complaint·January 15, 2026

The investigation revealed the following: Regarding the Allegation : Staff illegally evicted a resident in care. This complaint alleged that the facility evicted R1 from the facility. Records review indicate the following: Reviewed incident report (dated 11/29/2025), report indicates that R1 was aggressive with staff and wanted to leave the facility. R1 was transported to the hospital. 01/03/2026 R1 was aggressive and was transported to the hospital for psychiatric evaluation and treatment. 01/09/2026 hospital social worker called and advised that R1 requires a higher level of care due to safety concerns. Interviews indicate the following: S1 indicates that R1 was taken to the hospital and evaluated by social workers and doctors as needing higher level of care. S1 indicates that R1 never returned to the hospital and no notice of eviction was ever given. 3 out of 3 staff deny the allegation. R1 no longer lives at the facility and could not be interviewed. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff illegally evicted a resident in care” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff are serving food that is not of quality to residents in care. This complaint alleged that the facility does not serve quality food. LPA Calderon toured the facility and noted staff had served breakfast to residents and lunch. LPA Calderon noted 2-day supply and 7-day supply of food in kitchen. LPA Calderon did not notice any residents refusing or not eating the food. Records reviewed indicate the following: LPA Calderon reviewed the meal plan for the month. Interviews indicate the following: S1 indicates that S1 purchases quality food that the residents love to eat. S1 indicates that staff serve quality food to residents in care. 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 no longer lives in the facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff are serving food that is not of quality to residents in care” is found to be UNSUBSTANTIATED. Regarding the Allegation : Facility did not ensure that staff received training. This complaint alleged that the facility staff do not train staff that work for the facility. Records reviewed indicate the following: Reviewed training certificate for S1-S3. Training provided to staff CPR/First aid, Medication assistance. Interviews indicate the following: S1 indicates that the facility provides training to staff on an annual basis. S1 indicates that all staff must have training to work for the facility. 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 no longer lives at the facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “facility did not ensure that staff received training” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff are leaving residents unattended. This complaint alleged that the facility does not have staff working weekends. LPA Calderon toured the facility and noted staff working in both homes. Records reviewed indicate the following: LPA Calderon reviewed the LIC500 and noted staff working weekends. LPA Calderon noted staff working in the facility. Interviews indicate the following: S1 indicates that S1 has staff working every day. S1 indicates S1 family lives at the facility and can cover for staff that call in sick. S1 indicates that residents never go unsupervised. 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 no longer lives in the facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff are leaving residents unattended” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff withheld residents funds. This complaint alleged that the facility does not refund R1 money. Records reviewed indicate the following: LPA Calderon reviewed refund calculation (dated 01/09/2026), R1 refund check was given to R1 family. Interviews indicate the following: S1 indicates that R1 refund check was issued on 01/09/2026 and R1 family signed for the check. 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 no longer lives in the facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff withheld residents funds” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff did not keep facility free of clutter. This complaint alleged that the facility does not keep the facility clean and free of clutter. LPA Calderon toured the facility and noted staff have been cleaning. LPA Calderon noted the facility was clean and free of clutter. Interviews indicate the following: S1 indicates that staff clean every day and make sure that the facility is clean and free of clutter. 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 no longer lives in the facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff did not keep facility free of clutter” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff are not providing activities for residents in care. This complaint alleged that the facility does not provide activities for residents. LPA Calderon toured the facility and residents reading, watching tv and outside walking. Records reviewed indicate the following: LPA Calderon reviewed the activity calendar for the month. Interviews indicate the following: S1 indicates that residents have activities to do every day. 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 no longer lives in the facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff are not providing activities for residents in care” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff made altercations to the facility without notifying licensing. This complaint alleged that the facility has residents living in the garage. LPA Calderon toured the facility and did not note any garage or staff or residents sleeping or living in an area not designed for people. LPA Calderon noted 6 residents’ rooms in the facility. Interviews indicate the following: S1 indicates that there is no garage and no residents are sleeping in an area not for residents. S1 indicates that each resident has a room. 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 no longer lives in the facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff made altercations to the facility without notifying licensing” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff did not maintain a comfortable temperature for residents in care. This complaint alleged that the facility does not have AC for the facility. LPA Calderon toured the facility and noted heat in the AM and AC in the PM> LPA Calderon noted the facility had a comfortable room temperature. Interviews indicate the following: S1 indicates that the facility room temperature is controlled. 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 no longer lives in the facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff did not maintain a comfortable temperature for residents in care” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Najma Shaheen (S1).