complaint·December 8, 2025

Review of outing sign-up sheets for June and July 2025 showed that the facility offered transportation to multiple different religious services on Sundays. Outing sign-up sheets revealed that R1 signed up for transportation for almost every single recreational outing and religious services in June and July. Interviews with activities staff revealed that the facility owned three vehicles, a bus with a wheelchair lift, a van with a drive-up ramp, and a spare bus given to the facility from a different community. Interviews revealed that the facility’s two buses required repairs, one of which would not be repaired until 7/23/2025. The facility’s van also required smog testing on 7/22/2025 to renew its vehicle registration and facility staff feared that the van would not pass the smog testing. Due to these concerns, the facility had been borrowing a bus from a sister facility when that bus was not already in use by the sister facility. Interviews with staff revealed that R1 attended all outings and religious services that R1 signed up for except for a religious service on one occasion. Staff stated that R1 and another resident used electric wheelchairs and had both signed up for the same religious service, causing staff to question if the borrowed bus, which was the only available vehicle, could accommodate the size of both wheelchairs. Additionally, interviews with staff revealed that the borrowed bus had a physically smaller wheelchair lift with a lower weight capacity than the facility’s normal bus. Interviews revealed that R1 refused to provide facility management with information on the weight of R1’s wheelchair when asked by staff. Additionally, staff stated that due to the smaller size of the lift, R1’s wheelchair wheels would have hung off the edges of the lift, putting R1 in a very unsafe situation. Interviews did not reveal any other instances where R1 was not able to attend outings. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Executive Director Kristel Johnson, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).