Complaint Investigation Report

The investigation revealed the following: regarding the allegation “Licensee allows uncleared individuals in the facility.” It is alleged the licensee allows uncleared individuals in the facility. Four (4) out of the four (4) staff interviewed denied this allegation. Two (2) out of the two (2) clients interviewed denied this allegation. Client interviews revealed clients have only seen facility staff and medical professionals in the facility. LPA Ramirez reviewed staff files and staff roster and observed all staff on roster are associated to the facility. During the facility tour on 09/10/2025 at 8pm, LPA Ramirez did not observe uncleared individuals in the facility. 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 .

“Facility staff does not provide a safe environment for clients.” It is alleged that facility staff do not provide a safe environment for clients in care. Four (4) out of the four (4) staff interviewed denied this allegation. Two (2) out of the two (2) clients interviewed denied this allegation. During the facility tour on 09/10/2025 at 8pm, LPA Ramirez did not observe any hazards in or outside the facility. LPA Ramirez observed two (2) out of the four (4) clients in care, seated in the living room watching television. Clients appeared to be well groomed and alert. 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 .

“Facility staff did not ensure clients were adequately supervised.” It is alleged staff do not ensure clients are adequately supervised. Four (4) out of the four (4) staff interviewed denied this allegation. Staff interviews revealed two (2) permanent live-in staff reside at the facility and staff is always present in the facility. Two (2) out of the two (2) clients interviewed denied this allegation. Clients interviewed revealed staff are supervising clients in the facility however clients revealed they are free to go out into the community without staff supervision. During record review, LPA Ramirez observed C1 – C4 Physician’s Report (LIC 602), which revealed C1 – C4 may leave the facility unassisted. During the facility tour on 09/10/2025 at 8pm, LPA Ramirez observed two (2) out of the four (4) clients in care, seated in the living room watching television. Clients appeared to be well groomed and alert. LPA Ramirez observed one (1) staff seated in the living room area alongside two (2) out of the four (4) clients. 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 .

No deficiencies were cited for this complaint investigation. Exit interview was conducted. A copy of this report was provided.