Complaint Investigation Report

Allegation: Staff are not reporting incidents

It was alleged that on 01/30/2026, C1 was transported/seen at the Emergency Room (ER) and neither external nor internal Incident Reports were managed by anyone. To investigate this allegation, LPA conducted an interview with the Director of Hospitality and a Therapist, and both parties interviewed informed LPA at the facility expects staff to report incidents to management and from there, a written incident report must be completed and reported to licensing. LPA reviewed all incident reports on a system and did not observe any incidents being submitted to the Community Care Licensing Department (CCLD) since 01/01/2026 to present. LPA contacted facility’s Compliance Services Manager, who confirmed that no incident was submitted to the Regional Office (RO) and informed LPA that they began working at this facility as of 01/23/2026 and since the incident occurred within the first week of their employment, they “missed that part” and failed to submit the written report. Although all four (4) clients interviewed expressed no concerns regarding this allegation, the facility failed to ensure that a written incident report was completed and properly maintained for C1’s ER visit on 01/30/2026.

Exit interview conducted, appeal rights explained and copy of this report signed and delivered.