It was reported that on 03/25/2026 Resident 1 (R1) arrived at a medical appointment dirty and smelled of urine.

LPA reviewed LIC602 Physicians Report dated 08/12/2025 which states that R1 is able to bathe, dress, groom, and toilet themselves. Resident Appraisal (no date) states that R1 requires help with bathing and personal hygiene. Care Plan states R1 is aggressive when approached for care, staff instructed to document when R1 refuses showers or hygiene assistance. R1 is also aggressive when approached for toileting care and refuses briefs though shows signs of incontinence.

LPA reviewed observation notes for R1. 03/30/2026 Refused shower three times. 03/31/2026 Refused to use toilet or get out of bed. 04/01/2026 Refused help from staff, cursed at staff when asked to shower.

LPA interviewed 6 staff. All staff interviewed stated when they offer to assist R1 with activities of daily living (ADL) R1 refuses and becomes verbally and physically aggressive toward staff. Staff stated that R1 refuses showers and is physically and verbally aggressive when staff offers to assist R1 with showers and tells staff they have taken a “bird bath” and do not want to shower.

Executive Director stated R1 won’t let staff take care of them. R1 is verbally and physically aggressive to staff. R1 went out recently to the hospital and had a psych eval. When R1 goes out to hospital, staff does anything they can to clean R1’s room. R1 went to their doctor on 3/25/26 after a hospital stay. ED states staff can’t force R1 to take a shower but do offer R1 showers and R1 blatantly refuses.

It was determined that although it is true that R1 arrived at a medical appointment dirty, R1 continually refuses showers and staff assistance with ADLs. Staff cannot force R1 to shower or accept assistance with ADL’s. This allegation is unsubstantiated.

Continued on LIC9099-C

It was reported that R1 marked on a medical assessment form they do not feel safe where they are living.

All staff interviewed stated that R1 has never said they feel unsafe living in the facility.

Executive Director stated that R1 has never expressed that they feel unsafe living in the facility.

This allegation is unsubstantiated.

The facility has no administrator. - UNSUBSTANTIATED

It was reported that the facility does not have an administrator.

LPA reviewed documentation of Grace Hawkins being assigned as the facility administrator on February 23, 2026.

LPA has met with the current administrator at the facility on five separate occasions since they assumed their role.

All staff interviewed stated that the administrator is at the facility three to four days each week.

Executive Director stated they are at the facility at least three days each week. Staff are aware these are the days the administrator is in the building and staff have 24-hour access to the administrator.

It was determined that the facility has an administrator. This allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to Executive Director Grace Hawkins.