complaint·February 26, 2026

(Cont. from LIC 9099) Interviews with staff reported that they could not recall the resident ever sustaining an injury of this nature and stated that the resident did not report a burn or similar injury to them at the time. Records review of a photograph provided to the department showed a small mark on the top of R1’s nose that appeared consistent with a mole, however, the image was not clear enough to determine whether the mark was a burn or another type of skin irregularity. No evidence corroborates that R1 sustained a burn due to neglect/lack of supervision. Regarding the allegation that neglect resulted in a resident being drugged, R1 stated that the facility cook placed laxatives in R1’s food, though R1 could not recall the date and believed this occurred because the cook did not like R1. R1 also stated that on a separate occasion an unknown staff member put something in R1’s food that caused R1 to “pass out,” and believed the food had been drugged based on similar experiences at a previous facility. Interviews with staff did not corroborate the allegation, as staff stated that medications are never added to meals and that no staff were observed engaging in inappropriate food handling. Interviews reported that they believed R1 did not prefer specific staff members to prepare meals for R1, and that R1 may have disliked certain staff members. Staff stated that no residents, including R1, reported food tampering after meals, and that any adverse reactions would have been coincidental rather than the result of intentional actions by staff. Regarding the allegation that staff did not provide food of good quality, R1 stated that on one occasion, a hamburger patty appeared undercooked and that the cook served a burned grilled-cheese sandwich to another resident. Staff reported no complaints of undercooked or burned food from other residents, and stated that residents are always able to request preferred meals directly from the kitchen and are not required to eat only what is on the menu. Staff further reported that the kitchen makes efforts to adjust or substitute meals whenever possible to accommodate resident preferences. Resident interviews consistently stated that the food quality was acceptable, that meals were not undercooked or burned, and that they were able to request alternative meals from the kitchen when preferred. (Cont. on LIC 9099-C pg. 1) (Cont. from LIC 9099-C) Regarding the allegation that staff did not assist R1 with medication, interviews did not corroborate the allegation, as staff stated that medications were sometimes delayed only when R1 returned late from outings, but otherwise the resident routinely requested medications and declined to sign medication logs when offered. Interviews with residents reported receiving their medications consistently and did not experience any missed or withheld doses. Records review of R1's Physician’s Report (LIC 602) revealed that R1 is permitted to leave the facility unassisted and is able to manage their own medications, including administering and storing medications independently. Review of R1's medication list signed off by a physician revealed that multiple medications were authorized for R1 to self-administer. Regarding the allegation that staff did not treat R1 with dignity, R1 stated that staff made racial and demeaning comments, but R1 could not provide specific statements made by staff. R1 stated that staff had called law enforcement and told them that R1 had several diagnoses. Interviews with staff stated they did not recall any incidents in which police were called regarding R1 and reported that they had not observed any staff speaking to the resident disrespectfully or inappropriately. Records review of R1’s Individual Service Plan indicated that R1 is moderately impaired, is usually unable to make independent decisions, and has judgment that is frequently impaired, requiring cues and supervision for daily functioning. Based on interviews and records review, the department has determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator Susan Caccam, whose signature below confirms receipt of these rights.