Complaint Investigation Report

LPA received the four 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.

Regarding the allegation that, facility staff are not receiving required training's, the following has been concluded: LPA reviewed the training records for twelve facility staff. The training records reviewed included the initial and continuous training that staff have received. LPA observed that three out of the twelve 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 do not have the required first aid training, the following has been concluded: LPA reviewed the training records for the twelve facility staff, including their first aid training. LPA observed that one out of the twelve facility staff did not have a valid first aid training card on file. Based on the LIC500 Personnel Report dated September 16, 2025, Staff #1 (S1) was hired on February 23, 2025, and Staff #2 (S2) was hired on March 15, 2025. S1 recently obtained a valid first aid training card on August 21, 2025, however, S1 did not have a valid first aid training card prior to it. Therefore, S1 did not have a valid first aid training card between February 23, 2025, to August 21, 2025. S2 also recently obtained a valid first aid training card on August 21, 2025, however, S2 did not have a valid first aid training card prior to it. Therefore, S2 did not have a valid first aid training card between March 15, 2025, to August 21, 2025. 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 $1,965.82 in which a total of three 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.