Complaint·August 30, 2021

9/22/2021- This report has been amended on this date to clarify the verbiage. On 8/30/2021, Licensing Program Analyst (LPA) Han conducted an unannounced 10-day initial on-site complaint inspection. LPA was screened by the receptionist at the entrance. LPA met with the Executive Director, Stephanie Schmautz. LPA explained the purpose of the visit and reviewed the allegation. Regarding allegation of : staff wrote inappropriate letter to resident, LPA reviewed the daily census to determine the number of resident in care and to determine the names of the residents. Approximately five weeks ago, the facility has informed the Department of an incident which may have triggered this complaint. After reviewing the incident, LPA spoke to the Executive Director at the time (facility has a new Executive Director) who reported that the incident has been resolved and the previous Executive Director took actions to prevent incident from happening again and ensuring resident's safety. Base on record review and interviews during the course of investigation, this allegation is unsubstantiated. Although the above investigation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.