complaint·November 9, 2021

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Maria Flores and discussed the findings. During the course of this investigation site visits to the facility were made and observations taken; Records and documents were obtained and reviewed; statements were taken from staff, residents, and witnesses. The following determinations are made: While not required by regulation, the facility's mitigation plan calls for residents to wear masks in communal settings if tolerated; residents have been observed without masks in communal settings; most residents have a diagnosis of cognitive decline and cannot be relied upon to give factual statements; staff indicate that most residents do not tolerate masks and often complain or remove them from the face; With the exception of the Complainant, eight out of eight witnesses interviewed stated that the Covid protocols are followed by the staff when witnesses have visited the facility. While the allegations may be true, based upon the records reviewed and statements taken, the preponderance of evidence standard has not been met. Therefore, the allegations are UNSUBSTANTIATED.