Complaint Investigation Report

AMENDED 03/19/2026 (formatting error, added sentence) On 01/14/2026, QA and LPA conducted in-person interviews with Staff 1 (S1), S2, S3, and S4. S1-4 all denied any theft of client or staff belongings, and all denied knowing of any theft at the facility. At this time there is not enough evidence to support the allegation of, “Staff do not safeguard the resident’s personal items.” and is unsubstantiated at this time.

As to the allegations of “Staff handled resident in a rough manner.” and “Staff does not treat resident in care with dignity or respect.” It was alleged that Staff 1 (S1) has verbally and physically abused clients. S1 has yelled at and pushed clients, particularly Client 3 (C3) and C2. S1 frequently argues with clients and intentionally harasses C1. It was also alleged that S2, demonstrates hostile and inappropriate behavior toward both clients and staff. It was discovered through interviews by Licensing Program Analyst Jeffries (LPA) and Tri Counties Regional Center, Quality Assurance, Wesly Marking (Q1) on 01/14/2026 C1, C2, C3, and C4 all conducted in-person interviews with QA and LPA. C1-4 all stated that no staff have abused them at this facility. C1-4 all stated that they feel that they have not been yelled at or harassed by Staff at this facility. C1-4 all stated that no staff, client or other person has inappropriately touched of put hands on them at this facility. C1-4 all stated that they feel safe and respected at this facility. On 01/14/2026, QA and LPA conducted in-person interviews with Staff 1 (S1), S2, S3, and S4. S1-4 all denied showing any disrespect to clients in care. S1-4 all stated that they have not acted inappropriately with clients in care. S1-4 all stated that they have not physically abused clients in care. All S1-4 stated that they have not seen other staff physically abuse, or act inappropriately with clients in care. On 01/14/2026, QA and LPA conducted an in-person interview with facility Administrator, Rea Hallmon who stated that all clients are treated with dignity and respect and all staff are fully trained and have had no recent negative interactions with clients in care. At this time there in not enough evidence to support the allegations of, “Staff handled resident in a rough manner.” and “Staff does not treat resident in care with dignity or respect.” and both are unsubstantiated at this time.

As to the allegation of, “Staff mismanaged resident medication.” It was alleged that there are frequent medication errors. Two photographs of a medication “bubble packs” that had medication popped out of sequence (#13) was provide with complaint submission. The unidentified medication and unidentified month of said medication packet was not evident in submitted photographs. On 01/14/2026, LPA Jeffries conducted a medication audit of the facility dating back to October 2025 through current medication documentation on 01/14/2026, LPA noted that Medication Administration Record did not show any missed medication