Complaint·March 6, 2026

(Cont from 9099) During the interview with R1 on 12/04/25, R1 was asked about the identity of the unknown male who allegedly intimidated them. R1 indicated they did not know what male was being referenced and did not provide any explanation related to the allegation. When asked whether they had any safety concerns within the community and/or with staff, R1 stated they did not. They reported enjoying living in the community, participating in games and activities, and feeling safe in the facility. They did note, however, that some staff lack appropriate training for their roles. Interviews with five (5) of (6) six residents indicated they had never been intimidated by staff and had never observed staff intimidating other residents. Based on the information obtained during the course of this investigation, there is insufficient evidence to support the allegation Administrator intimidated resident. 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 deemed UNSUBSTANTIATED at this time. Staff allowed for a resident to expose themself indecently to others It was alleged that s taff allowed a resident to expose themself indecently to others. To investigate the allegations on 8/13/25, LPA Smith conducted a 10-day visit at which time LPA Smith requested documents relevant to the investigation, interviewed with the administrator and three (3) residents. Interview with S2 reveal was assisting resident #3 (R3) in their room when resident #2 (R2) opened door by accident and immediately apologized for opening the wrong door. Staff revealed that R3 did not get into R3 bed and/or expose themself indecently to others nor did R3 scream and run out of their room. Interview with administrator revealed follow-up was conducted with R2 who admitted to having a beverage containing alcohol prior to coming back to the facility and heading to their room. Interview with R2 revealed that they opened the wrong door on the way to their room but denied getting into R3’s bed and denied exposing themselves indecently to anyone. LPA was unable to interview R3 as residents no longer reside at the facility. Based on the information obtained during course of investigation, there is insufficient evidence to support the allegation. 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 deemed UNSUBSTANTIATED at this time. Continue to (9099C) (Cont from 9099C) Resident wandered out of the facility unsupervised Regarding the allegation above, interview with the ED (executive director) revealed that Resident #8 (R8) is not a resident of Encino Terrace Senior Living but of North Lake Villa and does not maintain any records on the resident additionally are no longer providing temporary location services for Northlake Villa residents as of 12/31/25. Per review of dept internal notes and/or incident reports R8 eloped from facility on 08/16/25. However, information received from staff #8 (S8) by licensing staff on 08/18/25 reveal that all relevant parties were contacted and due to R8 having good mental status, they were able to leave the facility unattended. Based on the information obtained during course of investigation, there is insufficient evidence to support the allegation. 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 deemed UNSUBSTANTIATED at this time Staff allowed for a resident to shout obscenities at other residents It was alleged that Staff allowed for a resident to shout obscenities at other residents. Interview with staff revealed that did not allow resident to shout obscenities however, (R3) has history of psychological issues and having behavior episodes so was sent to the hospital on 08/26/25 and then transferred to a skilled nursing facility (SNF). S1 revealed they took appropriate action to address behavioral issues with R3. LPA Smith was unable to interview R3 as residents no longer reside at the f acility. Based on the information obtained during course of investigation, there is insufficient evidence to support the allegation. 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 deemed UNSUBSTANTIATED at this time Staff did not assist a resident with an injury It was alleged staff did not assist a resident with an injury. Per interview with S1, resident # 9 (R9) has various repetitive soothing behaviors to include rocking, laughing, and putting tissue or straws in nostrils and S1 denies R9 have any injuries that required medical aid or treatment. Review of R9 physician’s report on 03/06/26 reveal R9 has multiple diagnoses to include but not limited to anxiety disorder and schizophrenia. LPA Smith attempted to interview R9 but R9 did not respond to any questions. During previous licensing visits LPA Smith observed R9 removing tissue from nostrils with no blood present on tissues with staff (cont from 9099C) attempting to assist R9. Based on the information obtained during course of investigation, there is insufficient evidence to support the allegation. 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 deemed UNSUBSTANTIATED at this time No hazards observed during visit. Exit interview /conducted copy of report sent.