Complaint·September 12, 2025

W2 reported that due to email issues, it is unknown whether the roster was sent by Hamed and not received due to technical issues or if Hamed simply never emailed the form. W2 reported a document was provided that appeared either incomplete or outdated. It could not be confirmed if this was the current LIC9120. A copy of this document was not obtained. Interview with Administrator Hamed revealed that on June 26, 2025, Hamed recalls being asked for the LIC9120. The Administrator revealed they recalled a discussion where it was mentioned that some information was missing from the LIC9120 and it was requested that the information be added to the form. Administrator Hamed reported that a request to email the LIC9120 was not received as it was Hamed’s observation that the form was received. Interview with 3 of 3 staff revealed they are aware of providing requested documentation upon request. Staff reported a current resident roster is posted in the designated staff area for review. Based on record review, staff and witness interviews, the allegation that facility staff did not provide resident roster to Ombudsman is Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided to facility representative.