Complaint Investigation Report

Facility submitted a copy of the resident roster and staff roster. LPA interviewed Administrator, Staff #2 (S2) to Staff #4 (S4), and Resident #1 (R1) to Resident #4 (R4) and Former Resident #1 (FR1). LPA was unable to interview Staff #1 (S1) due to language barrier. LPA reviewed and obtained documents from S1 to Staff #3 (S3’s) files that include: Staff Training and pertinent documents. LPA requested the monthly meal schedule and snack list. LPA toured the facility. LPA requested the Bed Repositioning Logs, Fire and Disaster Drill logs.

On 02/06/2026, LPA spoke to the Administrator over the phone and obtained S4’s staff training documents. LPA also interviewed S4 over the phone.

During today's visit, LPA obtained the following documents: staff and resident rosters.

The investigation revealed the following: In regards to the allegation “Staff do not communicate effectively.” It is alleged that S1 and S2 cannot communicate with the residents at the facility because they do not speak English. LPA interviewed the Administrator and three (3) out of four (4) staff denied the allegation stating that the on-duty staff are able to communicate with the residents. LPA attempted to interview S1 but S1 was unable to communicate effectively or answer LPA’s questions due to the language barrier. Administrator stated that there is an on-call night shift supervisor and administrator available to speak with residents over the phone. However, these individuals are not physically present at the facility. However, per Administrator there are times when S1 is the only staff on-duty and not everyone living at the facility speaks S1’s language. This is a possible concern in case of an emergency there may be a language barrier between emergency medical personnel and S1 can have a language barrier. LPA interviewed one (1) out of four (4) residents that corroborated with the allegation stating that language barrier is a problem and sometimes there is one (1) staff at night that is unable to communicate with the resident in English. LPA interviewed an additional former resident that corroborated with the allegation stating that one (1) staff was unable to communicate in English. LPA interviewed three (3) out of four (4) residents that denied the allegation stating that the staff are able to communicate with the residents. There’s enough evidence to substantiate.

Based on LPA interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

An exit interview was conducted with the Administrator, Diana Castellanos. A copy of the report and appeal rights were provided.