Complaint Investigation Report

The complainant concern is that the Licensee is operating outside of his approved ratio of clients. To investigate this allegation LPA reviewed the facility’s plan of operation, and per Licensee’s plan of operation, the Licensee will not lodge more than four (4) clients. According to the facility’s plan of operation the facility is operating outside of its ratio. Furthermore, LPA conducted an interview with the Licensee who confirmed that the facility already had four (4) clients when the Licensee accepted C1. Based on plan of operation review and interviews this allegation is Substantiated.

Staff do not have required health clearance

It was reported that during a random visit conducted on 02/13/2025, by the credible witness from NLARC that the facility staff did not have health clearance/TB on file. To investigate this allegation, LPA conducted an interview with the Licensee and the Administrator and both confirmed that S1 and S2 did not have a TB test clearance on file. Additionally, LPA conducted review of S1's and S2’s facility records and observed that S1 got hired on 12/06/2024 and S2 on 01/25/2025 and were not TB tested and cleared until 02/13/2025. Therefore, based on documentation review and interview this allegation is Substantiated.

Staff did not ensure resident had a table lamp and chair in room:

It was reported that during a random visit conducted on 02/13/2025, by the credible witness from NLARC that C1’s room did not have a table lamp and a chair in their bedroom. To investigate this allegation LPA conducted an interview with the Licensee who confirmed that C1’s bedroom did not have a chair on 02/13/2025; however, they placed a chair in C1’s room on that same day. Interview with C1 also confirmed the information provided by the Licensee. Based on the information gathered through interviews, this allegation is Substantiated.