complaint·December 15, 2025

Allegation : Lack of supervision resulting in a resident being assaulted by another resident. In regard to the allegation of lack of supervision resulting in a resident being assaulted by another resident: It is alleged that the facility failed to provide adequate supervision, resulting in Resident #1 (R1) reporting concerns regarding her roommate, Resident #2 (R2). During an interview, R1 confirmed the allegation and stated that R2 engaged in behavior including talking to herself and that R1 felt threatened by R2. R1 further alleged that she was sprayed in the face with an unknown chemical substance that smelled like a disinfectant and that her personal belongings were also sprayed and observed to be damp. R1 additionally reported that she has had three (3) previous roommates and stated that those roommates also sprayed her belongings. During an interview with R2, R2 disclosed that she has been unable to get along with R1 due to R1’s difficult personality. R2 denied spraying R1 in the face and denied spraying R1’s personal belongings. Interviews were conducted with other residents (R3–R7); none of the residents interviewed corroborated the allegation or reported concerns related to the alleged incident. LPA interviewed five (5) staff members (S1–S5). All staff stated they did not witness, nor were they aware of, any incidents between R1 and R2. Staff explained that if any incidents occur between residents, staff immediately intervene and address the issue. Administrative staff stated they maintain contact with staff at all times, and staff are aware they are required to report any incidents immediately. Staff further stated that if residents experience difficulties with roommates, staff attempt to address and resolve the issue, including intervening to promote an amicable living environment. (Continued on LIC9099-C) Allegation: Staff did not ensure hazards were inaccessible to residents In regard to the allegation that staff did not ensure hazards were inaccessible to residents: It is alleged that Resident #1 (R1) was sprayed in the face by her roommate, Resident #2 (R2), with an unknown chemical substance while at the facility. R1 reported that the substance smelled like a disinfectant and that her personal belongings were also sprayed and observed to be damp. It was further alleged that the identity and safety of the chemical substance were unknown at the time of the alleged incident. During an interview, R2 denied spraying R1 with any chemicals and denied spraying R1’s personal belongings. LPA and LPM toured the facility and sampled several resident rooms and common areas in an attempt to identify any exposed or accessible chemical substances. During the tour, LPA and LPM observed that facility chemicals were stored in two (2) locked closets located in a hallway near the entrance of the facility. LPA and LPM also observed the housekeeping cart to have a locked cabinet in which all cleaning chemicals were secured while the housekeeper was actively cleaning. No exposed or unsecured chemicals were observed during the tour. LPA and LPM conducted interviews with eight (8) residents (R1–R8). All residents interviewed denied having access to chemicals and stated they are aware that chemicals are not permitted in resident rooms. LPA interviewed five (5) staff members, all of whom confirmed that chemicals are locked at all times, are not accessible to residents, and should never be kept in resident rooms. Staff stated that there should never be resident exposure to chemicals and that staff are expected to closely monitor chemical storage and use at all times. Based on interviews and observations, none of the staff or residents interviewed corroborated the allegation. Based on direct observation, statements and interviews conducted with staff/residents there was not enough supportive evidence to concur with the reported 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, theref ore the allegation is UNSUBSTANTIATED . Exit interview was held, and a copy of thi s report was provided.