The investigation revealed the following:

It is alleged that facility staff failed to report a concern regarding R1. The complaint alleges that staff were aware of statements made by R1 indicating emotional distress and possible self-harm and did not take appropriate action to report. During staff interviews, staff reported that concerns regarding R1’s emotional well-being were first communicated by a private caregiver and were addressed once received. Staff stated the alleged self-harm statements were said to have occurred approximately two weeks earlier but were not reported by the private caregiver at that time. Staff reported that upon notification, supervisory and administrative staff were informed, R1’s safety was assessed, additional supervision was implemented, and R1 was referred for a mental health evaluation. Staff denied failing to report concerns and stated appropriate action was taken once the information was brought to the facility’s attention. During the resident interview, R1 stated she was feeling okay, expressed remorse for prior statements, denied any self-harm intent or behavior, and indicated she wished for the matter to be resolved. During the witness interview, the witness stated they have no concerns regarding the facility or the care provided to R1 and believed the facility responded appropriately to ensure R1’s safety. Community Care Licensing office received the self-harm report, and the facility submitted a detailed Special Incident Report (SIR) on 11/14/2025.

Based on the investigation conducted, including interviews with staff, witness and resident and review of relevant records, there was insufficient evidence to support the reported allegation. 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. Exit interview was held, and a copy of this report was provided.