Investigation Revealed the Following:

Staff do not provide quality food to clients.

The details of the complaint alleged that facility is serving frozen foods, waffles and eggs every day to clients in care.

On June 3, 2026, during the records review, the Department observed copies of the facility’s menu for the month of November 2025. The Department noted that the facility offers a variety of food items, and the total daily diet appeared to be of the quality and in the quantity necessary to meet the needs of residents. The menu reflected meals consistent with the Recommended Dietary Allowances established by the Food and Nutrition Board of the National Research Council. All food items were observed to be selected, stored, prepared, and served in a safe and healthy manner.

On April 9, 2026, during a health and safety check of the facility, the Department observed that the kitchen was clean, sanitary, and organized. Food items observed were well-prepared, properly stored, and not expired. The facility maintained a sufficient supply of perishable and non-perishable food, and documentation reflected that weekly food deliveries were occurring as scheduled.

On June 23, 2026, during the interviews with clients in care (C#1-C#8), (8) out of (8) stated that the food served at the facility is “okay” and reported that they are typically served meat, vegetables, and rice or potatoes, with no concerns expressed regarding food quality.

On April 9, 2026, during the interviews with facility staff (S#1-S#11), (7) out of (4) stated that they think the facility is providing a variety of quality food to clients in care.

Staff do not assist residents with ambulating.

The details of the complaint alleged that facility staff is not assisting (C#9) ambulating.

Evaluation Report continues LIC 9099-C

On June 3, 2026, during the records review, the Department observed a copy of (C#9)’s service plan dated November 4, 2025. Under the transfer section, the plan documented that (C#9) requires full assistance with transferring, specifically a two-person assist. Under the mobility section, the service plan indicated that (C#9) has standby assistance with a walker, uses an electric wheelchair, and utilizes half-bed rails for positioning. The plan further documented the use of a reaching device and noted that (C#9) requires two-person assistance for certain mobility tasks. The service plan stated that the care team would support (C#9) with safe ambulation, mobility, and repositioning.

On June 23, 2026, during the interviews with clients in care (C#1-C#8), (8) out of (8) stated that when they need help walking or moving to a chair, staff assist them.

On April 9, 2026, during the interviews with facility staff (S#1-S#11), (8) out of (11) staff stated that residents are assisted when needed, including assistance with transfers, ambulation, and general care.

Staff do not assist residents with obtaining medical care.

The details of the complaint alleged that facility staff are not assisting clients with their medical needs.

On April 9, 2026, during the records review process, the Department reviewed various staff training records related to client care and fair treatment. The records show that staff received training in areas related to resident supervision, responding to care needs, and procedures for reporting changes in conditions. Training documents also included topics such as infection control, resident rights, and protocols for coordinating medical appointments and outside medical services.

On June 23, 2026, during the interviews with clients in care (C#1-C#8), (8) out of (8) stated that when they need medical attention, staff help them get the care they need.

Evaluation Report continues LIC 9099-C

On April 9, 2026, during the interviews with facility staff (S#1-S#11), (7) out of (11) staff stated that residents are assisted with obtaining medical care, including wound care, diabetic support, and treatment for lice, or reported observing that medical care is provided by designated staff.

Licensee does not ensure that a skilled professional staff provides medical care to resident

The details of the complaint alleged that facility does not have skilled professional staff to provide medical care to the clients.

On June 4, 2026, during the records review, the Department observed a copy of (S#12)’s Vocational Nurse license, which reflects a current license with an expiration date of February 28, 2027. In addition, the Department reviewed a copy of the facility’s Personnel Report (LIC 500) dated December 10, 2025, which lists (S#12) as the facility’s Licensed Vocational Nurse with an employment start date of February 2020. Moreover, the Department reviewed various staff training records related to client care and fair treatment. The records show that staff received training in areas related to resident supervision, responding to care needs, and procedures for reporting changes in conditions. Training documents also included topics such as infection control, resident rights, and protocols for coordinating medical appointments and outside medical services.

On June 23, 2026, during the interviews with clients in care (C#1-C#8), (8) out of (8) stated that the nurse provides insulin injections and assists with medical tasks requiring skilled care.

Staff are not addressing pests inside at facility

The details of the complaint alleged that administration is not addressing the pests inside the facility.

Evaluation Report continues LIC 9099-C

On June 3, 2026, during the records review, the Department observed copies of pest control service reports from Dever Pest Control covering multiple service dates in October and November 2025. The records reflect that the facility receives weekly pest control services and periodic rodent rebaiting services. For example, one report dated October 17, 2025, documents that the technician “treated the building exterior and the following rooms, for roaches, with a liquid residual chemical: Rooms #2, 3, 5, 6, 38, 39, 40, 41, 42, 43”. Another report dated October 24, 2025, shows treatment of additional rooms for roaches, and a separate report from the same date documents the rebaiting of 16 rodent bait boxes, with the technician noting, “Cleaned and re-baited rodent stations as needed.” Subsequent service reports dated October 31, 2025, November 7, 2025, November 14, 2025, November 21, 2025, and November 28, 2025, show continued weekly pest control treatments, including exterior perimeter spraying and room-specific roach treatments, as well as additional rodent rebaiting services. The Department noted that the facility maintains ongoing contracted pest control services addressing both roach activity and rodent management, with documentation showing regular technician visits, identified treatment areas, and materials used.

On June 23, 2026, during the interviews with clients in care (C#1-C#8), (8) out of (8) stated that they have not noticed roaches, bed bugs, lice, or other pests in their rooms or around the facility at this time.

On April 9, 2026, during the interviews with facility staff (S#1-S#11), (6) out of (11) staff stated that they observed pests inside the facility while (5) out of (11) stated that they had not observed pest issues or reported only minimal occurrences.

Staff do not maintain facility in good repair

The details of the complaint alleged that the facility is in disrepair.

Evaluation Report continues LIC 9099-C

On April 9, 2026, during a health and safety check of the facility, the Department observed no signs of facility being in disrepair, there were no indications that the structure, fixtures, or common areas were damaged or unsafe.

On June 23, 2026, during the interviews with clients in care (C#1-C#8), (8) out of (8) stated that they have not seen anything broken or unsafe in the facility that has not been fixed.

On April 9, 2026, during the interviews with facility staff (S#1-S#11), (11) out of (11) staff stated that they have not observed issues related to the facility being in disrepair.

Facility is malodorous

The details of the complaint alleged that the facility is malodorous.

On April 9, 2026, during a health and safety check of the facility, the Department noticed that no strong or pervasive odors were present at the time of the visit.

On June 23, 2026, during the interviews with clients in care (C#1-C#8), (8) out of (8) stated that they do not notice any strong or unpleasant smells in their rooms or other parts of the facility.

On April 9, 2026, during the interviews with facility staff (S#1-S#11), (11) out of (11) staff stated that they had not observed any strong or unusual odors inside the facility.

Staff do not provide residents with laundry service

The details of the complaint alleged that the facility does not provide laundry services to the clients in care.

On June 5, 2026, during the records review, the Department observed a copy of clients’ admission agreements with various dates. The Department noted that the admission agreements list “personal laundry service” as a service included in the monthly rate.

Evaluation Report continues LIC 9099-C

On June 23, 2026, during the interviews with clients in care (C#1-C#8), (8) out of (8) stated that staff regularly wash their clothes and bedding for them.

On April 9, 2026, during the interviews with facility staff (S#1-S#11), (11) out of (11) staff who addressed the topic stated that laundry service is provided to clients.

During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, and a copy of the Complaint Report was given to Itzia Maciel /Assistant Administrator.