Allegation 1: Staff is physically abusing residents.

On 10/10/2025 at 10:10 AM, LPA conducted interviews with Staff members 1–8 (S1–S8) and 8 out of 8 staff members stated that they have not seen or heard of any resident being physically abused by a staff member, nor has any resident reported to them that they were physically abused in any way by a staff member.

LPA also conducted interviews with Residents 1–9 (R1–R9) and 9 out of 9 residents stated that they have not been physically abused by any staff member in any way, nor have they heard another resident reports being physically abused by a staff member.

During the investigation, while LPA was conducting interviews, LPA did not observe or hear any residents in care being physically abused in anyway by staff members.

Allegation 2: Staff is verbally abusing residents.

On 10/10/2025 at 10:10 AM, LPA conducted interviews with Staff members 1–8 (S1–S8) and 8 out of 8 staff members stated that they have not seen or heard of any resident being verbally abused by a staff member, nor has any resident reported to them that they were verbally abused in any way by a staff member.

LPA also conducted interviews with Residents 1–9 (R1–R9) and 9 out of 9 residents stated that they have not been verbally abused by any staff member or in any way, nor have they heard another resident report being verbally abused by a staff member.

On 10/10/2025 at 10:10 AM, LPA conducted interviews with Staff members 1–8 (S1–S8), and 8 out of 8 staff members stated that they are not aware of staff members falsifying documents of any kind, nor have they ever been instructed to falsify documents. Staff 1–3 (S1–S3) were asked directly whether they have ever falsified documents for any reason, and all three stated that they have never falsified documents, never directed any staff to falsify documents, and have never received such directives. They further stated that staff and resident files are updated as needed based on changes in condition.

LPA also conducted interviews with Residents 1–9 (R1–R9), and 9 out of 9 residents stated that they are not aware of any staff members falsifying documents. When asked whether they have ever been asked to sign documents that were not applicable to them or their circumstances, 9 out of 9 residents stated no.

During the investigation, the records/files for Residents 1–9 (R1–R9) were reviewed, including pre-placement appraisals, medication administration records (MARs), admission agreements, and needs and service plans. All documents appeared to be valid and signed by all required parties, and no discrepancies were observed.

LPA conducted interviews with Staff members 1–8 (S1–S8) and 6 out of 8 staff members stated that they assume the administrator is qualified to run the facility. S1 stated that they do meet the requirements as the administrator and S2 stated that the administrator does meet the requirements to serve as an administrator.

Allegation 3: Staff is mismanaging resident's medications.

On 10/10/2025 at 10:10 AM, LPA conducted interviews with Staff members 1–8 (S1–S8) and 5 out of 8 staff members stated that they are not aware of residents’ medications being mismanaged and believe that medications are administered to residents as prescribed by their physicians.

The remaining 3 staff members stated that residents’ medications are given as prescribed by their physicians and that no concerns have been brought to their attention regarding residents not receiving their medications or medications being mismanaged by any staff member. When asked if residents’ medications are given daily, 8 out of 8 staff members stated yes.

LPA also conducted interviews with Residents 1–9 (R1–R9) and 9 out of 9 residents stated that they have received their medications daily or as needed and do not believe their medications are being mismanaged by staff members.

During the investigation, LPA reviewed 9 residents files and it appears that residents are receiving their medications as prescribed by their physicians.

During the investigation, files for the staff certified as administrators were reviewed, and 3 out of 3 staff members’ files showed that they have met the requirements to operate as administrators.

Allegation 6: Staff is operating out of scope of license.

LPA conducted interviews with Staff members 1–8 (S1–S8) and 8 out of 8 staff members stated that, to their knowledge, the facility is operating within the scope of its license and is not caring for any residents outside their license.

LPA also conducted interviews with Residents 1–9 (R1–R9) and 9 out of 9 residents stated that they are unsure whether the facility is operating outside the scope of its license; however, they noted that many residents appear to have similar health concerns or issues and believe the facility is providing care to individuals with similar needs. During the investigation, including the pre-inspection file review and records reviewed, it was determined that the facility is operating in accordance with its plan of operation.

Based on the evidence gathered, observations, and interviews conducted during the investigation, the above allegations are is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted where this report was discussed and provided to Joe Saldana Administrator at the conclusion of the visit with appeal rights.