Complaint Investigation Report

The investigation revealed the following:

Regarding allegation: Licensee is operating beyond the scope of their license.

It is alleged that the licensee is operating beyond the scope of their license. LPA Richard interviewed the administrator about the complaint allegation. The administrator stated that during the pre-licensing on 11/16/23, the application initially was for six ambulatory residents. However, due to insufficient space the capacity was reduced to five (5) residents. The administrator stated that she has never gone beyond three residents since the facility opened, the facility has been losing residents for the last past two months. Now the facility capacity has been reduced by two (2) residents. LPA reviewed the resident roster and interviewed R1-R2. They both state that they only remembered two or three of them living here. R1-R2 stated that now it only the two of us.

Based on information gathered, records reviewed, and interviewed, LPA did not find enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore, the allegation is unsubstantiated.

Regarding the allegation: Licensee is not ensuring that the facility is properly secured.

It is alleged that Licensee is not ensuring that facility is properly secured. LPA Richard toured the facility with the administrator, LPA observed there is an auditory devices to notify staff when someone walks through the backdoor from the room. The administrator stated that the facility is not a locked and there are no alarms. However, the facility has an auditory device on exits through the backdoor.