Complaint Investigation Report

Interview with R1 revealed that they enjoy walking around the front and back of the facility and spend much of their time exercising. During a facility visit LPA directly observed R1 ambulating using their walker in the courtyard without issue. Records review revealed that R1 was independent and able to ambulate on their own without supervision around the facility. No evidence was found to prove that the Licensee was not meeting R1's supervision needs.

Regarding the second allegation, "Facility gate was in disrepair", it was alleged that an outside facility gate did not have a lock or handle, which resulted in a safety issue by allowing anyone to come and go from the facility. LPA direct observations of the gate in question revealed that the gate was located on the East side of the facility by the Assisted Living wing. LPA directly observed that a handle existed on the gate and was in good repair by physically testing it, and the gate could be opened without issue. Staff interview revealed that the Licensee was in the process of upgrading the gate to include a spring that allowed the gate to self-close, and a new handle that included an outward-facing lock for additional safety. Records review corroborated the staff statements regarding the repairs and showed the timeline of events for the upgrade. No evidence was found to prove that the Licensee allowed the facility gate to be in disrepair without taking action. Residents interviewed stated that the Maintenance Director is very timely with repairs, and addresses physical plant issues right away.

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