complaint·October 13, 2021

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegations. LPA met with Administrator and discussed the department's findings. During the course of this investigation statements were taken from staff; residents; witnesses. In addition, six unannounced site visited were made to the facility and photographs were taken of various areas. Numerous records and documents were obtained and reviewed. The following determinations have been made: Staff reports and site visits made support that the mitigation plan for the facility is being followed; Facility observed to be clean at all unannounced site visits; reviews of Medication Administration Record and other logs as well as statements made by staff and administrator indicate procedures for medication administration and record keeping is in line with Title Twenty-Two regulations. Although the allegations may be true, based upon the records and statements, as well as observations, there is not a preponderance of evidence to support the allegations. Therefore, the allegations are UNSUBSTANTIATED.