Incident investigation·September 25, 2025

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility to complete a case management visit. Upon arrival, LPA was met by Executive Director (ED) and was granted entry into the facility. LPA explained the purpose of the visit. On September 25, 2025, Community Care Licensing received an incident report from the facility regarding a concern that staff member (S1) overheard another staff member (S2) state, “we need to force her to bed,” in reference to a resident (R1). The facility’s Human Resources department conducted an internal investigation and determined that no abuse occurred. The incident was attributed to a language barrier between two staff members. During today’s visit, LPA conducted an interview with R1. R1 denied the allegations, and LPA did not observe any signs of physical abuse or negligence. Facility staff interviews and observations further supported that no abuse had taken place. Based on the information obtained during this visit, no deficiencies are being cited at this time. An exit interview was conducted, and a copy of this report was provided to the Executive Director.