complaint·November 24, 2025

Two of five staff members have not experienced any roaches at facility but stated that residents have complained about roaches and one staff stated they have witnessed roaches inside a residents room. Interviews with residents conducted have found that seven of ten residents have not experienced any roaches at facility. Three of Ten residents have experienced roaches inside their apartments located in cabinets, sinks and restrooms. The Three of Ten residents who have experienced roaches at facility all stated that facility has sent out exterminator to handle the issue and residents stated that roaches in their rooms have been terminated. Facility provided documentation invoices from Western Exterminator dated from 12/22/2020 to 11/14/2023 and records show company comes out monthly to conduct full service pest control maintenance. During investigation, LPA Tirre has not observed any roaches inside or outside facility during the following inspection dates: 1/12/2022, 10/22/2025, and 11/18/2025. Based on the information gathered during the investigation, the allegation Multiple residents have an issue with roaches in their room, the preponderance of evidence has not been met meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegation is deemed UNSUBSTANTIATED Regarding allegation patio are constantly subject to accumulated moisture and water, the department made observations and conducted interviews with staff & residents and the following information was provided. LPA Tirre conducted visits on 1/12/22, 10/22/25, and 11/18/25 and observed accumulated water on patio areas on 11/18/2025. During LPA’s visit on 11/18/2025 it was noted that the night before it rained. Facility interviews with staff revealed that Four of Five staff stated they have not experienced accumulated water or moisture in outside patio areas. One of five staff stated they have experienced accumulated water but also claimed that the water was a result of rain the night before. Interviews with residents state that five of ten residents don’t have patio areas while the other five residents stated that they have not had any issues with accumulated water or moisture in their patio areas. CONTINUED ON 9099C Based on the information gathered during the investigation, the allegation patio are constantly subject to accumulated moisture and water, has been determined the preponderance of evidence has not been met meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegation is deemed UNSUBSTANTIATED. Regarding the allegation facility has not had a driver and van for over a year, the investigation consisted of interviews and record review. Interviews with staff members stated that Six of Six staff stated that facility has never been without a driver and has transportation van and car available to take residents out on outings and errands. Staff 6 stated they have been facility driver since August 23, 2021. Interviews with residents state that six of ten residents have never had any issues regarding facility van. Four of ten residents stated that they don’t use facility van for transportation. Ten of ten residents stated that to their knowledge the facility van and driver have been available if needed. Records provided by facility show facility had a mileage log that was provided upon initial period of complaint from 1/4/2022 to 1/12/2022. Mileage log shows there have been eight visits during that time period. Additional Transportation Records where residents have signed out for outings show that from 1/2/2022 to 3/9/2022 facility had driver and used van everyday for the exception of five days where log shows that no residents went out of facility. Transportation log notes on two days (1/9/2022 and 2/4/2022) facility did not have any driver available for transportation. Based on information gathered by records reviewed and interviews conducted, the allegation facility has not had a driver and van for over a year was deemed UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported. Regarding Allegation difficulty communicating with Administrator/ General Manager, the investigation consisted of interviews and record review. Per staff interviews two of five staff stated they have not had any issues with Administrator in question, while two of five staff stated they did not work with Administrator in question. One of five staff stated that Administrator was difficult with residents and rude to others. Interviews with residents stated that nine of ten residents didn’t have any issues with staff members. One of ten residents stated that they witnessed rude behavior from Administrator. CONTINUED ON 9099C LPA conducted a record review on Administrator 1 (AD1) and found documentation that AD1 had a Team Member Action Plan dated 3/25/2022 where they were written up for numerous complaints regarding dismissive and unresponsive behaviors through their duties as Executive Director. LPA noted in Staff file that AD1 no longer works at facility and was separated as of 5/3/2022. Based on information gathered by records reviewed and interviews conducted, the allegation difficulty communicating with Administrator was deemed UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported. Regarding allegation smoke alarms are going off in a problematic manner, investigation consisted of interviews, record review, and observations. Per Staff interviews, five of five staff stated they have not experienced problematic alarms and staff stated sometimes alarms will beep if battery is running low. Interviews conducted with residents revealed that ten of ten residents have had no issues regarding problematic smoke detectors. Facility Annual inspections conducted by Department in 2021, 2022 and 2025 show that facility had operating smoke detectors and fire alarms which were inspected and passed by Cosco Fire Protection. During visits on 1/12/22, 10/22/25 and 11/18/25 LPA Tirre did not observe any issues with smoke detectors. Based on information gathered the allegation smoke alarms are going off in a problematic manner was deemed UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported. An exit interview was conducted with Business Office Manager Timarie Morrisey and copy of reports were provided to facility representative.