Complaint Investigation Report

On 06/02/2026 between 1:00 pm - 2:15 pm, the Department conducted a records review. The Admission Agreement states visiting hours are 9:00 am - 7:00 pm daily and that arrangements can be made for special visits at any time. The LIC 613C-2 Personal Rights document states residents may receive visitors privately and without prior notice during reasonable hours. The Personal Rights Policy (GP02) states residents have the right to attend religious services inside or outside the facility and the right to leave the facility at any time. The Resident Sign-In/Sign-Out Policy (GP08) requires residents to sign out when leaving but does not impose time restrictions, require prior approval, or permit staff to delay departure. None of the reviewed policies authorize staff to delay resident departure for religious services or require visitors to wait due to housekeeping activities.

The Department reviewed the Resident Sign-In/Out Log for March 2026 - May 2026. The log reflects that R1 routinely leaves the facility with her authorized representative for various outings including beach trips, shopping, meals, medical appointments, and religious services. The log demonstrates that R1 regularly departs the facility without documented restriction and staff consistently facilitate R1’s ability to leave for community activities in accordance with facility policy and resident personal rights.

On 07/02/2026 between the hours of 4 pm – 5 pm, the Department received additional written clarification from Administrator (A1). A1 stated the lobby is unlocked at 9:00 am daily and visitors may enter earlier with staff assistance using the video call system. A1 stated housekeeping normally mops the lobby at approximately 7:30 am and that any later mopping occurs only when housekeeping must respond to urgent cleaning needs elsewhere. A1 stated visitors are not required to wait outside and may be assisted through the lobby safely even when the floor is wet. A1 stated residents are not delayed when leaving for religious services and may depart at any time, including before 9:00 am.

Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted with Wesam "Sam" Kachouri (Administrator) and a copy of this report was provided.