complaint·February 20, 2026

Continued from LIC9099... There was an allegation of Licensee does not ensure staff are trained per regulation. According to the reporting party, new staff only had a little bit of training, and they have not completed all their required certifications such as mandated reporter training or CPR certification. Based on records review, LPA reviewed staff training records (S2, S3, & S4) have received hours annual of training including reporting requirements and CPR certification as required by regulation. Based on LPA’s interviews conducted with staff (S2, S3 & S4), it confirmed that they have received training and have described that they report any incident to the Licensee who fills out required documentation to notify the Department of any incident. The techniques described when performing CPR/1st aid appear to be adequate for this type of incident. A finding that the allegation of Licensee does not ensure staff are trained per regulation is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Another allegation of Licensee does not ensure staff are following safe and sanitary practices for residents in care. The reporting party stated that staff (S1) don’t follow sanitary practices because they walk around barefoot in the home. During investigation LPA reviewed records, conducted interviews and made observations at the facility. On 12/26/25, LPA Felias conducted a 10-day visit to the facility and subsequent visit conducted by LPA Cuadra on 02/05/26. Based on LPA’s observations during tour of the physical plant of the facility inside and outside, the bathrooms appeared clean, free of odors and sanitary condition. Also, staff on duty observed by LPAs had adequate footwear at the time of the visit. Based on confidential interviews conducted by LPA with staff (S2, S3 & S4) and residents (R1, R5 & R6) in care. LPA did not obtain any leading information that could result in any supportive evidence that violation regarding the safety and sanitary practices of staff with residents has occurred. Therefore, LPA has determined and confirmed that although the facility appeared to be clean and in a sanitary condition on recent LPA inspections conducted on 12/26/25 and 02/05/26, LPA is unable to determine if an area of the facility or their staff were in an unsanitary condition at a prior date. A finding that the allegation of Licensee does not ensure staff are following safe and sanitary practices for residents in care is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Continue to LIC9099C... Continued from LIC9099C... Regarding the allegation, staff does not ensure resident medication records are properly maintained. According to the reporting party, they have observed that medication entries are not being done by staff when the medications get passed and it’s hard to know if medication counts are off because the Licensee instruct staff to just sign any missing entries on the log. Based on records review conducted by LPA, medication records of residents (R1, R2, R3 & R4) did not reveal any inconsistency or discrepancy of with medication documentation. Based on interviews conducted with staff (S2, S3 & S4) did not lead to any supporting evidence that medication records have not been accurately maintained by staff. A finding that the allegation of staff does not ensure resident medication records are properly maintained is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. According to another allegation the Licensee does not ensure staff has a fingerprint clearance. Per Reporting party, the maintenance staff for the facility has not been fingerprint cleared prior to work at the facility. On 12/26/25 and 02/05/26, LPA conducted 10-day and subsequent visits to the facility made observations, reviewed records and conducted interviews with staff and residents in care. During the tour of the facility, LPA observed staff (S5) providing care and supervision to residents in care. Based on interviews conducted with staff (S2, S3 & S4) and residents (R1, R5 & R6) did not reveal any leading evidence that could indicate the presence of any uncleared staff at this facility. Although based on records review, the facility was previously cited during the annual visit conducted on 7/15/25 due to staff (S5) did not have fingerprint clearance per Guardian. However, the facility provided LPA with LIC500 Personnel report confirmed that staff listed including maintenance staff are associated to the facility through Guardian system. Therefore, it was determined that S5 is fingerprint cleared to provide care and supervision to residents in care. A finding that the allegation of Licensee does not ensure staff has a fingerprint clearance is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Continued to LIC9099C... Continued from LIC9099C... Allegation about Licensee does not ensure sufficient staffing is provided to meet the care needs of residents in a timely manner. The Reporting Party stated that the home has six residents and three of them are bedridden and are a two-person assistance, but the facility does not ensure there are two staff available to help transfer residents. The RP also stated that due to insufficient staffing, the residents’ care needs are not being met in a timely manner. The RP stated that residents have to wait longer to have their care needs met such as showers, diaper changes, etc. Based on records review, it was confirmed through review of their physician reports (LIC602) that there are currently three residents (R1, R2 and R3) who need assistance with incontinence care, and two residents (R1 and R4) who require assistance with repositioning and transferring. Residents care plans do not indicate that there are any residents who are two people assist. According to facility Personnel Report (LIC500) provided by the facility indicates compliance with staff schedule for the months of October, November and December 2025, which confirms that there are staff coverage for residents in care. Based on interviews conducted with residents (R1, R5 & R6) there were no concerns raised regarding the assistance and timely care provided by the facility staff. A finding that the allegation of Licensee does not ensure sufficient staffing is provided to meet the care needs of residents in a timely manner is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Final allegation of staff does not ensure medications are safely secured and inaccessible to residents at all times. The Reporting Party stated that the staff also don't lock the medication cabinet when they walk away from it with medications to dispense to residents. LPA Felias conducted 10-day visit on 12/26/25 and on 02/05/26, LPA Cuadra conducted a subsequent visit to the facility. Based on LPA’s observations, the facility medication was locked and Licensee opened cabinet using a key that it was located on the facility fridge. However, during subsequent visit on 02/05/26, the Licensee pulled out the key from a locked drawer located in the cabinet where the medication was storage. Based on staff’s (S2, S3 & S4) statements obtained by LPA who confirmed the above information by describing their medication pass process as safe, they ensure that medications are always maintained secured and inaccessible to residents in care. A finding that the allegation of staff does not ensure medications are safely secured and inaccessible to residents at all times is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during today's visit. Exit interview conducted with Licensee & copy of report was given.