complaint·October 2, 2025

LPA Kabariti interviewed ADM. ADM stated she could not open the shed. ADM called her husband/ licensee and placed her husband on speaker phone. The Licensee refused to open the shed. LPAs observed the shed was locked. The windows were black therefore LPAs could not see what was inside the shed. The shed had a power line that was running from the facility to the shed. ADM denied staff living in the shed. ADM states the shed is used for gardening supplies and only the gardener and owner has a key to the shed. On July 17, 2025 LPA Tarin interviewed ADM. ADM 1 stated staff did not live in the shed. On 9/25/2025, LPAs inspected the back yard. LPA Monter and LPA Marcella observed Staff S2 seated on a chair next to the storage shed in the back yard. LPA Monter asked S2 what’s inside the storage shed. S2 stated it’s a staff’s bedroom. LPA Monter asked S2 who’s bedroom does the shed belong to. S2 then clarified that he/she doesn’t know. LPA Tarin asked if LPAs could look inside the shed. S2 then stated the shed is locked and he/she doesn’t have the keys. LPA Tarin told S2, that the shed door is slightly ajar. S2 then went to check and acknowledged the shed was open. LPA Monter and Tarin observed the inside of the shed, which contained the following, but not limited to items: a mini fridge, bed (with blankets & pillows), an ignited lamp night stan d, dresser with phone charger on top of it, grooming products, and other personal items. (LPA took photographs of the inside contents of the shed.) S2 then clarified that the storage shed was a sleeping area for other employees, not just him/her. LPA’s interviewed staff S2 and S3. S2 states no staff live in the backyard shed. S2 states he/she only uses the shed when he/she's on break. S2 states it's a 'staff room." S3 states no staff live in the backyard shed. On October 2, 2025, LPA Tarin and Monter interviewed ADM. ADM stated no staff sleep in the shed or use the shed as a staff room. ADM stated the shed is a storage space. Based on review of the facility sketch and the facility fire clearance dated 10/6/2008 , the backyard shed is part of the facility and is not listed as a staff bedroom or sleeping area. Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Page 2 of 3 Facility staff not safeguarding resident's personal items. On 1/15/2025 the Department received a complaint alleging Facility staff not safeguarding resident's personal items. On January 15, 2025, the Department interviewed Witness W1. W1 stated S2 has stolen (R1) shoes. W1 stated when he/she had asked about R1's shoes, staff S2 brought them out from his/her room (storage shed). On January 24,2025, LPA Dolores interviewed Staff S1. S1 denied staff using resident's personal items. Staff denied observing other staff use a resident's personal items. On January 24 and July 17, 2025, the department interviewed ADM. ADM stated a caregiver used residents shoes because his/her shoes got wet when bathing a resident. S2 borrowed shoes to obtain dry shoes from his/her car. ADM immediately corrected S2 and apologized to R1. ADM stated she has never had issues with resident's personal belongings until the incident with staff S2 using R1’s shoes. On 9/25/2025 the Department interviewed staff S2 to S3. S2 states he/she has never worn a resident's personal belonging such as clothes or shoes. S2 stated he/she has never worn another residents shoes or personal belongings. S3 stated he/she is not aware of any staff using/wearing a residents shoes or personal belongings. Based on review of an Employee Individual Consultation document dated 6/18/2025, S2 was given a written warning by ADM, the document is signed by S2. Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED . Licensee stated if the complaint report involved the backyard shed, he would not sign the report. Page 3 of 3 On September 25, 2025, LPA Tarin interviewed Staff S2 and S3. Both staff interviewed were asked questions regarding this complaint investigation. Both staff were able to understand the questions that were posed by LPA’s and were able to provide responses to all questions posed. LPAs interviewed Resident R1 to R3. 3 Out of 3 Residents were did not provide responses to questions posed during interview. On October 2, 2025, LPA interviewed staff S1-S3, ADM 1 and ADM 2. S1 to S3, ADM 1 and ADM 2 were able to respond to LPAs questions regarding emergency procedures, evacuation routes, and general care questions. This agency has investigated the complaint alleging facility staff are not able to communicate to resident and cannot speak English. We have found that the complaint was UNFOUNDED , meaning that the allegation was false, could not have happened and/or is without a reasonable basis.