complaint·October 23, 2025

However, interviews with six out of six residents stated that staff are assisting residents with incontinence care and that they have no concerns regarding residents being left in soiled clothing. Additionally, three out of four outside agency representatives interviewed reported that they have not observed or detected any incontinence related odors during their visits to the facility. Based on observations and interviews statement conducted during the investigation process LPA Lee was unable to corroborate the allegation. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. An exit interview was conducted with care staff Peti, and a copy of this report was provided to the facility. On 10/21/2025, LPA Lee met with an individual who identified himself as the Assistant Administrator, Veresa Taqaso which LPA Lee was not made aware that the facility had an Assistant Administrator nor have LPA Lee met the individual. Assistant Administrator Taqaso stated that he believed staff #1 (S1) was the facility’s Administrator; however, LPA Lee confirmed that S1 is not associated with the facility as the designated Administrator. Former Administrator Barbara Williams reported that she has not been to the facility since late July and was informed by the Licensee Murphy Grant that he would handle the responsibility for administrative duties. She also confirmed that she resigned as Administrator as of 10/16/2025. Moreover, LPA Lee was not aware that Former Administrator Williams had stopped performing administrator duties and responsibilities. Interviews with two family members of residents corroborated that, following LPA Lee’s visit on 08/05/2025, Administrator Williams has not been present at the facility. They noted that various staff have been coming to the facility since that time and are not sure who are the main caregivers to the facility. Six out of six residents interviewed stated that Administrator Williams has not been seen at the facility since late July and that different staff have been appearing on-site. Residents and family members expressed confusion and concerns about who the caregivers and management staff. Two outside agencies also confirmed that they have not met or communicated with an Administrator at the facility and have only interacted with care giving staff. During a telephone call with Licensee Grant on 09/22/2025, he stated that Administrator Barbara Williams would continue to serve as the facility’s administrator until a new administrator was hired. However, it was learned that Administrator Williams had not been present at the facility since LPA Lee’s visit on 08/05/2025. According to the facility’s LIC 500 Personnel Report dated 08/27/2025, Barbara Williams was listed as the designated administrator. The LIC 500 however, did not specify the days and hours that administrator Williams would be present at the facility. During LPA Lee’s visit on 10/21/2025, a newly posted LIC 500 dated 10/20/2025, was observed at the facility. This updated report listed Filipe Naikaso as the designated administrator, with the following schedule: Saturday from 9:00 a.m. to 5:00 p.m., Sunday from 9:00 a.m. to 5:00 p.m., and Monday from 5:00 p.m. to 9:00 p.m. On 10/02/2025, Licensee Grant emailed LPA Lee requesting to change the designated administrator and associate Naikaso in the role as the new administrator to the facility. However, on October 13, 2025, LPA Lee sent a follow-up email to Licensee Grant indicating that Filipe could not be associated as the new administrator until documentation of Filipe’s education or equivalent qualifications was received. CONTINUED LIC 9099-C As of today, LPA Lee has not received the required documentation verifying Filipe’s education or equivalent qualifications. Based on observation, records review and interviews statement conducted during the investigation process LPA Lee was able to corroborate the allegation. As a result, this allegation is SUBSTANTIATED . A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with care staff Peti and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.