Complaint Investigation Report

A Department interview with the Licensee also revealed that C1 suffers from kidney issues, which cause fluid retention and fluctuating sodium levels. In 2008 a shunt was inserted into C1’s body to drain fluid from the body, which requires regular monitoring for infection. The Licensee stated that approximately 1-2 months ago they observed that C1 was not acting themselves and have been in constant contact with C1's doctor due to these issues. C1 had to visit the hospital on more than one occasion in the last few weeks due to these issues.

An interview with Outside Source #1 (OS1) from C1 doctor’s intake department revealed that the Licensee “goes out of their way” to communicate with the doctor and schedule appointments for C1. The interview also revealed that the Licensee follows-up immediately when C1 needs care and advocates for C1. An interview with Outside Source #2 (OS2), who advocates for C1, also revealed that there are no concerns regarding the care C1 receives at the facility. OS2 stated that they believe C1 receives good care at the facility.

An interview with the Licensee and the Back-up Administrator revealed that the day the doctor's office called the facility, on December 12, 2025, the Licensee had fallen and hurt themselves, which caused a slight delay in transporting C1 to the hospital ER. The Back-up Administrator, who is also a registered nurse, also stated that C1 was acting at baseline and they did not observe anything out of the ordinary with C1. C1 was transported to the hospital the morning of December 14, 2025. Finally, a Department interview conducted with a hospital representative where C1 had been admitted for monitoring revealed that C1’s sodium levels were checked and determined to be good on December 14, 2025. C1 was admitted to the hospital to monitor their sodium levels. There was not enough evidence to corroborate this allegation.

Due to a lack of corroborating evidence, the allegation that staff did not seek timely medical care for C1, resulting in hospitalization, is unsubstantiated. Although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violations occurred, therefore, the allegations are unsubstantiated.

An exit interview was conducted with Licensee Josefina So. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22) was provided. The signature below confirms the receipt of these documents.

***NOTE: LPA left the facility for a one hour lunch break, to make outside phone calls and to generate this report. LPA returned to the facility to deliver findings.