On 02/24/24, during the initial complaint visit, LPA Tihesha Smith toured the facility inside and out, requested, and reviewed copies of documents relevant to the investigation from approximately 10:35 a.m., to 2:30 p.m. These documents included, but were not limited to personnel report, and resident roster. LPA Smith was unable to interview S1 as they were not present at the facility during time of visit and four (4) of four (4) residents refused or were not able to engage in an interview. Interviews conducted with three (3) of three (3) staff members revealed they do not have any knowledge of an uncleared adult being present in the facility. During the interviews, the administrator confirmed that there are no known current exclusions for staff. To corroborate these statements, the Licensing database was reviewed by LPA Smith. This review confirmed that no facility staff have an active exclusion with the department. At the time of this visit LPA Rios reviewed staff time sheets compared with the information pulled from the Guardian Background Check System. The staff census matched the Licensing records.

Based on record review and interviews there is not enough sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time.

It was alleged that Staff smokes marijuana daily on the facility premises and in front of the resident’s in care. Interview with three (3) out of three (3) staff revealed have not smoked marijuana in front of residents and have not witness any other smoking marijuana in front of residents. Administrator revealed staff can smoke cigarettes outside, and all staff are aware that marijuana use in or around residents and facility is prohibited. During facility visits, LPA Smith did not smell any marijuana odors in or around facility and did not observe any discarded pieces of tobacco rolling paper, commonly known as "roaches," on the premises. At the time of this visit LPA Rios inspected the facility inside and out and did not smell marijuana odor or observe any staff smoking marijuana or cigarettes.

It was alleged that staff leave residents alone in the facility. To investigate this allegation, interviews were conducted with three (3) staff members. All three (3) staff members categorically denied ever leaving residents alone in the facility or arriving for their shifts to find residents unattended. Each staff member confirmed that there is always at least one (1) staff member present in the facility at all times. Additionally, two (2) of the three (3) staff members noted that S1's spouse occasionally picks up S1's vehicle, and no other vehicles may be parked at the house, which might give the impression that no one is home. However, these staff members emphasized that despite the absence of vehicles, staff are always present with the residents.

Based on interviews, there is insufficient pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No immediate health and safety hazard is noted during his visit.

Exit interview was conducted and a copy of report was issued.