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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601704
Report Date: 10/19/2025
Date Signed: 10/20/2025 08:35:54 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/10/2025 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250310121815
FACILITY NAME:HARMONY HOME CAREFACILITY NUMBER:
198601704
ADMINISTRATOR:DIONSIO, ANTONIAFACILITY TYPE:
740
ADDRESS:1318 215TH STREETTELEPHONE:
(310) 549-0218
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:6CENSUS: 4DATE:
10/19/2025
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Antonia DionsioTIME COMPLETED:
04:11 PM
ALLEGATION(S):
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9
Facility failed to care for resident with restricted health condition.
Staff forged resident's signature.
INVESTIGATION FINDINGS:
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13
On October 19, 2025, the Community Care Licensing (CCL) Licensing Program Analysts (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Administrator Antonia Dionisio greeted the LPA, who explained that the visit was to investigate the allegations mentioned above.

The investigation included interviews, record reviews, and a tour of the facility. Interviews with Staff members #1 (S1) and Resident members #2 to #5 (R2-R5) and Witness #1-Witness #2 (W1-W2) . The Department reviewed several documents, including the Resident Registered Roster LIC 9020 (dated 03/11/25), the Personnel Report (dated 12/16/22), (R1's) Physician’s Report LIC 602 (dated 05/24/23), the Preplacement Appraisal Information LIC 603 (dated 08/08/24), and the Appraisal/Needs and Service Plan LIC 625 (dated 08/08/24), Los Angeles County Sheriff's Department Incident Report (dated 03/09/25) and Harbor UCLA Medical Records Medical Records (dated 03/25/25) and other pertinent records associated with this complaint.
(Evaluation Report continues LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 9
Control Number 11-AS-20250310121815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704
VISIT DATE: 10/19/2025
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

ALLEGATION #2: Facility failed to care for resident with restricted health condition.

It is alleged that the facility failed to provide appropriate care for Resident #1 (R1) due to a specific health condition. Reports indicate that (R1) required catheter care, but the staff did not maintain the catheter properly, and the area was not kept clean. As a result, (R1) endured catheter associated urinary tract infections (UTIs) every month. No further details regarding this matter were provided.

On March 11, 2025, between 10:00 AM and 11:45 AM, the Department interviewed residents identified as Resident #2 through Resident #5 (R2-R5). Four (4) out of the four (4) residents were unable to support the claim. (R2-R5) reported that they have no health restrictions classified as a "restricted health condition" and expressed no concerns regarding the care and supervision provided by the staff at this facility.

On March 11, 2025, between 10:30 AM and 1:00 PM, the Department interviewed Staff #1 (S1). During the interview, (S1) admitted that (R1) required catheter care and was under hospice services at the time of admission. Later, (R1) received assistance from home health services for catheter care as well. (S1) claimed that (R1) would also receive catheter maintenance during visits from the primary physician. However, despite (S1)'s assertions that hospice or home health was assisting with catheter care, no documentation was provided as evidence. (S1) acknowledged that this is a restricted health condition but failed to notify Community Care Licensing and did not have a care plan in place to address the restricted health condition.

On April 17, 2025, between 2:30 PM and 3:30 PM, the Department interviewed Resident #1 (R1). (R1) confirmed that (R1) uses a catheter. (R1) stated that the facility staff provided care by transporting (R1) to Veterans Affairs (VA) for a catheter change. However, when asked how often (R1) see the primary physician, (R1) replied, “I never see him.” (R1) also confirmed to have never received any visits from the primary physician while at Harmony Home Care, nor have (R1) been seen by a Hospice Nurse or Home Health Nurse.

The Department reviewed Harbor UCLA Medical Records (dated 03/25/25), (dated 10/03/23), (dated 10/11/23), (dated 11/24/23), and (dated 12/14/24), which revealed that (R1) suffered from repeated urinary tract infections due to the use of an indwelling urinary catheter. A catheter should only be used if ordered by a doctor and included in a care plan that outlines skilled catheter care and proper staff training.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 11-AS-20250310121815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704
VISIT DATE: 10/19/2025
NARRATIVE
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In this instance, there was no evidence that these requirements were met. The absence of a catheter care plan led to the resident's recurrent infections. Further review of Los Angeles County Sheriff Department Incident Report (dated 03/09/25) revealed Staff #3 (S3), responsible for primary care for (R1), stated that (S3) is not a skilled nurse for catheter and wound care treatments.

