Complaint Investigation Report

It was alleged the Disaster Control Plan. Specifically, interviews conducted with staff and clients were reportedly unaware of their roles and responsibilities during a disaster drill.

It was also alleged that a review of clients’ Personal and Incidental (P&I) ledgers showed non-compliance with regulatory requirements. The review of cash resource ledgers showed facility staff did not record the balance for clients in care.

Based on a review of records, interviews that were conducted with staff and outside sources, and observations, the preponderance of evidence standard has been met. Therefore, the above allegations are determined to be SUBSTANTIATED. Due to time constraints LPA will return on a later date to issue deficiencies.

An exit interview was with Caregiver De Jesus, and a copy of this report and the Licensee Appeal Rights (LIC 9058 03/22) were reviewed with and provided to Licensee Mercedes at the conclusion of the visit. Signature below confirms receipt of these documents.