complaint·March 30, 2026

Administrator Oosting was interviewed and reported the following information. In December of 2023, Resident 1 (R1) resided in the facility and experienced behavioral challenges due to the progression of their dementia diagnosis. On two occasions, R1 was provided with dress assistance and later removed their own clothing. R1 then attempted to walk towards the beds of Resident 2 (R2) and Resident 3 (R3) while unclothed. However, Administrator Oosting and another caregiver were present during both incidents and successfully redirected R1 back to their room to put on clothing. Staff gently and physically redirected R1 by their arms guiding them towards their bedroom. R1 was never “pulled off” any resident in the facility and never made physical contact with the residents or their beds. Administrator Oosting later learned R1 enjoyed walking around their personal home unclothed and believes the incidents were a result of R1’s increased confusion. R1 was subsequently relocated to a different facility and their contact information is unknown. LPA conducted a collateral visit and interviewed R2. R2 reported that on one occasion, a disoriented resident walked into their room thinking it was their own room and were immediately redirected by staff. However, R2 was unable to identify the resident or recall whether they were clothed. LPA was informed R3 moved out of the facility years ago and has since passed away. CEO Oosting was interviewed and reported in December of 2023, the administrator was unaware the above incidents were required to be reported to Community Care Licensing. On 03/27/2026, the facility was cited for not meeting the reporting requirements regarding R1 and a plan of correction was put in place. Therefore, an additional case management deficiency is not warranted during today's visit. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report and Confidential Names list (LIC 811) was reviewed and provided to Administrator Oosting.