Complaint·May 7, 2026

LPA Peraldi conducted an interview with facility Executive Director (ED), Brandy McCauley, who stated that R1 was determined by his physician to be capable of managing their own medications and diet. ED stated that R1 “mostly follows (R1’s) special diet but once in a blue moon R1 has crackers and cookies. ED stated they have communication with his doctor.” On 03/20/2026, LPA Mark Jeffries conducted interviews with Residents 1-6 (R1, R2, R3, R4, R5, and R6). R1 stated that the facility is good about providing restrictive diet menus. R1 stated that the facility community activities there are prizes that consist of candy, and the facility does provide sugar free candy, but sometime R1 likes to eat the regular candy as well. R1 stated that occasionally R1 will eat menu choices that are not part of the special diet by choice. R2, R3, R4, R5, and R6 all stated, “facility is good about menu choices. And facility is good at providing special diets that are needed for residents. On 03/20/2026, LPA conducted an interview with facility Chief (S6) S6 demonstrated to LPA how special diets are identified in the facility kitchen so that the staff deliver special diets to residents that have special dietary needs, and requirements. Residents that are identified with special diets are posted on the kitchen wall with the resident’s name and what special diet is identified to a specific resident. S6 stated that these special diets are always available and presented to the residents that are identified. S6 stated that if those residents request additional food items or off the menu items they are provided with and the care staff is notified that the special diet was not followed. Based on documentation of special diet screening, interviews of resident stating availability of special diets provided by the facility, and interviews of residents exercising specific dietary choices, there is not enough evidence at this time to support the allegation of, “Staff are not following the residents’’ special diet.” and is unsubstantiated at this time. As to the allegation of, “Staff are not safeguarding the residents’ personal belongings.” and “Staff is retaliating against residents.” It was alleged that R1 lost 3 sets of pajamas in laundry and staff were retaliating against R1 due to not returning R1’s pajamas from laundry and not properly folding cleaned laundry. On 10/23/2025 LPA Peraldi conducted interviews with S1 - S6, all staff stated that there were no concerns regarding residents’ items being safeguarded by facility. S3 stated that, “Sometimes laundry gets mixed up and they check other rooms and linen closet. Usually, missing items are found.” However, R1’s missing items were never found over one year ago. On 03/20/2026, LPA Jeffries conducted interviews with R1-R6, R1 stated that the there was only one set of pajamas that were lost and, “never found or maybe I misplaced them.” R1 also stated that they have no issue with facility safeguarding personal property. R2-R6 all stated that they had no issues with facility safeguarding residents’ property. CONTINUE on LIC9099-C On 10/23/2025 LPA Peraldi conducted an interview with ED who stated, “staff have been trained on resident’s personal rights. She said they use Relias training. She said residents’ personal rights are posted on the wall. She said staff wouldn’t retaliate against residents. She said staff are loving and they know about personal rights.” On 03/20/2026, LPA Jeffries reviewed care giver training records for the facility and noted that all caregivers had current “Residents Personal Rights” training through Relias training program. Based on interviews, and records review, at this time there is not enough evidence to support the allegation of, “Staff are not safeguarding the residents’ personal belongings.” and “Staff is retaliating against residents.” and both are unsubstantiated at this time. As to the allegation of, “Facility does not have sufficient staff to meet the needs of residents in care.” It was alleged that staff are getting fired or leaving and there are no staff available for R1. On 10/23/2025 LPA Peraldi conducted an interview with ED who stated, “that they have enough staff to meet needs. She said there are no staff concerns or staffing shortage. In Memory Care (MC) there are three (3) caregivers and three (3) in Assisted Living (AL). She said there are medication technician (med-techs) on each shift.” On 10/23/2025 LPA Peraldi conducted interviews with S1-S6, all stated no concerns with staffing ratios. On 03/20/2026, LPA Jeffries conducted interviews with R1-R6. All stated they had no issues with staffing to resident ratios. R1 – R6 all stated that their needs are met on a daily basis and have no concerns. R1 stated that staff do a great job attending to (R1’s) needs. LPA Jeffries reviewed current facility staff schedules which showed care giver coverage that reflected staff converge in staff and resident interviews. At this time there is not enough evidence to support the allegation of, “Facility does not have sufficient staff to meet the residents needs.” and is unsubstantiated at this time. Exit interview, report read, and report provided.