Complaint Investigation Report

However, LPA also conducted six staff interviews. Four out of six staff interviews confirmed that S1 is not at the facility a sufficient amount of hours to administer the facility within compliance as required by regulations. Four out of six staff interviews conducted reported that S1 is at the facility once or twice a month for half the day. Based on the evidence gathering during this investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding the allegation that, facility staff are not receiving required training's, the following has been concluded: LPA reviewed the training records for eight facility staff. The training records reviewed included the initial and continuous training that staff have received. LPA observed that two out of the eight facility staff were missing the required training regarding principles of nutrition, food preparation and storage and menu planning. Based on the evidence gathering during this investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding the allegation that, facility staff did not safeguard the clients' cash resources and valuables, the following has been concluded: LPA reviewed an audit regarding the facility's Personal and Incidental (P&I) funds that was conducted between December 1, 2021, to March 31, 2022. LPA observed that the audit revealed a total discrepancy of $3,299.37 in which a total of six clients P&I were mismanaged. LPA also observed checks that have been made out to the client's families that were affected to refund the total amounts missing. LPA also conducted two staff interviews who confirmed the audit was accurate and that the clients who were affected due to the mismanagement of the P&I will be refunded. Based on the evidence gathering during this investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding the allegation that, facility does not have personnel records, the following has been concluded: Based on the LIC500 Personnel Report dated September 22, 2025, the facility currently has eight staff employed. During the initial visit on September 18, 2025, LPA requested the personnel records for all eight facility staff at 10:33 AM. The facility was unable to provide LPA the personnel records for two out of the eight facility staff during the visit. LPA received the two missing personnel records via email on September 19, 2025, at 11:53 AM. Based on the evidence gathering during this investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.