complaint·January 7, 2026

email correspondence between residents and/or responsible parties regarding renovations being conducted with details of changes, projected timeline, and floor order of work dated 9/23/2025,10/24/2025 and a copy of the Notice dated 9/23/2025. LPA also toured the facility and observed renovations had been done throughout the facility painted walls and new carpet/flooring. The investigation consisted of the following: Allegation 1: Licensee does not ensure that residents are able to sleep at night On 11/21/2025 LPA conducted interviews with staff members 1-5 (S1-S5) and 5 out of 5 staff members stated residents and their responsible parties were informed verbally and by correspondence/email and also provided with the executive director update notice dated 9/23/2025 of the renovations being conducted with details of changes, projected timeline, and floor order of work dated 9/23/2025. Staff also acknowledged some residents did have complaints but understood, under the circumstances, and were made aware of the community cosmetic updates being done and the staff /workers made efforts to minimize disruptions during the night to ensure residents could get sleep at night. The interviews with Resident 1-8 (R1-R8) were as follow, LPA attempted to interview R1 and they no longer reside at the facility, R2 stated that they could not remember anything and R3 was on their way to an appointment and was unwilling to talk. Interviews with residents R4, R5, R6, R7 and R8 revealed that they did not initially recall receiving a notice about the renovations. However, when shown the Executive Director’s update dated 09/23/2025, all five (5) residents acknowledged seeing the notice posted throughout the facility. They also recalled being verbally informed on several occasions about the changes taking place. Residents R4, R5, R6, R7and R8 reported that their sleep was occasionally interrupted due to the renovations but understood the reason for the disturbance and stated although there was some nighttime noise they were able to sleep, and staff/workers made efforts to minimize disruptions during the night. Continued Allegation 2- Licensee does not ensure facility plumbing is maintained in good repair On 11/21/2025 LPA conducted interviews with staff members 1-5 (S1-S5) and 5 out of 5 staff members stated when plumbing issues occur in the building the plumber is called and scheduled for service. LPA also observed documentation of the plumbing service conducted on 10/6/2025 and 10/18/2025 including correspondence confirming relocation of R1 into another room along with refund/credit for inconvenience. The interviews with Resident 1-8 (R1-R8) were as followed, LPA attempted to interview R1 who no longer reside at the facility, R2 stated that they could not remember having any plumbing problems and R3 was on their way to an appointment and unwilling to talk. The interviews with R4, R5, R6, R7 and R8 stated that they have not had any problems with plumbing in their rooms and if they did management would be informed and expressed confidence repairs would be made immediately. Based on interviews, documents reviewed and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and provided to Clifton Douyon - Administrator at conclusion of the visit with appeal rights. Clifton was unavailable to sign the report but Solaange Nkafu was authorized to sign the report