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13 | On 11/13/25 Licensing Program Analyst (LPA) Villegas conducted a initial complaint visit regarding the allegation(s) above. LPA met with Executive Director (S1) as the purpose of today’s visit was explained.
The investigation consisted of the following: On 11/13/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #2 (R1-R2) Emergency ID form, pre-appraisal, admission agreement, Physicians report, Service plan, Physicians orders, and incident reports, and tele-health progress notes. On 11/13/25 from 9:00 am- 11:48 am LPA conducted Interviews with Residents #2-11 (R2-R11), LPA unable to interview R1 as R1 is no longer receiving services at the facility. On 11/13/25 LPA conducted interviews with staff #1-6 (S1-S6) from 1pm-2pm, and from 2:15pm-2:45 pm LPA toured 5 bedrooms, smoking patio, lobby, and outdoor patio/garden area.
The investigation revealed the following:
Allegation: Staff did not seek medical attention for a resident in care. |