It is alleged that staff are not adequately trained. It is reported that staff do not have the appropriate training for all staff to include CPR/First Aid training. A visit was conducted at the facility on 3/10/25 by a third party entity where it was discovered that staff did not have appropriate documentation to provide direct client care and supervision. LPA interviewed Administrator and it was revealed that one of the staff members was in training and had previously refused to sign paperwork due to personal reasons, hence the missing and incomplete documentation. Administrator also stated that this same staff member resigned on 03/31/25 and is no longer employed at the facility. LPA explained to Administrator that unless staff is adequately trained, they cannot provide direct care to clients. LPA reviewed staff files, and it was observed that two (2) out of the two (2) staff that were present at the facility on 3/10/25 did not have valid CPR/First Aid training. One (1) staff member had CPR/First Aid that had expired on 02/16/25 and one (1) staff member had no proof of CPR/First Aid training until 03/10/25. Therefore, based on interviews, file review and observations, this allegation is deemed substantiated.

Citation issued. Appeal rights discussed and provided. Exit interview conducted and a copy of report given to Administrator.

It is alleged that Licensee does not ensure staff records are maintained on the premises. It is reported that during third party visit that facility files could not be located and only a few sheets of personnel records were available. LPA interviewed Administrator and it was revealed that Administrator was not available when third party was present therefore a designee was present, however designee was nervous and was not able to locate the files. Administrator states that the files are always in the facility as this is the only place where they can possibly be. Administrator showed LPA the location of files and they were all visibly in the facility. Administrator states that they do not know why the files were not located as they have always been in the same location in the file cabinet in the living room. Administrator also states that they were not made aware that anyone was looking for the files as there was no call made to Administrator to ask where the files were. LPA reviewed the files, and they are dated as far back as 1988, LPA also reviewed past visits from Licensing and files have always been made available. During the course of the investigation LPA Casillas was informed that that in reality the concern was that the files were incomplete not necessarily missing from the facility. Therefore, based on observations and interviews this allegation is deemed unsubstantiated.

Allegation: Staff are not dispensing medications as prescribed.

It is alleged that staff are not dispensing medications as prescribed. It is reported that medication was not provided to Client #1 (C1) for a period of ten (10) days from 03/01/25 to 03/10/25. LPA interviewed Administrator and Administrator stated that C1 has missed medication because the medication in question should be taken at 8:00 am, however C1 wakes up anywhere between 12:00 pm to 2:00 pm. According to Administrator C1 goes to sleep late and wakes up late, then refuses to take medication at the time scheduled. Administrator has mentioned this to C1’s provider who states that since the medication in question is a supplement, that it is ok for C1 to refuse it. LPA reviewed medication logs for C1 and observed that there is a notation in the medication log for the days that the medication is missed, and a reason is notated as well. LPA attempted to interview C1 but C1 refused to be interviewed. Therefore, based on observations, file review and interviews this allegation is deemed unsubstantiated.

Exit interview conducted. A copy of this report given to Administrator.