complaint·May 7, 2025

On the allegation: Uncleared person present at facility. It was alleged that an exclude person had resided at the facility. It was discovered through observations, interviews, and documentation, that on 05/07/2025, Licensing Program Analyst (LPA’s) Rankin and Jeffries observed one care giver (S1) and 4 residents. (R1, R2, R3, and R4). On 05/072025 LPA Rankin conducted resident interviews for R1 and R2, who both stated that the care was good, and both stated they had no knowledge of the exclude individual(s) presence at the facility. On 05/07/2025, LPA Jeffries conducted interviews with R3. R3 interview was inconclusive on exclude individuals being present at the facility but feels safe and comfortable in the facility. On 05/07/2025 LPA Rankin interview Care Staff (S1) and Administrator. S1 stated they work morning shifts and are not aware of the excluded individuals present at the facility. On 5/7/2025 LPA Rankin interviewed administrator who stated she was aware that excluded individuals are not to be at the facility. Documents collected were staff and resident rosters. The excluded individuals were not noted on either documents. All rooms occupied were of residents noted on the roster and there are no staff rooms at this facility. Based on interviews, observation and documentation, there is not sufficient evidence, at this time, to prove the alleged violations did or did not occur therefore the allegations are unsubstantiated. Exit interview conducted, copy of report given.