Complaint·December 2, 2025

The investigation revealed the following: Allegation: Facility staff failed to properly supervise a resident. It is being alleged that R1 is supposed to receive 16 hours of one-on-one care a day and is often left unattended. It is also being alleged that staff is sleeping while caring for R1. On 08/05/25, LPA Gonzalez conducted a review of records and revealed the following: A Care Plan for R1 notes that R1 requires total care, including feeding with aspiration precautions, and 24-hour supervision to ensure safety. A review of the facility’s Periodic Check Sheets (for the dates of 05/27/25 – 07/28/25) revealed that R1 was receiving around the clock care from facility and agency staff. On 08/05/25, between 11:20 AM and 01:30 PM, LPA Gonzalez conducted interviews with S1-S6. Of those interviewed, 6 out of 6 staff denied the allegation. 5 out of 6 staff said that R1 has not been left unattended by staff, and 1 out of 6 staff said they did not know if R1 has been left unattended by staff. 4 out of 6 staff said that no staff has been observed sleeping in R1’s room, and 2 out of 6 staff said that staff has been observed sleeping in R1’s room. An interview with Luz Rose, Administrator, revealed that it was brought to her attention that a staff member was observed sleeping in R1’s room while they were supposed to be caring for them. Luz Rose said that the caregiver in question was from an agency and not one of her caregivers at the facility. Furthermore, Luz Rose said they handled this matter immediately after becoming aware of it, and said the facility is no longer dealing with that agency. On 08/05/25, between 01:40 PM and 03:00 PM, LPA Gonzalez conducted interviews with R1-R6. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. 6 out of 6 residents said they are receiving assistance as needed from staff. 6 out of 6 residents said facility staff are meeting their needs as far as care. 5 out of 6 residents said they are receiving the services they signed up for, and 1 out of 6 residents said they sometimes receive the services they signed up for. 5 out of 6 residents said they are happy with the care and supervision the staff is providing them, and 1 out of 6 residents was unable to answer due to intense emotional distress. Continued on LIC9099-C On 08/05/25, LPA Gonzalez and Theresa Pascual toured the facility and inspected R1’s bedroom #320. LPA observed R1 laying down on their bed and watching TV. LPA observed a caregiver sitting on the chair next to R1 and engaging and caring for the resident. LPA observed R1’s room to be clean and sanitary. Based on observation, interviews conducted, and a review of records, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is unsubstantiated. No deficiencies were cited during this investigation. An exit interview was conducted, and a copy of this report was provided to Administrator, Luz Rose.