Complaint·February 21, 2026

{***THIS IS AN AMENDED REPORT***} LPA conducted interviews with four residents and four staff members, and all interviewees denied the allegations. LPA was unable to interview all residents in care because two of the six residents were unable to verbally communicate due to medical conditions, and reliable statements could not be obtained. Additionally, LPA toured the facility during the visit and did not observe conditions consistent with the allegations, including any resident bedroom being used as a passageway to another required area. LPA’s observations regarding the allegation that staff did not provide the resident with sufficient room to comfortably and safely accommodate the resident were consistent with the observations noted above and did not corroborate the allegation; additionally, four out of four staff and resident interviews denied this allegation. Record review further reflected that the Department conducted an annual inspection on May 14, 2025, which included a comprehensive inspection of the physical plant, and the inspection documentation did not note concerns or cite deficiencies related to fire clearance, building permits, or unsafe conditions in the facility. LPA’s observations during the current visit were consistent with the information documented during the prior inspection, and no corroborating evidence was identified during interviews or record review. Based on interviews, observations, and record review, the allegations that facility staff did not obtain a building permit prior to facility construction and/or alterations, that a resident bedroom was being used as a passageway to another room, bathroom, or toilet, and that staff did not provide resident with sufficient room to comfortably and safely accommodate resident were determined to be unsubstantiated. Although the allegations could have occurred, there was insufficient evidence to establish, by a preponderance of the evidence, that a violation occurred. An exit interview was conducted, and a copy of this report was provided to Licensee, Jay Shah. {***THIS IS AN AMENDED REPORT***}