Complaint Investigation Report

On 12/19/2024, LPA attempted to interview Resident (R2) at the facility, but R2 was sleeping at that time. LPA interviewed Resident (R1), who stated that they could come and go from the facility whenever they wanted and were free to move around inside the facility as well. LPA interviewed a staff member (S1), who stated that they had not heard any residents express a desire to leave the facility and confirmed that no resident was being held at the facility against their will.

On 12/24/2024, LPA reviewed the facility’s Staff Roster and noted that the care nurse's (GCM) name was not listed on the staff roster. LPA reviewed the facility’s Resident Roster and observed that R2’s name and room number were listed on the roster. LPA reviewed R2’s LIC 601 Identification and Emergency Information form and noticed that GCM’s name was listed under the placement agency and as an emergency contact (friend). The LIC 601 form had been completed and signed by GCM on 09/04/2024, with GCM's title written as "Geriatric Care Manager" on the form. From R2’s LIC 601 form review, LPA obtained the contact information for R2’s Family Member (FM1), Persons Responsible for Financial Affairs (FRP1 and FRP2), and Primary Care Physician (PCP2).

On 12/24/2024, LPA reviewed R2’s LIC 602 Physician’s Report, dated 09/19/2024, which stated R2’s primary diagnosis as Dementia with behavioral disturbances. LPA reviewed R2’s LIC 603 Preplacement Appraisal Information form, which had been completed and signed by GCM on 09/03/2024.

On 01/03/2025, LPA interviewed R2’s Fiduciary/Trustee/Financial Responsible Persons (FRP1 and FRP2). FRP1 and FRP2 stated they had been brought in by R2’s attorneys as co-trustees and had paid R2’s bills while ensuring R2’s needs were met. FRP1 and FRP2 stated that R2’s Family Member (FM1) had been the decision-maker and that the care manager (GCM) had advised FM1 regarding R2’s care. FRP1 and FRP2 stated that the decision to move R2 to the memory care facility had been made between FM1 and GCM.

On 01/03/2025, LPA interviewed Family Member (FM1), who stated that R2 had been moved to the facility around August or September 2024. FM1 stated that FRP1 and FRP2 had mentioned to them that R2 would not have enough money left for at-home care and that GCM, who had been hired by FRP1 and FRP2, had proposed that R2 be moved to a memory care facility due to Dementia. FM1 agreed, as this ensured R2’s money would not run out and R2 would receive proper care at the facility. FM1 stated they had tried and done their best in R2’s interest. FM1 stated that R2’s previous tenant (FTE), who had also been listed in R2’s will and had been R2’s POA, then had declined to continue as R2’s POA and FTE hired FRP1 and FRP2 to manage R2’s finances. FM1 stated that R2’s dementia had been slowly progressing since 2015.