complaint·November 24, 2025

Record reviews revealed the following; on 11/24/25 LPA reviewed October and November activities list, which pertained to dates listed as follows: 10/25/25, 10/26/25, 10/27/25, 10/28/25, 10/29/25, 10/30/25, 10/31/25, 11/10/25, 11/11/25, 11/12/25, 11/13/25 and 11/14/25. The dates provided include, but not limited to, indoor and outdoor activities. During LPA's tour, LPA observed an exercise activity that had began on 10/27/25 from 09:30AM to 10:00AM; also known as "Easy Fitness Exercise". At 10:38AM, LPA observed three (3) individuals conducting hair treatments, including hair coloring and cutting. On 11/24/25, starting at 2:30PM, there is a community meeting to discuss residents smoking outside of designated smoking areas in order to address smoke alarms that have been triggered. All two staff (S1-S2) and four (4) out of six (6) residents (R1-R3, R6) have not agreed the allegation has taken place. 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 the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . Regarding the allegation, "Facility is unkempt", it is being alleged that the outdoors of the facility is unkempt. Upon LPA's arrival, from 09:00AM through 1:30PM, LPA observed a team of landscapers pruning shrubbery and trimming the lawn of the facility. LPA also observed the indoors of the facility to be kept in clean, safe and sanitary fashion. Record reviews revealed the following: An invoice from the landscaping company, dated 10/15/25 and 11/24/25 by Star Garden Supply, have been marked as "clean-up" and "prune and trim" with respective dating. All two staff (S1-S2) and four (4) out of six (6) residents (R1-R3, R6) have not agreed the allegation has taken place. 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 the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . An exit interview was held with staff one, Maria Galvan (S1) and a copy of this report has been provided.