An exit interview was held and the copy of the report and appeal rights were provided to the Administrator, Denise Sutton.

Allegation: “Staff did not safeguard resident belongings.” It is alleged that several items mailed to the resident or personally brought to the facility have gone missing. LPA interviewed the Administrator and one (1) out of six (6) staff denied the allegation stating that residents’ personal items that have been mailed or personally brought to the facility have not gone missing. LPA interviewed four (4) out of six (6) staff that stated not being involved in handling personal items mailed to the resident or personally brought to the facility. However, those four (4) out of six (6) stated that there have been no residents recently reporting of any missing personal items that was mailed to the resident. LPA interviewed one (1) out of six (6) staff stated not being involved in handling residents’ mail. The Administrator stated that the procedure for personal items being brought or mailed to the facility are first brought to the front desk by the deliveryman. Per Administrator, those personal items are sent to the residents’ rooms with a Package Sign in sheet to confirm that the package was received from the staff to the resident. LPA reviewed facility theft and loss policy which indicates establishing uniform guidelines for safeguarding residents’ belongings and that the facility will make every reasonable effort to safeguard resident property and valuables. LPA reviewed copies of Report of Lost or Stolen Resident Property forms last documented from 09/25/2025 to 1/5/2026 that confirms an internal investigation of missing items was conducted by facility staff. LPA reviewed five (5) resident’s file that included Resident’s Safeguards to Property/Valuables to confirm how the facility keeps property’s are properly logged. [Continue to LIC9099-C]

Allegation: “Staff are unable to clearly communicate with residents.” It is alleged that there are staff who do not speak or understand English. LPA interviewed the Administrator and six (6) out of six (6) staff that denied the allegation stating that the on-duty staff are able to speak and understand basic English. However, Administrator and three (3) out of six (6) staff stated that there are some staff the speak primarily a different language despite being able to communicate in Basic English. In this case, the Administrator and five (5) out of six (6) staff stated that the facility would have staff available at all times that could provide communicating in English with the residents if further assistance is needed. LPA also observed that all the staff interviewed were able to clearly communicate and answer all the LPA’s questions clearly in the English language. LPA interviewed one (1) out of seven (7) residents that corroborated with the allegation stating that there are staff who do not speak or understand English since there are staff that speak Spanish. LPA interviewed an additional six (6) out of seven (7) residents that denied the allegation stating that the facility has staff available at all times that are able to communicate effectively with the residents speaking and understanding English. LPA interviewed six (6) out of seven (7) residents that stated not witnessing any staff unable to clearly communicate with residents. LPA observed that the facility staff were able to clearly communicate in English with the residents during the visit. There’s enough evidence to substantiate.