Staff #3 (S3) could not be interviewed due to (S3's) unavailability, as (S3) is no longer employed at the facility. Furthermore, (S3) did not provide any contact information, such as a phone number or forwarding address, which made it unattainable to reach out for further insights or comments about (S3's) awareness of this allegation.

Based on the information gathered, there is sufficient evidence to support the allegation mentioned above.

ALLEGATION #4: Staff forged resident's signature.

It is alleged that facility staff forged the signature of Resident #1 (R1). Reports indicate that facility staff admitted to having forged (R1's) initials on the facility's admission agreement contract. No further details were provided in reference to this matter.

On March 11, 2025, between 10:00 AM and 11:45 AM, the Department interviewed residents identified as Resident #2 to Resident #5 (R2-R5). Four (4) out of the four (4) residents were unable to support this claim. (R2-R4) recalled being informed about all the legal documents signed during their admission. None of the residents noticed any inconsistencies or unauthorized reproductions of their handwriting or signatures in the records.

On March 11, 2025, between 10:30 AM and 1:00 PM, the Department interviewed Staff #1 (S1). During the interview, (S1) admitted to signing a portion of the admission agreement for Resident #1 (R1). (R1) had missed some initials on a few sections of the document. (S1) claimed that this action was taken with (R1's) completed authorization and in (R1's) presence. (S1) stated that (R1) did not want to complete the rest of the document signing. Still, it was necessary to do so for licensing purposes to maintain complete compliance.

On April 17, 2025, between 3:00 PM and 3:30 PM, the Department interviewed Resident #1 (R1). (R1) was presented with a copy of Harmony Home Care's admissions agreement, (R1) expressed concerns about the signature and initials, stating they did not appear to be (R1’s). (R1) speculated that it might be (R1’s) Power of Attorney (POA), might have made the signature. However, (R1) clarified that (R1) did not have a POA upon entering the facility on June 08, 2023.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 11-AS-20250310121815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704
VISIT DATE: 10/19/2025
NARRATIVE
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A review of the Los Angeles County Sheriff Department Incident Report (dated 03/09/25), indicates in a statement from (S1) to have admitted having signed a portion of the (R1’s) contract in a few sections.

Staff #3 (S3) could not be interviewed due to (S3's) unavailability, as (S3) is no longer employed at the facility. Furthermore, (S3) did not provide any contact information, such as a phone number or forwarding address, which made it unattainable to reach out for further insights or comments about (S3's) awareness of this allegation.

Based on the information gathered, there is sufficient evidence to support the allegation mentioned above.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegations are found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citation issued (ref. LIC 9099 D).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 11-AS-20250310121815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2025
Section Cited
CCR
87507(c)
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87507 Admission Agreements (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative...no later than seven days following admission...
This requirement is not met as evidenced by:
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Licensee/Administrator shall review Tittle 22 87507 Admissions Agreement and submit in written statement have reviewed and will comply with the regulation requirements. The plan must be submitted by POC date 11/02/25 to ernand.dabuet@dss.ca.gov
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Based on interviews, observation, and record reviews, the Licensee admitted having falsified (R1’s) Admission Agreement by illegally signing another person's name or initials on the legal contract. This violation poses a potential health and safety risk to residents in care.
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Type B
10/19/2025
Section Cited
CCR
87623(a)(1-2)(B)
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87623 Indwelling Urinary Catheter (a) The licensee shall be permitted to accept or retain a resident...requires the use of an indwelling catheter.. (1) Ensuring that insertion and irrigation of the catheter shall be performed by an appropriately skilled professional. (2) Ensuring that the bag and tubing are changed by an appropriately skilled professional... (B) There shall be written documentation by an appropriately skilled professional outlining the instruction... procedures delegated...
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Licensee/Administrator shall review Tittle 22 87623 Indwelling Urinary Catheter and submit in written statement have reviewed and will comply with the regulation requirements. The plan must be submitted by POC date 11/02/25 to ernand.dabuet@dss.ca.gov
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This requirement is not met as evidenced by:
Based on interviews, observation, and record reviews, the Licensee failed to provide as evidence a catheter care was performed by a skilled professional nor provided an outlining instruction of procedures in a written care plan. This violation poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/10/2025 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250310121815

