complaint·March 14, 2025

Information obtained from a review of documentation corroborated that law enforcement was called to the facility to speak C1 and Administrator. Administrator then allowed C1 to enter the facility and law enforcement escorted C1 back into their room. Based on client and staff interviews and the review of documentation, the allegation that Licensee refused to allow resident to enter the facility has been deemed as substantiated. A substantiated finding indicates the preponderance of the evidence standard has been met. This poses a potential health and safety risk to clients in care. The facility will be cited. An exit interview was conducted. A copy of this report, along with a copy of the LIC9099D, LIC 811, and Appeal Rights were provided. For the allegation that Licensee is not allowing Client to have visitors, it was reported that C1 had their mother denied entrance for a visit. Information obtained from interview with Administrator denied the allegation. Administrator stated that there was an incident were Client’s visitor was knocking rudely on the facility door. Administrator stated when the door was open, the visitor bumped into a staff member who was leaving the facility. Administrator stated the visitor was still allowed to complete the visit. It was advised that the facility maintains a log of all visitors which includes additional details. Interview with Client corroborated the information. Client stated that staff had a verbal altercation with a visitor, but their visitor was still able to meet with Client. Interviews with additional clients and staff corroborated that all clients are allowed visit and no visitors have been turned away. LPA observed the facility did maintain a monthly log for visitors. No concerns regarding visits were advised. Based on the evidence pertaining to the allegations of Licensee not following proper eviction protocols and Licensee not allowing Client to have visitors, the allegations are unfounded. A finding of unfounded indicates that the allegation is false, could not have happened, or is without a reasonable basis. An exit interview was conducted where a copy of this report was provided to Administrator Ma Satchel Lecita. Continuation of Amended report LIC9099-A. It was also reported that when staff would attempt to assist R1 with toileting needs, R1 would refuse assistance. Additional staff interviews were conducted, where 2 of 3 staff reported R1 is verbally abusive and does not allow staff to assist with toileting needs. An interview with R1 was conducted. R1 reported contradicting statements. R1 initially reported staff did assist them with toileting but later in the interview they disclosed that staff do not assist them with toileting. LPA obtained facility records titled “Diaper Log”. This log documents staff assistance with toileting needs. The log is not specific to a resident but instead documents daily assistance. The log was reviewed for January 2025. The log documented R1 refused assistance with toileting a total of 18 times in that month. The log documented R1 accepted assistance with toileting a total of 15 times in that month. Based on interviews and record reviews, the allegation facility staff do not assist with toileting needs is deemed 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. A copy of this report was provided to the Administrator, Ma Satchel Lecita.