Complaint·March 10, 2026

with a padlock at night, typically between 9:00 PM and 10:00 PM, to prevent intruders from entering the facility. Based on these interviews with facility staff, LPA Lee was able to corroborate the allegation that the front gate is locked by staff. As a result, this allegation is SUBSTANTIATED. The finding that the complaint is substantiated means that the allegation is valid because the preponderance of the standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with care staff Mataitoga and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. LPA Lee interviewed five out of five residents, who stated they have no concerns regarding the facility phone. It was also learned that some residents have their own cell phones and primarily communicate with family members using their personal phones rather than the facility phone. Based on interviews with residents and staff, it was reported that residents had been informed that the facility phone was temporarily not working due to issues with the cable service. The facility had reported the issue to the service provider and informed residents that they could use the staff member’s cell phone if needed while the service was under maintenance. The complainant also stated they were unaware that there had been a change of ownership and had been calling the previous phone number associated with Abounding Love III. The complainant was not aware that a new phone number had been established under the new ownership. During observations conducted on 01/08/2026 and 03/10/2026, LPA Lee observed a house phone located in both the kitchen and the staff room. On 03/10/2026 it was observed that the phone is in good repair. Additionally, it was reported that the concerns by the complainant were related to the previous licensee prior to the change of ownership. Based on interviews and observations conducted during the investigation, LPA Lee was unable to corroborate the allegation. It was alleged that staff do not ensure residents are served a variety of foods. This investigation included interviews with residents and staff, as well as observations. LPA Lee interviewed four out of five residents, who stated they have no concerns regarding the food being served. Resident 1 (R1) stated that the “food is good,” but also mentioned that the facility has “limited variety.” Interviews with facility staff denied the allegation and stated that they do provide a variety of foods to residents in care. Based on observations conducted on 01/08/2026, LPA Lee observed the following items being served for breakfast: scrambled eggs, strawberries, sausage, waffles, and coffee. For lunch, LPA Lee observed hamburgers, fries, oranges, apples, water, soda, beef patties, lettuce, mushrooms, tomatoes, and onions being served. During 03/10/2026 visit, LPA Lee also observed a variety of food being served for breakfast and lunch. Additionally, it was reported that the concerns by the complainant were related to the previous licensee prior to the change of ownership. Based on interviews and observations conducted during the investigation, LPA Lee was unable to corroborate the allegation. It was alleged that staff do not meet residents’ incontinence needs and staff do not ensure residents’ personal needs are being reassessed as needed. CONTINUED LIC 9099-C This investigation included interviews with residents and staff, a review of records, and observations. LPA Lee interviewed five out of five residents, who stated they have no concerns regarding their incontinence needs not being met and and four out of the five reported that they are able to manage their own care. (R1) stated that they do not require assistance with incontinence care and is able to manage it independently. Facility staff interviewed denied the allegation and stated that two residents require assistance with incontinence care and that staff regularly change the residents’ incontinence briefs. Based on records reviewed, R1’s Physician’s Report dated 02/03/2026 and Needs and Services Plan indicate that R1 does not have bowel or bladder incontinence and is able to perform activities of daily living independently, with the exception of medication management. During facility visits on 01/08/2026 and 03/10/2026, LPA Lee did not observe any incontinence odors in the facility. Additionally, it was reported that the concerns by the complainant were related to the previous licensee prior to the change of ownership. Based on interviews, records review, and observations conducted during the investigation, LPA Lee was unable to corroborate the allegation. It was alleged that staff threatened residents. This investigation included interviews with residents and staff, as well as a review of records. LPA Lee interviewed five out of five residents, all of whom denied being yelled at or threatened by staff and stated that they had not observed staff yelling at or threatening other residents. R1 also denied being threatened by facility staff, reported no concerns, and stated that they feel safe living in the facility. Facility staff were interviewed and denied the allegations. During the investigation, it was also learned that R1 had been smoking in their room, which is against the facility’s house rules. Staff reminded R1 that the designated smoking area is located in the courtyard and reported that R1 had been redirected on two separate occasions. Staff also explained to R1 that failure to follow house rules could result in eviction, as smoking inside the room poses a fire safety risk to all residents in the home. A review of R1’s admission agreement confirmed that smoking is not permitted inside the premises and is only allowed in designated outdoor areas. House rules were also reviewed up admission and posted in the facility. Since that discussion, R1 has stopped smoking in their room. Additionally, it was reported that the concerns by the complainant were related to the previous licensee prior to the change of ownership. Based on interviews, records review, and observations conducted during the investigation, LPA Lee was unable to corroborate the allegation. CONTINUED LIC 9099-C It was alleged that staff do not meet residents’ personal care needs. This investigation included interviews with residents and staff, observations, and a review of records. LPA Lee interviewed five out of five residents, all of whom denied that staff do not meet their personal care needs. R1 stated that they receive assistance with hygiene when needed. During LPA Lee’s visit to the facility on 01/08/2026 and 03/10/2026, all residents were observed to be clean and groomed. On 01/08/2026, R1 was observed to have long hair and a beard. R1 stated that they preferred to keep their hair and beard long and did not wish to have them cut. R1’s fingernails and toenails were also observed and were not overgrown. During a facility visit on 03/10/2026, R1 was observed to be clean and well-groomed. R1 no longer had long hair or a beard, and it was learned that R1 had decided to have them cut. Additionally, R1’s toenails were observed and were not overgrown. R1 reported that they are able to trim their own toenails, and when assistance is needed, facility staff will provide support. R1 also stated that they have no concerns and confirmed that they receive assistance with personal care when necessary. A review of R1’s LIC 602 Physician’s Report and Needs and Services Plan indicates that R1 is able to provide their own self-care, including bathing, grooming, and managing their own toileting needs. Additionally, it was reported that the concerns by the complainant were related to the previous licensee prior to the change of ownership. Based on interviews, records review, and observations conducted during the investigation, LPA Lee was unable to corroborate the allegation. It was alleged that staff did not ensure medications were inaccessible to residents. This investigation included interviews with residents and staff, as well as observations. LPA Lee interviewed five out of five residents, all of whom stated that they do not keep medications in their rooms and that facility staff securely store them in a locked cabinet. Residents also confirmed that they receive their medications from staff. Facility staff denied the allegations and stated that all residents’ medications are stored in a locked, secure area designated for that purpose. During visits on 01/08/2026 and 03/10/2026, LPA Lee observed that no medications were present in residents’ rooms and that all medications were securely stored in the entry closet, making them inaccessible to residents. Additionally, it was reported that the concerns by the complainant were related to the previous licensee prior to the change of ownership. Based on interviews, records review, and observations conducted during the investigation, 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.