Complaint Investigation Report

Resident interviews revealed that residents do not normally wait an unreasonable amount of time to be helped by staff when they engage the signal system or the pendent alert system. Residents told the LPA that on average, facility staff attend to them within five (5) to fifteen (15) minutes.

Records review of the signal system alerts demonstrated that on average, more than eighty (80) percent of calls were responded to in under 15 minutes with an additional ten (10) percent of calls coming in under 20 minutes. This corroborates resident interviews.

On 04/16/2026 it was alleged "Staff did not ensure resident's room was clean." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review.

Regarding the allegation, "Staff did not ensure resident's room was clean", it was alleged facility staff do not clean resident rooms on a regular basis.

Resident interviews revealed that facility staff clean rooms once a week. All interviewed residents stated that they had no issues with getting help from staff to clean rooms. Interviewed resident rooms were clean and sanitary.

Records review revealed that facility staff have assigned rooms to a schedule of cleaning and sign off on the shift that the room was cleaned. Residents whose rooms are not cleaned on their assigned days are given the opportunity for staff to come at a later time to perform cleaning duties.

LPA Observations of rooms in the facility demonstrated that rooms in both the memory care and assisted living portions of the facility were clean and sanitary. This corroborates resident interviews.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with ED Brandon Cho, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.