complaint·September 5, 2025

All five residents (R1-R5) have confirmed they have not received any eviction notice. Witness one (W1) has revealed two (2) names of the reporting parties. Record reviews revealed the following: Eviction notice(s) were requested of any eviction to resident(s) in care. When requested these alleged document(s) were not available during today's visit. Furthermore, the names provided by W1 were not present on the resident roster (LIC9020) nor on the in-house resident roster. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation, “staff confines residents inside of the facility”, it is being alleged that the facility places chairs, indoors, against entrance and exit door knobs which prevents residents to depart from the facility. Interviews have revealed the following: three (3) out of four (4) staff (S1-S2, S4) and all five residents (R1-R5) have denied the allegation has taken place. On 09/05/25, at 10:39AM, LPA's observation revealed the following: LPA observed chairs placed in front of the "original front entrance" (OFE). Staff three (S3) agreed that they have seen chairs placed in front of OFE, yet also stated the following, " Whoever has done that MUST be a resident. I know it was a resident because I saw ( revealed name ) putting the chairs there 'to help keep the facility safe'. They have since moved out, but there is no way a staff is doing that. I can guarantee you it is still a resident doing that, because we have all been trained not to block any entrance/exit door(s)." Based on LPA's interviews and LPA's observation(s) conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation, “staff do not maintain facility in good repair”, it is being alleged that the fire alarm goes off at least twice a week, for no reason. Interviews have revealed the following: all four staff (S1-S4) have confirmed that the fire alarm was emitting an alarm quite often. S 2 stated the following, " We have had that repaired, but we’re waiting to receive the report from the fire department who had come on the same day as our annual visit by LPA Dabuet.". LPA Leon attempted to contact LPA Dabuet to confirm this statement. LPA Dabuet was not available for contact. Record reviews were not available to confirm this statement. All five residents (R1-R5) have confirmed that the fire alarm system has not bothered them; that since the fire department has visited, the alarm has not gone off again and that they are prepared to leave the facility in case of fire. During LPA's one-and-a-half (1.5) days at the facility, LPA has not heard nor observed the fire alarm. Report continues, see LIC9099-C. Based on interviews conducted and LPA's observation(s), the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation, “staff do not ensure that doors are free of obstruction”, it is being alleged that the facility places chairs, indoors, against entrance and exit door knob(s). Interviews have revealed the following: three (3) out of four (4) staff (S1-S2, S4) and all five residents (R1-R5) have denied the allegation has taken place. On 09/05/25, at 10:39AM, LPA's observation revealed the following: LPA observed chairs placed in front of the "original front entrance" (OFE). Staff three (S3) agreed that they have seen chairs placed in front of OFE, yet also stated the following, "Whoever has done that MUST be a resident. I know it was a resident because I saw ( revealed name, date unknown ) putting the chairs there “to help keep the facility safe”. They have since moved out, but there is no way a staff is doing that. I can guarantee you it is still a resident doing that, because we have all been trained not to block any entrance/exit door(s). Record reviews have revealed the following: While LPA reviewed the resident roster, the revealed name is no longer listed which indicate revealed name has since moved out of the facility . While LPA's observation confirms the alleged violation has taken place, LPA has decided this observation has not been conducted by a staff member, as S3 has confirmed "Staff six (S6) even asked me, 'What's up with the chairs at the door?'. So, no, it was not the staff who had done that. It was some resident who ‘wanted to help'. " Based on interviews, LPA observation(s) and record reviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation, “staff do not assist residents with obtaining medical care”, it is being alleged that residents have fallen and there is no staff available to assist residents after their fall. Interviews have revealed the following: All four (4) staff (S1-S4) and four (4) out of five (5) residents (R1, R2, R4, R5) have denied the allegation has taken place. On 09/05/25, from 11:30AM through 12:00PM, LPA observed servers providing all care to residents during today's barbeque in the outdoor, shaded, patio. Record reviews have revealed the following: All four staff (S1-S4) are associated to the facility and have conducted sufficient hours under Title 22, Division 6, Chapter 8, Article 07. Personnel. 87407, 87411 and 87412. Based on interviews, LPA observation(s) and record reviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Report continues, see LIC9099-C. Regarding the allegation, “staff do not monitor residents for change in condition”, it is being alleged that staff do not seek medical care for residents in care. Interviews have revealed the following: All four (4) staff (S1-S4) and four (4) out of five (5) residents (R1, R2, R4, R5) have denied the allegation has taken place. Record reviews have revealed the following: All four staff (S1-S4) are associated to the facility and have conducted sufficient hours under Title 22, Division 6, Chapter 8, Article 07. Personnel. 87407, 87411 and 87412. Crossover notes (dated 08/15/25 through 09/04/25) have presented numerous crossover notes in order to ensure the health and safety of residents in care have been provided to residents in care. Based on interviews, LPA observation(s) and record reviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with staff one, Gloriella Jara - Executive Director and a copy of this report has been provided.