Complaint Investigation Report

Based on records review, Resident #1 (R1) was admitted to the facility on 12/4/2022 and left the facility on April 4, 2023. R1 is non-ambulatory and has a mild cognitive impairment. R1 has a special diet of low sodium and low sugar.

Regarding allegation: Staff physically assaulted resident while in care.

LPA Montoya conducted interviews with three staff (S1-S3), five residents (R1-R5) and one witness (W1). Based on interviews conducted, all three staff (S1-S3), all five residents (R1-R5) denied staff physically assaulted resident while in care. S1 stated there are no reported incidents that staff physical assaulted residents while in care. W1 stated W1 heard that it was alleged that R1 was physically assaulted but W1 did not witness the incident and does not have any proof for the allegation. LPA did not observe any signs of physical assault to any residents in care during investigation visits. . Based on gathered information, there is no sufficient evidence to prove that staff physically assaulted resident while in care.

Regarding allegation: Facility has pests.

It was reported that rats are coming out of the wood planks in the back patio. LPA Montoya conducted interviews with three staff (S1-S3), all five residents (R1-R5) and a witness (W1). Based on interviews conducted, all three staff (S1-S3), and all five residents (R1-R5) denied that facility has pests. S2 and R2 stated sometimes squirrels appear on the retaining wall of the facility but they have not observed any rats inside and outside the facility. W1 stated W1 has not witnessed that facility has pests as W1 has not been to the facility. LPA did not observe any pests in the facility during the complaint visits. Based on gathered information, there is no sufficient evidence to prove that facility has pests.

Regarding allegation: Staff did not meet resident's dental hygiene needs.

It was reported that staff failed to brush R1’s teeth for weeks. LPA Montoya conducted interviews with three staff (S1-S3), all five residents (R1-R5) and a witness (W1). Based on interviews conducted, all three staff (S1-S3), and all five residents (R1-R5) denied that staff did not meet resident's dental hygiene needs. W1 stated W1 cannot provide comment to this allegation because W1 did not check on R1’s teeth. LPA was not able to observe R1’s teeth because R1 was no longer residing at the facility during the investigation visits. Based on gathered information, there is no sufficient evidence to prove staff did not meet resident's dental hygiene needs.