complaint·December 18, 2025

(Continued from LIC9099 p.1) Both Wellness Coordinators (supervisors) were working the NOC shift during the timeframe of incident. No witnesses or injuries were found in the internal investigation, and Resident 2 (R2) denied touching R1 or getting up in the middle of the night, as accused. Staff noted that the accusation was also inconsistent with R2's typical behaviors. Both residents reside in the facility's Memory Care building. Resident interviews did not corroborate the allegation, as R1 refused to speak about the situation to LPA during interview. R1 did not confirm that they made the allegation about someone hurting them when asked. R2 was aware that R1 accused them of hurting them, but stated that they did not. R2 informed that they try to stay away from R1 and do not engage with them. Outside source interviews did not corroborate the allegation. An outside advocacy agency staff (OS1) familiar with the facility informed that they did not have concerns about the facility's supervision of residents. OS1 advised having visited the facility and speaking with the residents, none of whom have expressed concern about staff supervision. OS1 stated that the staff properly addressed the situation when the allegation was made. OS1 had not seen any resident care needs go unmet related to supervision. A second outside source familiar with the allegation informed that no physical marks or injuries were observed on R1 when the allegation was made, and that no specific date or time was advised regarding when the event occurred. There were no witnesses to the alleged incident. Records review revealed facility progress notes detailing the accusation, the facility's internal investigation, and required reporting. The "Physician's Report for Residential Care Facilities for the Elderly (RCFE)" for both residents showed that both residents suffered from cognitive impairments, and that neither resident had behaviors of aggression. Preplacement Appraisals for both residents indicated that the residents tended to say to themselves. During and unannounced facility visit LPA walked the property twice. LPA observed caregivers, housekeepers, and maintenance staff walking around the facility. LPA observed caregivers engage with residents and ask how they were doing, as well as provide assistance with Activities of Daily Living (ADLs). LPA observed staff in all buildings where residents were residing throughout the visit. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Clinical Director Yolie Torres , to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.