complaint·January 28, 2026

Allegation #1: Staff did not get timely medical care for resident. It was alleged that on 12/03/25, resident #1 (R1) was brought to the Emergency Department. R1 had blurred speech the day before and it was not clear why R1 was not sent to ER within the same day. LPA interviews with the Executive Director and other staff revealed that R1 was sent to the emergency department (ED) immediately when slurred speech was observed. Furthermore, staff revealed that medical assistance, such as calling 9-1-1 during an emergency, has been used for all residents when needed. Residents revealed that in addition to staff, they also have access to call 911 if they need to. A review of facility internal documents verified the information revealed from interviews. Therefore, based on LPA observations, record reviews, and interviews, this allegation is deemed Unsubstantiated . Allegation #2: Staff do not treat residents with respect. Regarding the above allegation, it is alleged that staff was rude and mean to R1 and R1 is trying not to call the police as it was going to make things worse for R1. Interviews with residents revealed that they are happy and have not experienced such treatment from staff. Interviews with staff revealed that they treat all their residents with respect and dignity. Upon review of facility records, including internal incident logs, LPA did not obtain any information to support the allegation. Based on observations, record reviews, and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation #3: Due to lack of supervision, residents go into other residents’ bedrooms at night. It was alleged that a few different men have been going in and out of R1’s room in the middle of the night. LPA interview with S1 revealed that staff would not enter the resident's bedroom unless they are called. Staff would knock first before entering their bedroom. LPA interview with residents revealed that they are happy with the night staff and were well taken care of by the staff and provided with all the care they need. A review of internal records did not provide any information to verify the a validity of the allegation. Therefore, based on the information gathered during this and prior visits, these allegations are deemed unsubstantiated at this time. Continue to LIC 9099-C Allegation #4: Staff handled resident roughly. It was alleged that R1 was slammed against the wall by "a big Hispanic guy" staff member. Interviews with staff and the S1 revealed that no staff handle residents roughly or abuse them. They have no staff matching that description. During a facility tour on 12.16.2025, LPA observed staff handling residents gently and with respect. Based on interviews and observations, there was no evidence corroborating the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to S1.