FACILITY NAME:HARMONY HOME CAREFACILITY NUMBER:
198601704
ADMINISTRATOR:DIONSIO, ANTONIAFACILITY TYPE:
740
ADDRESS:1318 215TH STREETTELEPHONE:
(310) 549-0218
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:6CENSUS: 4DATE:
10/19/2025
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Antonia DionsioTIME COMPLETED:
04:11 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide timely medical information to authorized representative.
Staff did not communicate with resident's authorized representative.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
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13
On October 19, 2025, the Community Care Licensing (CCL) Licensing Program Analysts (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Administrator Antonia Dionisio greeted the LPA, who explained that the visit was to investigate the allegations mentioned above.

The investigation included interviews, record reviews, and a tour of the facility. Interviews with Staff members #1 (S1) and Resident members #2 to #5 (R2-R5) and Witness #1-Witness #2 (W1-W2) . The Department reviewed several documents, including the Resident Registered Roster LIC 9020 (dated 03/11/25), the Personnel Report (dated 12/16/22), (R1's) Physician’s Report LIC 602 (dated 05/24/23), the Preplacement Appraisal Information LIC 603 (dated 08/08/24), and the Appraisal/Needs and Service Plan LIC 625 (dated 08/08/24), Los Angeles County Sheriff's Department Incident Report (dated 03/09/25) and Harbor UCLA Medical Records Medical Records (dated 03/25/25) and other pertinent records associated with this complaint.
(Evaluation Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 11-AS-20250310121815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704
VISIT DATE: 10/19/2025
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

ALLEGATION #3: Staff did not provide timely medical information to authorized representative.

It is alleged that facility staff failed to provide timely medical information to the authorized representative. It is reported that the facility staff failed to provide a copy of (R1’s) medical information, the “Admission Agreement,” to the authorized representative. No further details regarding this matter have been provided.

On March 11, 2025, between 10:00 AM and 11:45 AM, the Department interviewed residents identified as Resident #2 to Resident #5 (R2-R5). Four (4) out of the four (4) residents were unable to support this claim. (R2-R4) reported no issues with staff providing medical or admission agreements to their authorized representatives, and they received them promptly.

On March 11, 2025, between 10:30 AM and 1:00 PM, the Department interviewed Staff #1 (S1). (S1) explained (R1) was self-responsible when (R1) was admitted on June 08, 2023. (R1) was responsible for all healthcare matters and contracts until a legal authorized representative to represent (R1). (R1) did not have an authorized representative with Power of Attorney for Health Care. As a result, the authorized representative was unable to obtain a copy of (R1's) contracts or medical records until they presented the necessary legal documentation. According to (S1), this issue was resolved when (R1's) authorized representative requested a copy of the "Admission Agreement" on March 10, 2025, and provided the required legal documentation as proof.

On April 17, 2025, between 3:00 PM and 3:30 PM, the Department interviewed Resident #1 (R1). (R1) has confirmed that (R1) was responsible upon being admitted to Harmony Home Care. However, (R1) does not remember when (R1) consented to the Power of Attorney for Health Care. Nevertheless, (R1) acknowledges that an authorized representative is acting as the Power of Attorney (POA) for (R1). However, the POA did not have authorization to legally access (R1's) medical information or contracts while (R1) was still capable of making decisions according to (R1).

