complaint·December 5, 2025

Allegation #1: The Facility does not have sufficient staff to meet residents’ needs. The complaint alleged that residents were wandering unsupervised and that no staff were available. On December 4, 2025, LPA Richard interviewed Administrator #1 (A1), who denied the allegations and stated that the facility employs three staff members per shift. A1 also mentioned that they have two staff on call every day, seven days a week. During the same time frame, LPA Richard interviewed five residents (R1-R5), all of whom denied the allegation. Additionally, LPA Richard interviewed four staff members (S1-S4), all of whom also denied the allegations. They confirmed that the facility provides 24-hour care and that residents are never left alone and stated that the facility operates in three shifts: 6:00 A.M. to 2:30 P.M., 2:30 P.M. to 10:30 P.M., and 10:30 P.M. to 6:30 A.M., from Sunday through Saturday. On December 4, 2025, LPA Richard reviewed the staff schedule and confirmed that the facility maintains three staff members per shift, along with additional staff on call. Based on the information collected from the facility inspection, interviews, and records reviewed, LPA found no evidence to support the above allegations. Although the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegation is unsubstantiated. Report Continued LIC9099C Allegation #2: Resident had access to medications. The complaint alleged that residents were eating breakfast and had small cups on their trays with different pills. On December 4, 2025, LPA Richard interviewed Administrator #1 (A1), who denied the allegations and stated that the facility has a locked room for storing medications, accessible only by staff. A1 also mentioned that staff need a code to open the medication room. The staff regularly assists residents with their medications by placing them on their trays at breakfast, lunch, and dinner. LPA Richard interviewed four staff members (S1-S4), all of whom also denied the allegation. On December 4, 2025, LPA Richard toured the facility and observed that without a code, the medication room could not be opened. Based on the information collected from the facility inspection, interviews, and records reviewed, LPA found no evidence to support the above allegations. Although the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator Venkata Sivaganesh Mullapudi.