complaint·January 21, 2026

Staff interviewed stated that R1 sustained some falls due to R1 attempting to transfer herself, even though she required assistance with transferring. Staff interviewed also stated that the facility put fall prevention methods in place for R1. The fall prevention methods put in place for R1 included a lowered bell, a fall mat, a tab alarm, and additional routine checks. Additionally, staff interviewed stated that R1 did not sustain any injuries from her falls at the facility. Although R1 sustained falls while at the facility, staff interviewed confirmed that fall prevention techniques were put in place to deter future falls, and prevent any serious injuries. Regarding the allegation, facility forcing resident to take medications, the following has been concluded: It was alleged that R1 was forced to take medications. The Department conducted an interview with R1. However, R1 was unable to provide a statement regarding this allegation. The Department conducted seven resident interviews. One resident was unable to be qualified for an interview and another resident declined to be interview. However, five out of the seven residents interviewed denied the allegation and stated that they have never been forced to take any medications. The Department conducted four staff interviews. Four out of the four staff interviewed denied the allegation and stated that R1 was never forced to take any medications. Regarding the allegation, facility not allowing resident access to their bedroom, the following has been concluded: It was alleged that the facility did not allow R1 access to her bedroom. The Department conducted an interview with R1. However, R1 was unable to provide a statement regarding this allegation. The Department conducted four staff interviews. One out of the four staff interviewed was unable to recall any information about this allegation. However, three out of the four staff interviewed denied the allegation. Staff interviewed stated that R1 was encouraged to be in the main activity room so that she could be observed by more staff since she had a history of falls at the facility. Staff interviewed also stated that they would assist R1 to her bedroom if she requested to go there. The Department conducted seven resident interviews. One resident was unable to be qualified for an interview and another resident declined to be interview. However, five out of the seven residents interviewed denied the allegation and stated that they are allowed to go to their bedrooms whenever they want to. Regarding the allegation, facility administering medication without obtaining consent from resident's responsible party, the following has been concluded: It was alleged that the facility administered R1's PRN Ativan medication without obtaining consent from R1's responsible party. CONTINUED ON LIC9099-C Regarding the allegation, facility not providing a variety of meals to resident, the following has been concluded: The Department conducted seven resident interviews. One resident was unable to be qualified for an interview and another resident declined to be interview. However, five out of the seven residents interviewed denied the allegation. Residents interviewed stated that they are satisfied with the food provided by the facility. Residents interviewed also confirmed the facility provides alternative food options if they do not like the meals that are served on that day. The Department conducted four staff interviews. Four out of the four staff interviewed denied the allegation and confirmed the facility provides alternative food options if residents are not satisfied with the meals that are served on that day. The Department inspected the food menu provided to residents and observed the facility provides a variety of food options to residents. The Department also observed that residents are able to order off of the alternative menu if they are not satisfied with the food options served on that day. Based on the evidence gathered during this investigation, the complaint is UNFOUNDED, meaning that the two allegations are false, could not have happened and/or is without reasonable basis. An exit interview was conducted with Executive Director Enrique Ledesma and a copy of the report was provided. The Department conducted an interview with R1. However, R1 was unable to provide a statement regarding this allegation. The Department conducted four staff interviews. One out of the four staff interviewed was recall any information about this allegation. However, three out of the four staff interviewed denied the allegation. Staff interviewed stated that consent was received from R1's responsible party regarding R1's PRN Ativan medication. The Department was unable to review any medication administration records for R1 due to R1 moving out of the facility on September 19, 2022. Additionally, the facility no longer has any records for R1 on the premises. Due to the conflicting information received during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the four allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Enrique Ledesma and a copy of the report was provided.