Complaint·January 21, 2025

Interviews with the licensee, staff, and staff at St. Paul’s Pace, including medical personnel, was conducted. It was determined College Town licensee and staff had contacted St. Paul’s Pace on several occasions prior to R1’s last hospitalization while at College Town to request he be transferred to another facility that could provide a higher level of care to R1. Interviews revealed that College Town had reported a change in behavior and declining health to St. Paul’s Pace due to R1 not being able to stand and being more prone to falls. Interviews with outside source revealed a social worker from St. Paul’s Pace confirmed this and provided documentation. Interviews revealed that although several injuries were documented there wasn’t any documentation of concern for neglect, abuse, or non-accidental injuries were noted. The investigation did not produce substantiating evidence or supporting witness statements to substantiate the allegation of neglect or lack of supervision therefore the allegation is unsubstantiated. An exit interview was conducted with Miguel Sanchez, Caregiver. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.