complaint·March 25, 2026

During the visit, LPA observed the ramp in the living room/common area where the television is located. The ramp measured approximately 5 inches high, 92 inches wide, and 55 inches long. At the time of the visit, all residents present were ambulatory, with the exception of one resident. LPA asked each resident to walk up and down the ramp to observe whether the ramp created a safety issue. Resident 1 walked up and down the ramp without any issues or visible difficulty. R1 told LPA, in Spanish, that they had no problems or concerns using the walkway. Resident 2 also walked up and down the ramp without difficulty. R2 stated they had no problems ambulating on the ramp and mentioned they sometimes use a walker but have never had trouble going up or down the living room walkway. Resident 3 used their walker to go up and down the ramp, also without any issues or signs of distress. R3 stated they have never had any problems using the walkway. LPA interviewed an outside source who regularly visits Resident 4, who is non ambulatory. The outside source stated they have never had any issues or concerns when using the living room walkway during visits. LPA then interviewed Staff 1, who stated they have never witnessed or heard of any residents falling or tripping on the ramp. LPA also interviewed the administrator, who reported that approximately two weeks prior, a delivery person arrived to drop off a printer. The administrator stated that the delivery person tripped while walking down the ramp. Facility staff provided first aid, and the delivery person declined 911 services. The administrator explained that the individual then continued to carry in two heavy printers. Later, the delivery person called the administrator and reported that they had gone to the emergency room due to the injury. The administrator stated they have never witnessed or received reports of any resident or staff member tripping or falling on the walkway ramp. Based on observations, resident interviews, staff interviews, and information obtained during the investigation, there is not enough evidence to prove that the facility failed to maintain a hazard free environment for residents in care. Although an outside source reported an injury, there were no reports of residents experiencing issues with the ramp, and LPA did not observe any hazards affecting residents during the visit. Therefore the complaint is unsubstantiated. An exit interview was conducted with Cherry Cook. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Cherry Cook, whose signature below verifies receipt of these rights.