Complaint Investigation Report

LPA conducted interviews with 3 staff and asked if there were any concerns that clients' personal rights were being violated by any other staff. 3 of 3 staff stated there were no personal rights being violated. LPA conducted an inspection of the facility and found there was adequate perishable and nonperishable food. An examination of the expiration dates found there were no expired foods in storage at the time of visit. In addition, LPA requested receipts of grocery purchases and found that an adequate amount of food was purchased for the four clients in residence at the facility, including fresh fruits and vegetables on a regular and continuous basis. Based on the interviews of clients and staff and the inspection of the facility and the review of grocery receipts the allegation that clients’ personal rights are not being observed is Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated .

The complaint alleges that the facility is not clean. LPA Nakagawa has inspected the facility on multiple occasions (2/23/2026. 3/19/2026, 7/2/2026 and 8/4/2026) and found the facility to be clean, orderly and well-maintained therefore the allegation that the facility is not clean is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated .

The complaint alleges that there is insufficient staffing. The complainant states that there are ongoing staffing concerns and there are routinely insufficient staff members and the house manager is left alone from approximately 6:00 p.m. to 10:00 p.m. LPA Nakagawa interviewed three staff members who stated that there were no staffing issues as well as reviewed the clients' service plans, which indicate no clients require a one to one. House Manager stated that there was sufficient staff and provided a copy of the staff schedule which indicates that there is sufficient staff coverage. Based on interviews with staff, house manager, Administrator and review of staff schedule the allegation that there is insufficient staffing is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated .

The complaint alleges that Facility staff are not dispensing medication as prescribed. The complainant states clients are being over-medicated by staff (S1) in an effort to reduce client behaviors. A review of medication administration records (MAR) found that PRNs were dispensed as prescribed by physician and the pill count was correct. Based on review of MAR and medication count the allegation that Facility staff are not dispensing medication as prescribed is Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.