 of 5 residents denied the allegation, while two residents were unable to participate in the investigation due cognitive difficulties. Residents that were interviewed stated that they have access to all of their personal items and the staff has never denied them access to them. The department toured the facility and observed that all residents had full access to their belongings. There were no locks or barriers observed in the resident’s room to prevent them from accessing any items that belonged to them. Based on interviews conducted, there is insufficient evidence to support the allegation that the Staff denied a resident access to their personal belongings. 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 . Allegation #2 - Staff denied the residents from being properly fed while in care. It is alleged that the residents are not being provided nutritious and adequate meals at the facility. On 05/15/25, the department interviewed staff (S1-S4), and residents (R1-R5) from 10:00am-2:00pm about the allegation. 4 of 4 staff denied the allegation that Staff denied the residents from being properly fed while in care. All staff (S1-S4) stated that they have never denied any resident any food in the facility. They further state that all residents are provided three nutritional meals per day along with snacks. The department interviewed residents (R1-R5) about the allegation and 3 of 5 residents denied the allegation, while two residents were unable to participate in the investigation due cognitive difficulties. Residents that were interviewed stated that they have never been denied any food at the facility. They further state that they receive as much food as they desire to eat and are not deprived of anything. Report Continued on LIC9099-C The department toured the kitchen area and observed that there is more than enough food to provide for the residents in care. The department observed that there is enough perishable and non-perishable food available, which is stored properly. Based on interviews conducted, there is insufficient evidence to support the allegation that the Staff denied the residents from being properly fed while in care. 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 . Allegation #3- Staff did not keep the facility free from rodents. It is alleged that the facility has rodents, and they can access resident’s room because of a rat hole by their bed. On 05/15/25, the department interviewed staff (S1-S4), and residents (R1-R5) from 10:00am-2:00pm about the allegation. 4 of 4 staff denied the allegation that the Staff did not keep the facility free from rodents. All staff (S1-S4) stated that the facility does not have any pests. They state that they have not seen any roaches, mice, rats, or other rodents in the facility. The department interviewed residents (R1-R5) about the allegation and 3 of 5 residents denied the allegation, while two residents were unable to participate in the investigation due cognitive difficulties. Residents that were interviewed stated they have not seen any pests or rodents in their rooms or the facility. The department toured the facility, resident’s bedrooms, and the exterior; and did not observe any pests of any kind. Based on observation and interviews conducted, there is insufficient evidence to support the allegation that the Staff did not keep the facility free from rodents. 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 . Allegation #4- Staff mishandled the resident’s medications. It is alleged that the staff overmedicated a resident in the facility because staff thought their behavior would put them at risk. On 05/15/25, the department interviewed staff (S1-S4), and residents (R1-R5) from 10:00am-2:00pm about the allegation. 4 of 4 staff denied the allegation that the Staff mishandled the resident’s medications. All staff (S1-S4) stated that they have not mishandled residents’ medication nor made any errors in giving the medication. They further stated that if an error was to occur, they would notify the resident’s primary physician, family, as well as licensing about the mistake. Report Continued on LIC9099-C The department interviewed residents (R1-R5) about the allegation and 3 of 5 residents denied the allegation, while two residents were unable to participate in the investigation due cognitive difficulties. Residents that were interviewed stated that the staff have never made any errors to their knowledge with their medication. They state that they receive their medication daily. The department reviewed the medication for all residents at the facility and did not observe any evident medication mistakes or errors. Based on records reviewed and interviews conducted, there is insufficient evidence to support the allegation that the Staff mishandled the resident’s medications. 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 . Allegation #5- Uncleared staff is providing care and supervision. It is alleged that the facility is allowing staff who have not been cleared to work in the facility by not having a criminal record clearance. On 05/15/25, the department interviewed staff (S1-S4), and residents (R1-R5) from 10:00am-2:00pm about the allegation. 4 of 4 staff denied the allegation that the Uncleared staff is providing care and supervision. All staff (S1-S4) stated that all staff that are working in the facility are cleared to work. They state further that no one is allowed to work until being cleared. The department reviewed all staff files and cross checked those files with our own, and did not observe any discrepancies. Each staff file was incompliance with Title 22 regulations and had the required documentation. Based on records reviewed and interviews conducted, there is insufficient evidence to support the allegation that the Uncleared staff is providing care and supervision. 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 . Allegation #6- Staff do not ensure a resident's hygiene need is being met. It is alleged that the resident’s hygiene needs are not being met because staff are not ensuring that the residents are assisted with all activities of daily living. On 05/15/25, the department interviewed staff (S1-S4), and residents (R1-R5) from 10:00am-2:00pm about the allegation. 4 of 4 staff denied the allegation that the Staff do not ensure a resident's hygiene need is being met. All staff (S1-S4) stated that they do ensure that all resident’s hygiene requirements are met. They further state that each resident is bathed daily, along with grooming, dressing, shaving, and personal care. The department interviewed residents (R1-R5) about the allegation and 3 of 5 residents denied the allegation, while two residents were unable to participate in the investigation due cognitive difficulties. Residents that were interviewed stated that the staff does ensure that their hygiene needs are met daily. They state further that they are satisfied with the care and supervision they are receiving from the staff. Based on interviews conducted, there is insufficient evidence to support the allegation that the Staff do not ensure a resident's hygiene need is being met. 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 . No citations were issued for this complaint. An exit interview was conducted, and a hard copy of this Complaint Investigation Report was provided to Angela Love, Administrator.