complaint·January 21, 2026

Regarding the allegation: Staff are in violation of residents’ personal rights. It was alleged that staff have violated residents’ personal rights. To investigate the allegation, LPA attempted interviews with five (5) residents and two (2) staff members. LPA’s interview with three (3) of the five (5) residents denied staff locking them in their room/bed, leaving them unattended and taking away their personal belongings. LPA attempted to interview R4 and R5 but due to their inability to validate the questions being asked, LPA terminated the interview. LPA’s interview with both staff members revealed that a former staff member, who has been terminated but refuses to leave the premises, has caused issues among staff and residents. LPA’s interview with S1 revealed they are in the process with the courts to take care of the matter and have ensured that the residents will not be left alone with said ex-employee. During LPA’s physical plant tour, LPA observed S2 to be present and assisting the residents. LPA did not observe the residents to be left alone or unattended. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Uncleared adults are supervising residents. It was alleged that staff members were working without obtaining proper background clearance. To investigate the allegation, LPA conducted interviews with three (3) residents and two (2) staff members. LPA’s interview with all three (3) residents revealed there are two (2) main caregivers (S2 and S3). LPA’s interview with S1 revealed that a former staff member, who was mentioned by the Reporting Party (RP), is no longer employed by the facility. LPA’s interview with all three (3) residents and two (2) staff members declined that an additional staff member, mentioned by the RP, has not worked at the facility. LPA conducted record review of the following documentation: Personnel Report, Department of Social Services Guardian Background Check System and Licensing Information System (LIS). LPA’s record review confirmed that the six (6) staff members listed on all documents had background clearance and were associated to the facility, including S1, S2 and S3. Based on interviews, observations and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (continue to LIC 9099-C) Regarding the allegation: Licensee does not ensure the Egress alarms are properly working. It was alleged that the facility’s auditory alarms were not working. To investigate the allegation, LPA conducted a physical plant tour. LPA observed a total of two (2) auditory alarms. One located in the front entrance/exit and the other located on the sliding door exit leading towards the backyard. LPA observed both to be functional and in proper condition. LPA observed both auditory alarms to signal when the doors would open. LPA attempted to observe room 5, which has an exit door per the facility sketch, but LPA observed room 5 to be locked. Per S1, room 5 is being occupied by the ex-employee who will not leave the facility. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator. Regarding the allegation: Staff do not follow proper medication management protocol. It was alleged that staff were administering medication to residents without a physician’s order. To investigate the allegation, LPA conducted interviews with three (3) residents and two (2) staff members. LPA’s interview with all three (3) residents revealed that staff have not given them unprescribed medication nor have they witnessed that to be done so. LPA’s interview with both staff members confirmed that all resident’s medications are centrally stored, locked and given as prescribed. However, during LPA’s physical plant, LPA observed R2’s medication to be accessible within the fridge and not locked. LPA observed medications to be stored in multiple areas of the refrigerator. LPA observed R2’s medication to be stored within a zip lock bag located where the perishable foods are kept. Additionally, LPA observed an unprescribed medication to be within a glass bottle wrapped in aluminon foil stored on the second shelf behind the food containers. In addition, LPA observed an unprescribed medication bottle to be located on the door of the refrigerator. LPA’s interview with S1 revealed that R2’s medication is to be locked in a container within the fridge and was unsure how their medication ended up outside of said container. Based on observation and interviews, LPA observed R2’s medication not locked and accessible to residents in care as well as unprescribed medication, therefore the allegation is SUBSTANTIATED, at this time. Citation issued, Please refer to 9099-D. No other immediate health and safety issues observed during the day of the visit. Exit interview was conducted, appeal rights and a copy of this report was provided to the Administrator.