complaint·November 20, 2025

The investigation revealed the following: Allegation: Unqualified staff providing medical care. The detail of the complaint alleges that “staff are asked to do ‘medical tasks’ that they aren’t qualified to do.” On November 20, 2025, at 1:15 pm, the Department interviewed Nisha Henson, Residential Care Coordinator(A1) who denied the allegation stating there are no unqualified staff providing medical care. All the Med Techs and the care staff are qualified. On October 28, 2021, the Department interviewed 5 staff members, including the administrator (S1–S5), about the allegation. 2 of the 5 said some staff may be asked to perform tasks outside their usual scope when needed, but those staff are typically cross-trained in related duties such as medication technician and caregiver tasks. The other 3 staff said they are not asked to perform tasks outside their scope. On October 28, 2021, the Department interviewed 3 residents (R1–R3). All three residents said they are well cared for and that only medication technicians have administered their medications. On November 20, 2025, the Department reviewed 4 staff files and found that they contained required certifications and training. Additionally, the Department reviewed and evaluated the staff training certificates (dated: 4/1/21). Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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, therefore the allegation is UNSUBSTANTIATED. Page 2 of 3 Allegation: Staff tested positive for COVID The detail of the complaint alleges that a staff member tested positive for COVID and was asked not to disclose information to other staff. On November 20, 2025, at 1:15pm, the Department interviewed Nisha Henson, Residential Care Coordinator (A1). A1 denied the allegation and stated the facility has a COVID mitigation plan on file that staff follows. The complaint alleges a staff member tested positive for COVID and was told not to disclose it to other staff members. COVID test results are confidential, and a positive result is not a violation of Title 22. Interviews and review of documents show the administrator addressed the positive test with staff and arranged testing while maintaining staff confidentiality. Based on the information gathered there is insufficient evidence to support the allegation mentioned above; 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, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today's visit. Exit interview conducted and copy of report provided. Page 3 of 3