Complaint·June 29, 2025

Allegation #1 : The Licensee left the resident in a soiled diaper. The complaint alleges that the caregiver left a resident either "soaking wet or that the bedding smelled of urine". On June 28, 2025, between 10:30 AM and 12:00 PM, the Licensing Program Analyst (LPA) interviewed the Memory Care Director (MCD) Alicia Ballard, who denied the allegation. The MCD stated that all residents in memory care receive care checks every 2 to 4 times a day, or as needed, to ensure they are changed and that their continence issues are addressed. The MCD also noted that each resident has different care needs throughout the day. For example, Resident #1 (R1) is checked more frequently due to specific needs. The MCD emphasized that no residents are ever left in soiled diapers or with dried urine. During the same day, between 10:30 AM and 12:00 PM, the LPA interviewed six staff members (S1-S6). Of those, 4 out of 6 denied the allegations, stating that they continuously monitor the residents and promptly change them whenever they notice they are soiled, ensuring residents are placed in dry diapers. Later, on June 28, 2025, between 1:30 PM and 3:00 PM, the LPA interviewed six residents (R2-R7). Five out of 6 denied the allegations, confirming that they are changed before breakfast, after breakfast, before lunch, after lunch, as needed, and at bedtime. They also stated that they are never left in soiled diapers, nor does their bedding smell of urine. On June 29, 2025, the LPA interviewed with Resident #8 (R8), who denied the allegation. Evaluation Report continues LIC 9099-C Additionally, the LPA reviewed R1's Needs of Service Plan dated November 2, 2022, which indicated that R1 is being toileted six times a day and as needed. On 06/29/25, the LPA visited residents' rooms #101 and #107, where the residents appeared to be well cared for, healthy, clean, and showed no smell of urine. The LPA was unable to interview Resident #1 because R1 had passed away. No date was provided. Based on interviews, observations, and records reviewed, there is insufficient evidence to support the allegation: “Licensee left resident in soiled diaper.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; the allegation is Unsubstantiated. Allegation #2: Licensee did not safeguard resident's property. The complaint alleges that the Licensee failed to safeguard a resident's property, which resulted in damage to the hearing aid. On June 28, 2025, between 10:30 AM and 12:00 PM, the Licensing Program Analyst (LPA) interviewed the Memory Care Director (MCD), who denied the allegation. The MCD explained that all residents in Memory Care do not keep valuable items in their rooms; instead, their families retain them. The MCD also stated that for residents who use hearing aids, the nurse places them in the residents' ears each morning, removes them before bedtime, and stores them safely in the Med Tech cart until the next morning. Additionally, the MCD noted that the facility has a theft and loss policy in place for all residents. Evaluation Report continues LIC 9099-C During the same time, the LPA interviewed six staff members (S1-S6). Of those, four out of six denied the allegations, stating that residents had never complained to them about missing items from their rooms. On the same day, between 1:30 PM and 3:00 PM, the LPA interviewed six residents (R2-R7) regarding the allegation. All six residents denied the allegation, asserting that the facility keeps their belongings safe and that they have not lost any of their items; they mentioned that sometimes they might misplace things within their rooms. Additionally, on June 29, 2027, between 11:00 AM and 11:24 AM, the LPA interviewed one resident #8 (R8), who also denied the allegation. Furthermore, during a record review of the admission agreement on June 29, 2025, the LPA found that the inventory policy for resident #1 (R1) did not list any items. LPA was unable to interview resident #1 R1 due to the resident's passing. No date was given. Based on LPA's observations, interviews, and reviews, LPA did not find sufficient evidence to support the allegation that the Licensee did not safeguard the resident’s property. Although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove that it is valid or did occur; therefore, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of the report was provided to Community Relation Director Cynthia Cisneros.