Complaint·January 22, 2026

S1-4 all stated that rooms with dual occupancy, residents being changed are done with door closed and when resident roommate in not in the room as much as possible. On 01/15/2026, LPA Jeffries conducted an interview with Administrator who stated that all staff are up to date on training of resident rights and treat all residents with dignity and respect according to their training. LPA observed all staff training to be current, including resident rights training. On 01/15/2026, LPA Jeffries did not observe any staff disregarding resident privacy. At this time there is not enough evidence to support the allegation of, “Staff did not provide privacy to resident when changing resident” and is unsubstantiated at this time. On the allegation: Due to lack of supervision, resident pushed another resident. It was alleged R1 told another resident not to watch staff change R2, and as a result the resident pushed R1. On 01/15/2026 LPA Jeffries conducted an interview with Administrator who stated that there has only been one incident at the facility where a resident pushed another resident on 02/22/2025, where staff were present. LPA observed Incident Report (LIC-624) dated 02/22/2025 indicates staff attempted to intervene and another staff present. On 01/15/2026, LPA Jeffries conducted interviews with S1-4 who all indicated that they feel there is always enough staff to meet residents’ needs. S1-4 all stated that they recalled only one incident where resident pushed another resident, and all S1-4 identified the described incident dated 02/22/2025. On 01/15/2026, LPA Jeffries observed enough staff present during the visit to meet current residents’ needs. Based on interviews documentation and observations, number of staff present that was documented, at this time there is not enough evidence to support the allegation of, “Due to lack of supervision, resident pushed another resident.” and is unsubstantiated at this time. On the allegations: “Staff did not treat resident with respect.” and “Staff had resident sleeping in living room.” It was alleged staff made R1 pick up things and made fun of the resident and staff started making R1 sleep in the living room. Both R1 and R1’s RP stated R1’s roommate screamed all night. On 01/15/2026, LPA Jeffries conducted an interview with Administrator who stated that all staff are up to date on training of resident rights and treat all residents with dignity and respect according to their training. LPA observed all staff training to be current, including resident rights training. On 01/15/2026, LPA Jeffries did not observe any staff disregarding resident privacy. Administrator stated that R1 had never slept in the living room and staff had to often redirect R1 to bed. Administrator stated that staff always treat residents with dignity and respect and would not make fun of the residents. CONTINUED on LIC9099-C On 01/15/2026, LPA Jeffries conducted interviews with S1-4 all who stated they have training in residents’ rights and personal rights. S1-4 all stated that they have never made fun of a resident and have not wittiness any other staff make fun of a resident. On 01/15/2026, LPA Jeffries observed all staff treating residents with dignity and respect. Based on interviews, training documentation, and observation there is not enough evidence at this time to support the allegations of, “Staff did not treat resident with respect.” and “Staff had resident sleeping in living room.” and are both unsubstantiated at this time. On the allegation: Staff charged resident for toilet paper. It was alleged staff made R1 pay for toilet paper. LPA reviewed invoices for R1 while they lived at this facility. There are no invoices for toilet paper and no indication R1 paid for toilet paper. The admission agreement states toilet paper will be provided to residents as part of the services. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated at this time. On the allegation: Staff did not notify the authorized representative of move. It was alleged that R1’s RP was not told R1 was moving to another facility associated with the Administrator. LPA reviewed a 30-day notice of intent to vacant for R1 dated 04/18/2025 and signed by R1. The 30-day notice is required per R1’s signed admission agreement. On 01/15/2026, LPA Jeffries conducted an interview with Administrator who stated that, “R1 was undergoing medical treatment that made R1 weak, however, R1 did not have a power of attorney and R1 moved at R1’s request.” LPA Jeffries observed R1’s LIC-602 (Physicians Report) that stated that R1 was capable of making their own decisions. Additionally, LPA observed a “Voluntary Consent to reside in a Secured Perimeter Unit.”, this document was singed by R1 on 04/18/2025. At this time there is not enough evidence to support the allegation of, “Staff did not notify authorized representative or move.” and is unsubstantiated at this time. On the allegation: Improper eviction. It was alleged staff made R1 move to another facility associated with the Administrator. LPA reviewed a 30-day notice of intent to vacant for R1 dated 04/18/2025 and signed by R1. The 30-day notice is required per R1’s signed admission agreement. R1 provided a written 30-day notice of their intent to move, and there is no evidence to show an eviction notice should have been issued to R1. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated at this time. CONTINUED on LIC9099-C On the allegation: Staff did not refund resident. It was alleged R1 was not provided a refund, even though R1 moved to another facility associated with the Administrator. Records show R1 lived at the licensee’s other facility Mission Gardens at first, which uses the same billing and rates as this facility. Records show room and care from 2/26/2025 to 3/28/2025 cost $6200. Records show the prorated room and care rate for 3/29/2025 and 3/20/2025 cost $306.54. R1 issued a 30-day notice on 3/11/2025 and moved from Mission Gardens to this facility. Records show room and care from 4/1/2025 to 4/30/2025 were $6200. All amounts were paid. R1 issued a 30-day notice on 4/18/2025 and moved to a different facility affiliated with the Administrator but not owned by her. No refund was issued after R1 moved out, but R1 was not charged for a full 30-days from the date of the notice. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated at this time. Exit interview, report read and report provided.