During today's visit LPA and ED briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. Starting at 10:26 a.m. and throughout the visit LPA conducted five (5) in-person interviews, three (3) staff and two (2) residents, attempted (1) resident interview, file and record review for Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), staff file review and obtained copies of pertinent documents relevant to the investigation.

On the allegations, Staff did not properly supervise residents, resulting in multiple elopements, it is the concern of the Reporting Party (RP) that the facility staff have failed to conduct door checks and supervise residents resulting in multiple elopements. To investigate this complaint, LPA conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation.

Staff interviews revealed that the facility has not had any recent elopements; however, staff reported two (2) attempted elopements. Staff stated that in both incidents, the residents were supervised at all times.

The first attempted elopement involved R1 in the assisted living department. R1 exited through the front door and was immediately followed by the concierge and an additional staff member. Staff were able to redirect R1 back into the community without incident.

The second attempted elopement involved R2 and R3 in the memory care unit. Both residents exited when a family was entering the facility. Staff #2 (S2) observed the residents exiting and verbally alerted other care staff, as S2 did not have a walkie-talkie at the time. Staff #3 (S3) and Staff #4 (S4) responded and followed R2 and R3. Staff reported that the residents proceeded down the hallway, down the stairs, and exited through the side door; however, staff maintained visual supervision throughout. Additional staff exited the building through other doors to assist. Once R2 and R3 reached the parking lot, staff were able to redirect both residents safely back into the community.

Staff reported that during both incidents, all residents involved remained safe and under staff supervision.

LPA attempted to interview R1 at 12:11 p.m. and R1 refused to be interviewed. Report continued on LIC 9099-C PAGE 3...

Interview with R2 revealed that due to cognitive decline, R2 was unable to recall the incident. R2 stated, “It’s hard to leave, I have tried,” and when asked further, R2 stated, “That’s the rules.” R2 also reported that they “have not left the community by themselves or with anyone else.”

Interview with R3 revealed that due to cognitive decline, R3 was unable to recall the incident. R3 stated that they “have not left the community on their own or with anyone else.” R3 also reported that they have attempted to leave; however, they understand they are not permitted to leave unaccompanied.

Random resident interviews indicated that residents were not aware of any individuals exiting the facility unsafely. Residents reported that staff consistently monitor the doors for safety and stated that they feel staff are actively supervising and attentive to their needs.

Record review revealed that R1, R2, and R3 each have a diagnosis of Major Neurocognitive Disorder (NCD) documented on their physician reports.

Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not properly supervise residents, resulting in multiple elopements is deemed unsubstantiated at this time.

On the allegation, Staff speak to residents in an inappropriate manner, it is the concern of the Reporting Party (RP) that S1 speaks rudely to residents and has slammed the door in their faces’. To investigate this complaint, LPA conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation.

Assisted Living resident interviews indicated that residents have not been spoken to in an inappropriate manner by any staff. Residents did not report any concerns regarding S1 and stated they have never been spoken to in an inappropriate manner by S1.

Memory Care resident interviews indicated that residents enjoy the care provided by staff and reported no concerns regarding any staff members. Due to cognitive decline, memory care residents were unable to identify S1.

Report continued on LIC 9099-C PAGE 4...

An interview with the Memory Care Director (MCD), S1’s direct supervisor, revealed that S1 has not received any disciplinary action and there have been no complaints regarding S1. MCD stated they have never observed or heard S1 speak to residents in a rude manner, and no staff or residents have voiced concerns about S1’s behavior.

During an interview with S1, S1 stated that they believe they have positive interactions with all residents. S1 reported that they respect and uphold residents’ personal rights and have never yelled at a resident, spoken to a resident in a rude manner, or slammed a door in a resident’s face. S1 stated they treat all residents with dignity and respect.

Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff speak to residents in an inappropriate manner is deemed unsubstantiated at this time.

On the allegation, Staff did not provide proper supervision, resulting in a physical altercation between residents, it is the concern of the Reporting Party (RP) that residents engage in physical altercations and have happened numerous times. To investigate this complaint, LPA conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation.

Staff interviews revealed that, to their knowledge, there have not been any physical altercations resulting from poor supervision. Staff reported one recent incident on 07/04/2026 in which a resident became agitated and pushed another resident, then became physically aggressive toward staff. The resident was subsequently transported to the hospital for evaluation. Staff stated that they were in close proximity during the interaction and intervened immediately. Staff further reported that they have not witnessed or heard of any other physical altercations within the community.

Resident interviews indicated that they have not heard of any physical altercations occurring in the community. Residents described staff as consistently present and stated that staff would not allow such incidents to occur. Residents reported that they feel safe within the community.

Report continued on LIC 9099-C PAGE 5...

Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not provide proper supervision, resulting in a physical altercation between residents is deemed unsubstantiated at this time.

On the allegations, Staff did not provide adequate food service, it is the concern of the Reporting Party (RP) that facility staff leaves residents in bed and skips their meals. To investigate this complaint, LPA conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation.

Staff interviews revealed that staff make multiple attempts when a resident refuses a meal. Staff reported that residents are typically asked up to three times, after which another staff member will attempt to offer the meal. If the resident continues to refuse, staff contact the resident’s family, which staff stated is usually effective. Staff described ordering the resident’s usual meal and leaving the tray set up for accessibility. Staff stated they make every effort to ensure residents eat and do not skip a resident’s meal unless the resident has clearly refused after multiple attempts and alternative options have been offered. Staff reported they have never intentionally skipped a resident’s meal.

Resident interviews indicated that the facility provides adequate food services, offering a variety of options. Residents may dine in the dining room or request a tray in their room. Residents reported that they have never been forced to skip a meal by staff.

Record review, including but not limited to meal rosters, revealed that during the period of 06/30/26 through 07/06/26, there was only one meal refusal recorded, and all breakfast meals were served.

Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not provide adequate food service is deemed unsubstantiated at this time.

The Executive Director (ED) departed at 4:23 p.m. and designated the Business Office Director (BOD) to sign the report on their behalf.