complaint·April 23, 2025

The investigation revealed the following: Allegation #1-Staff are not meeting resident's needs. The details of the complaint alleged that the staff does not assist resident with dressing and putting on back support for an injury. On 4/23/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R8) regarding the allegation. Staff (S1-S4) denied the allegation that the Staff are not meeting resident's needs. Staff (S1-S4) stated that the facility does help residents with any assistance that is needed. They stated that each resident has a phone and a call button in their room to use if assistance is needed, day or night. They further state that the facility is sufficiently staffed to meet the needs of all their residents. The department interviewed residents (R1-R8) about the allegation and 7 of 8 residents that were interviewed denied the allegation that Staff are not meeting resident's needs. The majority of residents interviewed (7 of 8) stated that the staff are meeting their needs and are satisfied with the care and supervision they are receiving at the facility. The Department reviewed the Resident Service Plan (Dated: 03/17/25, 03/17/25, 03/24/25), Physicians Report (Dated: 06/03/2024, 06/11/2024, 03/07/2025 & 07/03/2024), Identification and Emergency Information (Dated: 10/16/2024, 02/02/2022, 06/24/2021, & 10/31/2023), Resident Appraisal (Dated: 02/17/2025, 02/06/2024, 09/28/2024 & 03/07/2025) and observed that the residents interviewed have a documented service plan in place and a supportive team to assist them with their individualized needs for care in the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are not meeting resident's needs. 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 Unsubstantiated . Allegation #2- Staff are not preventing residents from smoking in non-designated smoking areas. The details of the complaint alleged that the facility is not preventing residents from smoking all over the facility without restriction and smoke comes into the building. On 4/23/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R8) regarding the allegation. Staff (S1-S4) denied the allegation that Staff are not preventing residents from smoking in non-designated smoking areas. All staff (S1-S4) stated that the facility does enforce restricted smoking. They state that there is a non-smoking and a smoking patio area for residents to sit outside of the facility. They state that smoking is not allowed in the building and if residents are caught smoking in the building, they are reminded of the house rules and given a warning that it is grounds for eviction if not followed. The department interviewed residents (R1-R8) about the allegation and 7 of 8 residents that were interviewed denied the allegation that Staff are not preventing residents from smoking in non-designated smoking areas. The majority of residents that were interviewed stated that the staff does enforce smoking only in designated areas. They state that smoking is only allowed in the smoking only section patio and in the outer parking lot of the facility. They further state that they have not seen residents smoking inside the facility. Report Continued on LIC9099-C Page 2 of 3 The Department reviewed the House Rules (Dated: 09/11/2023) and observed that in the rules of the facility, it is documented that smoking is not permitted in buildings or in rooms, and designated areas are available. Additionally, it states that failure to follow the house rules are grounds for eviction. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are not preventing residents from smoking in non-designated smoking areas. 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 Unsubstantiated . Allegation #3- Staff are not meeting residents’ level of care needs. The details of the complaint alleged that the staff are not meeting the level of care for residents in the facility. On 4/23/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R8) regarding the allegation. Staff (S1-S4) denied the allegation that Staff are not meeting residents’ level of care needs. All staff (S1-S4) stated that the facility has individualized resident service plans for each resident and deny that they are not meeting the residents care needs. They also stated that each resident has a call button and a telephone in their room if assistance is needed and they have enough staff to meet the needs of all their residents in the facility. The department interviewed residents (R1-R8) about the allegation and 7 of 8 residents that were interviewed denied the allegation that Staff are not meeting residents’ level of care needs. The majority of residents interviewed (7 of 8) stated that they were satisfied with the level of care being provided to them by the staff at the facility and had no complaints. The Department reviewed the Resident Service Plans (Dated: 03/17/25, 03/24/25) and Resident Appraisals (Dated: 02/17/2025, 02/06/2024, 09/28/2024 & 03/07/2025) and observed that the facility has service plans in place for the residents and they have been appraised before admittance into the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are not meeting residents’ level of care needs. 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 Unsubstantiated . No citations were issued. An exit interview was conducted with Hermelinda Cardenas, Administrator, and a hard copy of this Complaint Investigation Report was provided. Page 3 of 3