It was alleged that licensee does not ensure staff have the ability to communicate with residents this investigation consisted of facility observation and interview with residents. On 12/12/2025 LPA Hughes conducted a visit to the facility and spoke with 3 facility staff present in the facility LPA did not observe any delays in communication between residents and facility staff. LPA spoke with 3 residents in care, who all expressed no concerns about facility staff ability to communicate with residents. Additionally, LPA attempted to contact (2) facility staff present during NOC shift but was unable as the facility stated the staff no longer work for the facility. There is not enough evidence to corroborate this allegation, therefore the allegation is unsubstantiated.

Allegation: Staff did not prevent resident from engaging in a physical altercation with another resident

It was alleged that staff did not prevent resident from engaging in a physical altercation with another resident. This investigation consisted of interviews with facility staff and residents, and records review. On 11/05/2025 LPA spoke with 2 out of 3 facility staff who stated that an altercation between resident (R1) and (R2) was promptly intervened by facility staff. An interview was attempted with resident (R1) and (R2) however, no additional information was obtained due to both residents being primarily non-verbal. LPA reviewed a LIC 625 Unusual Incident/Injury Report sent from the facility regarding an incident that occurred in the facility on 10/20/2025 regarding resident (R1) and (R2) it was reported that facility staff promptly responded to an incident that occurred between residents in care and provided support and redirection. Due to insufficient evidence, this allegation is unsubstantiated.

Allegation: Staff did not seek medical attention for resident in care

It was alleged that staff did not seek medical attention for resident in care. This investigation consisted of interviews with facility staff and residents. On 11/05/2025 LPA spoke with 2 out of 3 facility staff who all stated the facility seeks medical attention promptly for residents in care. Interview with 3 out of 3 residents in care expressed no concerns about the facilities ability to seek medical attention for residents in care in a timely manner. There is not enough evidence to corroborate this allegation, therefore the allegation is unsubstantiated.

Continuation 9099-C

It was alleged that licensee does not ensure staff are in good physical health to perform assigned tasks. The investigation consisted of interview with facility staff and records review. On 12/17/2025 LPA conducted interviews with 2 out 4 facility staff which reflected that staff are not required to work when experiencing illness. Additional review of 4 out of 4 facility staff records LIC 503 Health Screening Report, indicated that facility staff are in compliance with health screening requirements. There is not enough evidence or information to corroborate this allegation, therefore the allegation is unsubstantiated.

Allegation: Staff did not observe changes in residents health condition

It was alleged that staff did not observe changes in residents’ health condition. This investigation consisted of interviews with facility staff and residents. On 12/12/2025 LPA conducted a visit to the facility. LPA interviewed 2 out of 3 facility staff, who stated the facilities protocol for assisting residents when a change in condition occurs for residents in care. Additional interview with 2 residents in care expressed no concerns about the facility not assisting residents when changes are observed in their health conditions. There is no evidence to corroborate this allegation, therefore the allegation is unsubstantiated.

It was alleged that staff do not ensure facility is kept in a clean and sanitary condition. This investigation consisted of interviews with facility staff, residents, and facility observation. On 10/31/2025 LPA Hughes conducted interviews with 2 out of 3 facility staff who stated that the facility bathrooms are often unsanitary. Interview with 3 out of 4 residents in care expressed no concerns about the facility being unsanitary, however interview with resident (R1) reported concerns about the facility bathrooms being left unsanitary. LPA conducted a tour of the facility on 10/28/2025 and observed the facility bathrooms to be unclean and left in unsanitary conditions. The allegation was observed not in compliance with Title 22 regulation 87303(a)(1) Maintenance and Operation. As the facility did not ensure the facility was clean, sanitary, and odorless at all times.

Allegation: Facility plumbing is in disrepair

It was alleged that the facility plumbing is in disrepair. This investigation consisted of interviews with facility staff and residents, and facility observation. On 10/31/2025 LPA conducted 3 out of 3 interviews with facility staff who stated that the facility plumbing in staff and resident bathrooms have been in disrepair for over 2 months. Additional interview with 3 out of 4 residents in care expressed no concerns about the facility plumbing in bathrooms being in disrepair. Interview with resident (R1) reported concerns about a resident bathroom being in disrepair. LPA conducted a tour of the facility on 12/2/2025 and observed 1 resident bathroom toilet in disrepair. This allegation was observed not in compliance with Title 22 regulation 87303(a) Maintenance and Operation. As the facility did not ensure the facility was in good repair at all times.

Allegation: Staff are not properly trained

It was alleged that staff are not properly trained. This investigation consisted of interview with facility staff and records review. On 12/17/2025 LPA conducted an visit to the facility, and interviewed 2 out of 3 facility staff, which reflected that facility staff are not properly trained on Medication Administration. LPA reviewed 4 out of 4 staff files, and observed no training records for the staff files reviewed.

Continuation 9099-C

As a result, this allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Kimberly and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.