Complaint Investigation Report

Second allegation: Licensee does not have a working smoke detector. Regarding the allegation, LPA conducted an interview with Staff #1 LPA went over the alleged allegation with Staff #1 and informed Staff #1 that a walkthrough of Client #1 bedroom will need to be conducted. Staff #1 informed LPA that permission from Client #1 will be required due to client’s aggressive behavior. Client #1 granted LPA with permission to enter client’s room during the walkthrough LPA observed a smoke detector to be present and in working condition. LPA asked Client #1 about the missing smoke detector and Client #1 informed LPA that the last smoke detector made noise and client decided to pull it out.

Third allegation: Staff are not meeting the needs of the residents. Regarding the allegation stated above, LPA conducted an interview with Staff #1, Staff #2, and Staff #3, LPA went over the alleged allegation with Staff#1-3. During the interview Staff #1-3 informed LPA that facility is following Client#1 needs based clients individual plan however, Client #1 does not comply and has extreme aggressive behaviors when redirected. On 2/9/2026, LPA conducted a walkthrough of Client#1 room during the walkthrough LPA witnessed Client #1 who became verbally aggressive with Staff #1 after Staff #1 attempted to accompany LPA on the walkthrough. Based on corroborating evidence the department has determined that the above allegations are Unsubstantiated, meaning that 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.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to DSP/Caregiver John Kasendwa.