complaint·August 1, 2025

The investigation consisted of the following: On 12/20/2024 Licensing Program Analyst (LPA) Watson requested, reviewed, and obtained copies of the Staff Roster, Client Roster, Face Sheet & Emergency Info. Appraisal Needs and Services, Admission Agreement (05/25/21), Physicians Reports (09/28/24), ID & Emergency Information (12/06/24) Copy of Citi Bank Check, December Dietary Calendar, December Activities Calendar (12/25). On 12/20/24 LPA Watson interviewed Staff#1-Staff#4 (S1-S4) and Residents #1-Residients #5 (R1-R5). CONTINUED ON LIC-9099C The investigation revealed the following: Allegation: Staff do not meet residents’ dietary needs. It is being alleged that the staff do not make the necessary dietary adjustments for meals served to the residents. On 12/20/2024 LPA Watson conducted interviews with Residents #2- Residents #6 (R2-R6). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the visit. LPA Watson asked the residents if staff neglected to meet their dietary needs. Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 LPA Watson interviewed Staff #1- Staff #4 (S1-S4). LPA Watson asked the staff if they met the residents’ dietary needs. Of those interviewed, 4 out of 4 staff stated that residents’ dietary needs were met. ON 7/25/2025 LPA reviewed the Physicians Report for (R1), and it showed a special diet recommendation of mechanical soft food. On 7/25/2025 a letter was provided by facility cook, which states that facility kitchen prepared a mechanical soft diet for R1. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson 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, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not meet residents’ dental hygiene needs. On 12/20/2024 LPA Watson conducted interviews with Residents #2- Residents #6 (R2-R6). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the interviews. LPA Watson asked the residents if staff helped them with their dental hygiene needs. Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 LPA Watson interviewed Staff #1- Staff #4 (S1-S4). LPA Watson asked the staff if they assisted residents with their hygiene needs. Of those interviewed, 4 out of 4 staff denied the above allegation. On 7/25/2025 LPA Watson reviewed the Physicians Report for R1 and it showed that R1 needs help with her dental hygiene. Based on the information gathered, interviews conducted, and review of records LPA Watson 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, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not provide outdoor activities for residents. It is being alleged that staff do not schedule outdoor activities for the residents. On 12/20/2024 LPA Watson conducted interviews with Residents #2- Residents #6 (R2-R6). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the interviews. LPA Watson asked the residents if staff provided outdoor activities for them. Of those interviewed, 5 out of 5 residents interviewed stated that activities were provided to them by the facility. On 04/30/25 LPA Watson asked the residents if they were allowed to go outside and participate in outdoor activities. 5 out of 5 residents interviewed stated that they were allowed to go outside and participate in outdoor activities. On 12/20/2024 LPA Watson interviewed Staff #1- Staff #4 (S1-S4). LPA Watson asked the staff if the facility provided outdoor activities for the residents. 4 out of 4 staff interviewed stated that the facility provided outdoor activities for the residents. On 04/30/25 LPA Watson asked the staff if residents were allowed to go outside and participate in outdoor activities. 4 out of 4 staff interviewed stated that residents were allowed to go outside and participate in outdoor activities. On 12/20/24 LPA Watson reviewed the facilities Activities Calendar for December 2024 and observed that every day of the month, the facility scheduled activities for the residents. Further review of records shows that admissions agreement, addendum O, states facility activities programing includes neighborhood walks, field trips and occasional outings. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson 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, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not provide comfortable accommodation to residents. It is being alleged that staff do not ensure that residents living accommodations are comfortable at the facility. On 12/20/2024 LPA Watson conducted interviews with Residents #2- Residents #6 (R2-R6). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the interviews. LPA Watson asked the residents if staff provided comfortable accommodation. Of those interviewed, 5 out of 5 residents stated that the staff provided comfortable accommodations for the residents. On 12/20/2024 LPA Watson interviewed Staff #1- Staff #4 (S1-S4). LPA Watson asked the staff if they provided comfortable accommodation such as private rooms free of noise. Of those interviewed, 4 out of 4 staff stated that residents are provided with comfortable accommodation. LPA Watson toured the facility with the Resident Care Coordinator Marcus Falanai and observed residents being accommodated comfortably in a minimal noise free environment. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson 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, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not provide refunds to responsible parties. On 12/20/2024 LPA Watson conducted interviews with Residents #2- Residents #6 (R2-R6). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the interviews. LPA Watson asked the residents if staff provided refunds to responsible parties. Of those interviewed, 5 out of 5 stated that the staff have never had to issue a refund to them because they and or their responsible parties handled their money. On 12/20/2024 LPA Watson interviewed Staff #1- Staff #4 (S1-S4). LPA Watson asked the staff if they provided refunds to responsible parties. Of those interviewed, 4 out of 4 staff stated that they do not handle or have access to the residents’ monies. LPA Watson reviewed the Admission Agreements for (R1) and it shows on Page 8, under Section VI A. Termination:” This Agreement may be terminated by Resident within thirty (30) days’ written notice, with the rate provided in this Agreement and thereafter modified from time to time, payable to the end of that termination date or Resident’s unit is vacated.” LPA Watson reviewed the Admission Agreement for Resident # 1 (R1) and it states on Page 8, under Section VI “Refunds: Refunds are generally available only if Resident gives Community thirty (30) – days’ advanced notice of his/her intention to leave Community, Refunds , needs will not be adequately met by care provided in the Community, and Resident’s condition prevents him/her giving thirty (30)-days’ written notice to Community/ In such case, a refund will be made on a daily pro-rated basis. Daily charges will not be incurred if the Resident’s person effects are removed from the Community by 12:00 p.m.” LPA Watson followed up with Administrator Joel Niblett regarding refunds and was informed that facility did not receive Thirty day notice of termination from family of R1. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson 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, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not keep the facility in a sanitary condition. It is being alleged that the facility is not maintained in a clean and sanitary condition. On 12/20/2024 LPA Watson conducted interviews with Residents #2- Residents #6 (R2-R6). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the interviews. LPA Watson asked the residents if staff do not keep the facility in a sanitary condition? Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 LPA Watson interviewed Staff #1- Staff #4 (S1-S4). LPA Watson asked the staff if they do not keep the facility in a sanitary condition. Of those interviewed, 4 out of 4 staff denied the above allegation. LPA Watson toured the facility with the Resident Care Coordinator Marcus Fulanai and observed the facility clean, sanitary and in good repair. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson 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, therefore the allegation is Unsubstantiated. An exit interview was conducted with the Administrator Joel Niblett and a copy of this report was provided.