complaint·April 23, 2026

Psychiatric Emergency Team Assessment (10/10/25), and Placement for Evaluation and Treatment documentation (10/10/25). On 10/24/2025 between 08:01 AM – 04:56 PM the department conducted interviews with Staff #1 – #5 (S1–S5) and Resident #2 – #11 (R2–R11). An attempt to interview Resident #1 (R1) was made, but the resident was no longer at the facility and could not be contacted. LPA Watson toured the facility with the Assistant Administrator, Catherine Dacara, and found the facility clean and in good repair. The investigation revealed the following: Allegation: Staff do not prevent residents from smoking inside the facility. It was alleged that staff failed to prevent residents from smoking inside the facility, resulting in R1 reportedly igniting their shirt while smoking in their bedroom, creating a fire hazard and risk of injury. On 10/24/2025 between 08:01 AM – 04:56 PM LPA Watson interviewed Staff #1 – #5 (S1–S5). Out of those interviewed, 5 out of 5 staff denied the above allegation. On 10/24/2025 LPA Watson interviewed Residents #2 – #11 (R2–R11). Out of those interviewed, 10 out of 10 denied the above allegation. On 10/24/2025 between 08:01 AM – 04:56 PM the department conducted an interview with the Assistant Administrator, Catherine Dacara (S1), and they were asked the question: does staff prevent residents from smoking inside the facility? S1 answered that residents and staff are not permitted to smoke inside the facility, and that a designated smoking patio outside the facility is provided for this purpose. The facility enforces its posted house rules prohibiting smoking on the premises, and staff assist residents by holding their cigarettes to ensure compliance and safety. LPA Watson reviewed the Smoking Policy records, and it showed on pg. 1, section 8, under Procedures that “There will be designated times for supervised smoking set by the administration.” A review of the Unusual Incident Report dated 10/09/25 – 10/10/25 revealed that R1 was witnessed on 10/09/25 at approximately 7:00 AM trying to set his shirt on fire using a lighter and attempted to put it out with a broom, causing heavy smoke inside his room. Further review of the Unusual Incident Report also showed that R1 told staff fireworks were shot into his room and caused the smoke, but there was no evidence or proof of fireworks being recovered from that incident. The Department reviewed R1’s file and did not find any other similar incidents. CONTINUED ON LIC9099-C Based on record reviews, staff and client interviews, and observations, there is insufficient evidence to support the allegation: “Staff do not prevent residents from smoking inside the facility.” 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 Assistant Administrator, Catherine Dacara, and a copy of this report was provided.