complaint·September 3, 2025

LPA De Leon spoke with Administrator and provided the fire department with a updated clearance for approval or denial. The facility had a new company come out to the facility and install delayed egress on the front entry/exiting door and it is not currently working as the Licensee is waiting for the approval from Fire to be able to use the device. On 08/26/2025 Witness 1 (W1) visited the facility and was not able to leave until the staff put the code in the front door to exit. W1 said the front door has a sliding lock located towards the top of the door that is used by sliding it over to lock. The door knob still has a key coded lock on it and it locks from the inside to go outside, the staff would need to come to the door with the code to let someone exit. The fire department has not granted or denied the delayed egress inspection request at this time. LPA has spoken to administrator and let them know the door knobs will need to be removed and a normal locking door knob placed until the fire department can come out to inspect and approve the delayed egress. The front entering door can remain locked at night and overnight for safety but can not have day time locks or delayed egress until it is approved by the fire department and sent to CCL for final approval on the license. Based on the evidence this allegation is deemed Substantiated at this time. Exit interview conducted, deficiency cited, civil penalty assessed, copy of report and appeal rights printed for Administrator. LPA watched the video surveillance on the date of 08/26/2025 around 10:00am and 1 staff was on break sitting at the bar counter between the kitchen and dining room. At no time did a resident enter the kitchen area. According to the staff there was 3 staff on duty, 2 caregivers helping residents and one housekeeper, the housekeeper was on break and if needed would have re-directed any residents that would have tried to go in the kitchen area at this time. Witness 1 (W1) stated the sharps and knives drawer was unlocked and accessible to residents in care. After watching the video surveillance the housekeeper was siting between the kitchen and the dining area and no residents had attempted to go into the kitchen area, the knife drawer was unlocked with a staff in the immediate area making it inaccessible to residents in care. Staff were directed to lock the drawer and did so at that time. Based on the staff being in the immediate area and no residents entering the kitchen area this allegation is Unsubstantiated at this time. Exit interview conducted and copy of report printed for Administrator.