complaint·November 6, 2025

Continued from LIC9099 Staff interviews revealed that once a resident, a responsible party, friend or other staff identify a maintenance problem, the problem is immediately entered into the TELS system, and a member of the maintenance team sets out to fix the problem or will call an outside vendor if needed. Finally, an interview with R1 revealed that in fact, the maintenance staff had quickly responded to their toilet concern and that their toilet was never truly clogged but just slow to flush and R1 reports always being able to use their toilet and never having to use a toilet outside their room. LPA interviewed resident (R2) in an adjoining room to R1 which revealed they never had a problem with their toilet during the same time frame and that the maintenance team was quick to respond to their requests for repairs. Based on observations made, records reviewed, and interviews conducted, this allegation is Unsubstantiated . A finding that the complaint allegation is Unsubstantiated means that 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. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Tetra Godfrey - Administrator Signature on form confirms receipt of documents.