LPA observed residents eating lunch during the visit and verified that the facility’s food supply was sufficient. The observed meal included generous portions, and staff followed the posted menu. LPA also reviewed the facility’s food menus from May 2025 through July 2025 and confirmed compliance with meal planning requirements. See continued LIC9099-C page 5.

LPA also interviewed residents #2–6 (R2–R6). All five residents (5 out of 6) stated that they are free to use the restroom whenever they need to and stated that they are independent and do not require staff assistance for restroom use. R2–R6 denied the allegation.

LPA observed residents moving freely throughout the facility during the visit, including access to restrooms without staff interference. No evidence was observed to support the allegation.

Allegation #4: Staff are not allowing a resident to use a medical device.

LPA observed residents during the visit and noted that medical devices were present and in use as appropriate. LPA reviewed residents’ medical records and confirmed that physician orders for medical devices were documented and followed. No evidence was found to support the allegation.

See continued LIC9099-C page 4

Unusual Incident/Injury Report (dated 02/10/2024 & 02/16/2024), Sign In and Out Sheet (dated 01/2025--02/2025), and Flex Note (2/17/2025, 02/21/2025, 03/01/2025, 03/02/2025. and 03/04/2025.

On 12/19/2025, between 10:00 a.m. and 3:00 p.m., LPA Pamela Bunker conducted interviews with staff members #1–#4 (S1–S4) and with residents #2–#6 (R2–R6). Resident #1 (R1) was unavailable for an interview as they no longer reside at the facility. R1 transferring to a higher level of care facility.

The investigation revealed the following:
Allegation #1: Staff handled the resident in a rough manner.
LPA interviewed staff members #1–4 (S1–S4). All four staff members (4 out of 4) stated that facility staff did not handle any resident in a rough manner. 4 out of 4 staff members stated that no staff member caused a resident to cry or slam a resident’s wheelchair to the ground while the resident was seated in it. S1–S4 denied the allegation.

LPA interviewed residents #2–6 (R2–R6). All five residents (5 out of 6) stated that the staff has never handled any resident roughly. 5 out of 6 residents reported that staff provide a safe and comfortable environment and would never harm a resident. 5 out of 5 residents reported feeling safe in the facility and stated that staff cares about their well-being. 5 out of 6 residents reported being happy with the staff and the care they are receiving, and they had no problems or concerns. R2–R6 denied the allegation.

LPA observed staff interactions with residents during the visit and noted that staff were respectful, gentle, and attentive to residents’ needs. No evidence was found to support the allegation.

Allegation #2: Resident sustained an unexplained injury while in care.
LPA interviewed staff members #1–4 (S1–S4). All four staff members (4 out of 4) stated that no resident sustained an unexplained injury while in care. Staff explained that any injuries are documented immediately, and incident reports are completed and submitted to the Department as required. S1–S4 denied the allegation.

LPA also interviewed residents #2–6 (R2–R6). All five residents (5 out of 6) stated they did not witness any resident sustaining an unexplained injury while in care. Residents reported feeling safe and confirmed that staff respond promptly to any concerns. R2–R6 denied the allegation.

See continued LIC 9099-C page 3.

LPA interviewed residents #2–6 (R2–R6). All five residents (5 out of 6) stated they receive three meals per day plus snacks and have plenty of food to eat. Residents stated they are satisfied with the meals provided and had no complaints about the food. R2–R6 denied the allegation.

LPA inspected the kitchen and pantry areas and confirmed that the facility maintained the required two-day supply of perishable foods and seven-day supply of non-perishable foods, in accordance with Title 22 regulations. No evidence was found to support the allegation.

LPA interviewed staff members #1–4 (S1–S4). All four staff members (4 out of 4) stated that the facility is cleaned daily and maintained in good condition. 4 out of 4 staff members explained that cleaning schedules are followed consistently, including sanitizing common areas, resident rooms, and bathrooms. S1–S4 denied the allegation.

During the visit, LPA observed the facility to be clean, organized, and in good repair. Floors, furniture, and bathrooms were free of dirt and clutter, and no safety hazards were noted. The facility appeared well-maintained and met Title 22 requirements for cleanliness and sanitation.

LPA also interviewed residents #2–6 (R2–R6). All five residents (5 out of 6) stated that staff cleans the facility every day and confirmed that the environment is kept neat and sanitary. Residents reported no concerns regarding cleanliness. R2–R6 denied the allegation.

LPA reviewed the facility’s housekeeping schedule and confirmed that daily cleaning tasks are documented and completed. No evidence was found to support the allegation.

LPA also interviewed residents #2–6 (R2–R6). All five residents (5 out of 6) stated they were not aware of any illegal eviction and stated that they themselves had not received an eviction notice. R2–R6 denied the allegation.

LPA reviewed the resident’s file and observed documentation indicating that the resident’s condition had changed, requiring a higher level of care. The facility followed proper procedures by notifying the responsible party and assisting with the transition to an appropriate care setting. No evidence was found to support the allegation of an illegal eviction.

LPA also interviewed residents #2–6 (R2–R6). All five residents (5 out of 6) stated that staff do not leave residents in soiled diapers and stated that staff respond promptly when assistance is needed. R2–R6 denied the allegation.

LPA observed staff providing care during the visit and noted that proper diapering procedures were followed. LPA reviewed the facility’s care logs, which documented regular diaper checks and changes in accordance with the facility’s policy and Title 22 regulations. No evidence was found to support the allegation.

A copy of the Complaint Investigation Report LIC9099 and LIC9099-Cs was provided to Lorenzona Medina, Administrator.

No deficiencies were cited during this visit. An exit interview was conducted.