Complaint·November 13, 2025

On 11/13/25 at 10:05 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an initial 10-day visit to investigate the above allegation. At the time of visit, LPA conducted a physical plant tour; no health and safety issues were observed. LPA requested and received resident and staff roster, Resident#1 (R1's) file, and documents relevant to the investigation. Between 11:15 am the 1:45 pm, LPA conducted interviews with Admin, Staff, and Residents. Prior to this visit on 01/06/2026, LPA Comer conducted a phone interview with the Resident Services Supervisor, and discussed staffing schedule and duties. In addition LPA Comer spoke with other parties involved in R1’s care. At the time of this visit, at 11:15am, LPM Margaryan and LPA Comer conducted a tour of physical plant and observed facility staff assisting residents for various activities of daily living. In addition, between 11:45am and 12:30pm, additional interviews were conducted with the staff present at the facility. Administrator and Staff revealed that the facility maintains sufficient number of staff to provide adequate care and supervision for all residents. Staff interviewed during investigation were able to explain their work assignments and the time they spent assisting each resident with various tasks of the activities of daily living. Staff stated their response to residents is completed within an average of two to ten minutes. Resident's room health checks are completed a minimum of every two hours per shift. LPA interviews with ten (10) out of (11) residents stated that they had no concerns about staff assistance, and they feel there is adequate staffing at the facility. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time. An exit interview was conducted with the Administrator. A copy of this report was provided, and appeal rights were provided.