complaint·September 30, 2025

(Continued from LIC 9099) (page 2 of 3) Residents (R2, R3) confirmed that staff responded quickly, though R3 noted occasional delays of 15–20 minutes. Staff interviews (S1, S2) acknowledged that wait times could be longer during peak hours, but staff communicated with residents when delays occurred. While some delays were acknowledged, there is insufficient evidence to support that staff failed to respond in a timely manner in violation of regulations. The facility has since upgraded its call system, and multiple residents confirmed timely assistance. It was also alleged licensee charged fees for services not listed in the Admission Agreement. More specifically, R1 alleged that the facility charged a $5 tray service fee and a $2.49 rent payment processing fee, neither of which was disclosed in the Admission Agreement. Review of R1’s Tenant Ledger showed no charges for tray service or rent processing fee. The Admission Agreement (Exhibit 4) clearly lists a $5 tray service fee, and staff (S6, S7) confirmed that Assisted Living Waiver residents like R1 were not charged. The $2.49 fee is a third-party processing fee disclosed during onboarding and is optional; residents may pay by check without a fee. The $5 tray fee is disclosed in the Admission Agreement, and there is no evidence R1 was charged. The $2.49 fee is not imposed by the facility and is avoidable. There is insufficient evidence to support that a tray service fee was charged, as well as the optional fee processing charge. It was also alleged Licensee did not provide adequate food service. More specifically, residents were served cold food, had long wait times, and were denied food. LPA reviewed menus, observed meal service, and interviewed staff and residents. Menus showed multiple entrée options and a dietitian's approval. Residents (R2, R3, R4) reported satisfaction with food and timely service. Staff (S3–S5) explained that delays occurred when residents arrived early or requested tray service. LPA observed 9 trays being delivered to residents who were either bedbound or paying for the service. The facility provided adequate food service with multiple options and reasonable delivery times. No evidence supports that residents were denied meals or consistently served cold food. (Continued on LIC 9099C page 3) (Continued from LIC 9099C) (Page 2 of 3) It was also alleged that staff used the resident's room as a passageway to another room in the facility. More specifically, R1, the staff entered R1’s room through the patio door on two occasions, startling R1 and their roommate. R1 no longer resides at the facility and could not be interviewed. Staff (S6) confirmed the concern was reported and internally investigated. The department observed R1’s former room and found that the sliding door had two interior locks and no exterior access. The Executive Director confirmed that staff do not have keys to patio doors. No witnesses or documentation corroborated the alleged entry. There is no evidence to support that staff used R1’s room as a passageway. The physical layout and locking mechanisms make unauthorized entry unlikely without resident cooperation. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred; therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Reginald Jones, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.