Complaint Investigation Report

***THIS PAGE OF REPORT HAS BEEN AMENDED***

Based on the interviews of residents and LPA’s observations the allegation that staff are locking residents in the facility is Unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is Unsubstantiated.

The complaint alleges that Staff are not providing comfortable accommodations to residents in care. The complainant states that staff recently placed a second resident in a now shared room and positioned the second bed in front of the sliding glass door. LPA inspected all bedrooms in the facility and found there were no beds in front of a sliding glass door obstructing the exit and that required furniture was present. The facility has a fire clearance and is licensed for two beds for each of the bedrooms. The resident (R1) living in the room under investigation was not paying for a private room and therefore the addition of a roommate would have been allowed under the lease agreement. Based on the fire clearance, the lease agreement and observations the allegation that Staff are not providing comfortable accommodations to residents in care is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is unsubstantiated.

The complaint alleges that Staff do not prevent vulnerable residents from leaving the facility without care, supervision or assistance. The complainant states that the resident (R1) dislikes the facility and tries to leave often and has been brought back to the facility in the past by the Police . LPA reviewed police records and found that R1 made multiple 911 calls but according to police reports R1 was found to be safe within the facility. Based on review of police reports the allegation that Staff do not prevent vulnerable residents from leaving the facility without care, supervision or assistance is Unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence to to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Amended Report (Page 9099-C) was reviewed with Acting Administrator Charlotte Lewis via phone and signed by Carestaff Isabell Ruiz on 7/29/2026.