The Department reviewed the Identification and Emergency Information LIC 601 (dated 08/08/24) revealed (R1) was responsible for financial, care, and legal issues. Further review of VA Durable Power of Attorney for Health Care and Living Will (signed 07/07/23) verified the primary POA for Health Care. However, the Signature and Seal of Notary Public was not notarized to make it legally binding outside VA Healthcare setting. Upon further review of the written communication between (S1) and (POA), (dated 03/10/25), it was confirmed that (R1's) Admission Agreement had been provided.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 11-AS-20250310121815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704
VISIT DATE: 10/19/2025
NARRATIVE
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Staff member #3 (S3) could not be interviewed due to (S3's) unavailability, as (S3) is no longer employed at the facility. Furthermore, (S3) did not provide any contact information, such as a phone number or forwarding address, which made it unattainable to reach out for further insights or comments about (S3's) awareness of this allegation.

Based on the information gathered, there is insufficient evidence to support the allegation mentioned above.

ALLEGATION #5: Staff did not communicate with resident's authorized representative.

It is alleged that the facility staff did not provide timely medical information for Resident #1 (R1) to the authorized representative. Reports indicate that on March 2, 2025, Staff #3 (S3) failed to contact the appropriate authorized representative when (R1) was lethargic for several days and required hospital medical attention. Instead, another representative was notified. No further details regarding this matter have been provided.

On March 11, 2025, between 10:00 AM and 11:45 AM, the Department interviewed residents identified as Resident #2 through Resident #5 (R2-R5). Four (4) out of the four (4) residents were unable to validate this claim. (R2-R5) reported to have no issues or concerns with this matter. All residents reported that the facility staff adheres to proper call procedures and will promptly notify the authorized representatives of any changes in condition or hospitalization.

On March 11, 2025, between 10:30 AM and 1:00 PM, the Department interviewed staff identified as Staff #1 and Staff #2 (S1-S2). Two (2) out of the two (2) claim this accusation is false. (S1-S2) stated they follow the proper notification procedures and will promptly advise the authorized representatives of any changes in condition or hospitalization. (S1) reported that (R1) when admitted was self-responsible and did not have an authorized representative as power of attorney for health care. (R1) was the one who contacted 911 on March 2, 2025, without the staff awareness and the authorized representative was contacted by Staff #3 (S3). When the primary authorized representative is not available, then the secondary authorized representative is contacted.

On April 17, 2025, between 2:30 PM and 3:30 PM, the Department interviewed Resident #1 (R1). On March 2, 2025, (R1) recalled making the call to 911. (R1) preferred not to involve the authorized representative and understood that the staff would contact the primary representative. Instead, (R1) requested that the secondary representative be notified, allowing (R1) to take action to avoid the problem.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 11-AS-20250310121815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704
VISIT DATE: 10/19/2025
NARRATIVE
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On October 19, 2025, between 11:14 AM and 11:25 AM, the Department interviewed Witness # 2 (W2). (W2) confirmed (S1’s) statement that the facility staff contacted the primary authorized representative and was unavailable. Additionally, (W2) validated that (R1) prefers to inform (W2) about healthcare matters. (W2) specified that the facility did not commit any injustice by continuing with its processes; ultimately, a representative was notified.

The Department reviewed Los Angeles County Sheriff Department Incident Report (dated 03/09/25), and Physician’s Report LIC 602 (dated 05/24/23), the Preplacement Appraisal Information LIC 603 (dated 08/08/24), and the Appraisal/Needs and Service Plan LIC 625 (dated 08/08/24) revealed (R1) had no mental condition that would limit the ability to make decisions for health matters. The Identification and Emergency Information LIC 601 (dated 08/08/24) revealed (R1) was responsible for financial, care, and legal issues. Further review of Durable Power of Attorney for Health Care and Living Will (signed 07/07/23) verified the primary POA for Health Care. However, the Signature and Seal of Notary Public was not notarized to make it legally binding outside VA Healthcare setting.

Staff member #3 (S3) could not be interviewed due to (S3's) unavailability, as (S3) is no longer employed at the facility. Furthermore, (S3) did not provide any contact information, such as a phone number or forwarding address, which made it unattainable to reach out for further insights or comments about (S3's) awareness of this allegation.

Based on the information gathered, there is not enough evidence to support the allegation mentioned above.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegation are Unsubstantiated.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2025
LIC9099 (FAS) - (06/04)
Page: 9 of 9