Complaint Investigation Report

On 03/13/26, between 9:36 a.m. and 3:30 p.m., the LPA conducted a telephone interview with one (1) staff, conducted a file review, and collected pertinent documents relevant to the investigation. On 03/26/26, the LPA conducted one (1) phone interview with former staff, attempted to conduct phone interviews with Client 4 (C4), and one (1) witness, conducted a file review and collected pertinent documents relevant to the investigation. During today's visit the LPA conducted two (2) staff interviews telephonically, and attempted to conduct one (1) telephone interview with a former client.

On the allegation, “Staff restrict residents from using their mobility devices” it is the concern of the Reporting Party (RP) that the Program Director denies admission to individuals using wheelchairs and prohibits the use of canes for clients attending the Day Program. To investigate the complaint, the Licensing Program Analyst (LPA) conducted staff and client interviews and a file review.

Interviews with Program Director Nicole Lomeli and the Executive Clinical Director revealed that the facility is currently licensed only for "ambulatory" clients. This status was confirmed by a review of the facility’s Fire Safety Inspection Request, which reflects a fire clearance for a capacity of 16 ambulatory individuals. Facility management stated that the Fire Marshal explicitly prohibited the admission of non-ambulatory clients. Management further clarified that while they cannot admit non-ambulatory individuals (those requiring staff assistance to exit during an emergency), they do allow clients with short-term needs and have previously admitted clients using canes or crutches.

During the investigation, most staff members interviewed denied witnessing any resident being restricted from using a mobility device. They noted that clients are assessed during intake to ensure they meet ambulatory criteria. Furthermore, all clients interviewed stated they had never seen staff restrict anyone from using a mobility aid. Although the allegation may have happened or is valid, based on the information gathered the department does not have sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation, ‘Staff restrict residents from using their mobility devices” is UNSUBSTANTIATED at this time.

Exit interview was conducted. A copy of the report was issued.