complaint·January 17, 2026

In regard to the allegation “Facility staff retaliated against resident for filing a complaint”, it is alleged that R1 was put on a 5150 hold for making a complaint against facility. During interviews with residents nine (9) out of ten (10) residents stated staff has never retaliated or treated them poorly for filing a complaint or doing something staff doesn’t agree with. During interviews with staff six (6) out of six (6) stated they have never retaliated against residents for filing a complaint. Administrator stated that a 5150 hold was placed on R1 because of aggression only after being evaluated by the clinician. In regard to the allegation “Facility staff refused resident re-entry resulting in a forced eviction”, it is alleged that when R1 was released from hospital R1 was refused entry to facility. During interviews with residents nine (9) out of ten (10) residents stated that they have never been denied re-entry into the facility. During interviews with staff six (6) out of six (6) staff stated R1 was not denied re-entry to facility. Administrator stated that R1 is conserved and conservator made the decision to move R1 to another facility. R1 was never evicted. In regard to the allegation “Facility staff did not ensure inventory of residents personal belongings were maintained”, it is alleged that R1 had accumulated more inventory and inventory was never taken. During interviews with residents nine (9) out of ten (10) residents stated staff does ask residents to update inventory list when new items are brough in. Residents stated that staff helps them to update list. During interviews with staff six (6) out of six (6) stated they remind residents that inventory list needs to be updated. S3 stated that front desk will stop residents if they see them coming in with something to update their list Staff stated that it is both the responsibility of staff and residents to ensure the list is updated. In regard to the allegation “Facility staff did not ensure residents personal items were safely secured”, it is alleged that items were missing from R1’s belongings when delivered to new facility. During interviews with residents nine (9) out of ten (10) residents stated that nothing has been missing from their rooms due to staff neglect. During interviews with staff six (6) out of six (6) staff stated they take inventory of every item they pack and take pictures before items are delivered or released to residents. Administrator provided inventory list and pictures of R1’s items that were packed. S2 stated they never throw items away and even still have items from three months ago because a resident has not been able to pick them up. In regard to the allegation “Facility staff does not ensure communication is answered promptly and appropriately “, it is alleged that R1 has been contacting facility and staff won’t return phone calls. During interviews with residents eight (8) out of ten (10) residents stated staff does their best to answer them promptly. R2 stated there so busy but they always come to check on me. During interviews with staff six (6) out of six (6) staff stated they have not heard from R1 since he/she has left the facility except when he called to wish the staff a happy new year. Administrator stated R1 has not left any messages. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Ariadna Flores.