complaint·September 4, 2025

Identification and Emergency Information (08/15/24), Physician’s Report (05/16/24), Bank Statement (06/19/24 – 07/22/24), Internal Incident Report (11/12/24), interviewed two staff members and one resident, and observed room 261. On 08/25/25, LPA received R1’s bank statements (12/20/24 – 05/20/25, 06/16/25 – 07/11/25). On 09/04/25, LPA interviewed the Maintenance Director and Executive Director. The investigation revealed the following: Regarding the allegation, “Staff did not safeguard resident’s personal belongings,” it is being alleged that the staff did not safekeep resident’s personal belongings, such as television and purse, during hospitalization. Record review of R1’s personal property inventory (08/15/24) revealed R1 had clothes, five pairs of shoes, two purses, one mirror, and a 32” Sony television (Model #W830K) upon admission. The form does not indicate that it was revisited upon discharge due to missing signatures. Record review of notice (04/14/25) revealed Witness #1 picked up four boxes of personal property for R1. Interview with Maintenance Director indicated that R1’s television was broken because R1 requested maintenance to look at it. LPA observed the broken television (Model #W830K) and there was no visual. Maintenance Director indicated that he doesn’t see the personal property inventory sheet but packs up the resident’s belongings. The Maintenance Director indicated that the clerical staff will complete the inventory sheet. The Executive Director indicated that the inventory sheet is completed unless a resident moves out prior. Three out of five resident interviews (R2, R4 - R5, R7 - R8) indicated that their personal items are safeguarded. Regarding the allegation, “Staff did not safeguard resident’s personal belongings,” based on observations, record reviews and interviews, 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. Continue to LIC9099-C. Regarding the allegation, “Staff did not protect resident from financial abuse,” it is being alleged that R1 left purse with the cards on R1’s bed during hospitalization. On 07/14/2025, R1’s bank informed R1 that there were multiple fraudulent charges made to R1’s debit card totaling $8,240.33. Record review of bank statement revealed R1's balance was $8,583.23 as of 07/22/24. Internal incident report (11/12/24) revealed R1 might go to a nursing home for short-term. Interview with Witness #2 indicated that R1 was admitted into the nursing home on 11/13/24 and was discharged on 03/04/25. Record review of bank statement revealed R1's balance was $1,054.17 as of 12/20/24. Theft and Loss Prevention Program revealed if a resident has to temporarily leave the community for various reasons such as medical care in a hospital, skilled nursing facility, or vacationing, the resident will have a double lock placed on their door to their unit so that no individuals can enter their room. However, R1 had a roommate. Interview with the Executive Director indicated that the facility will place valuables in a locked cabinet at the resident’s request. Six out of six staff interviews (S2 – S6) indicated that the residents have a key to their bedroom door. Four staff indicated (S2, S4 - S6) residents keep their debit cards. Five out of five staff interviews (S2 – S6) indicated that the facility investigates when items are reported lost or stolen. Three out of five resident interviews (R2, R4 - R5, R7 - R8) indicated that their personal items are safeguarded. Regarding the allegation, “Staff did not protect resident from financial abuse,” based on record reviews and interviews, 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. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator Catherine Dacara.