Allegation: Staff do not prevent resident from threatening resident

The detail of the complaint alleges that R1 was threatened with a knife by another resident when R1 lived at the facility.

On August 6, 2026 at 10:00am the Department interviewed Assistant Administrator (A1), who stated that a R1 informed staff that R1’s roommate threatened R1 with a knife, however when staff searched the room there was no knife found. A1 further stated that sometimes the residents will bring in items that are not allowed, however staff will confiscate the items. Lastly, A1 states that there have been no knives found in the facility.

On August 6, 2026 between 10:15am and 11:00am, the Department interviewed 5 staff (S1-S5) regarding the allegation, and of those interviewed, 5 out of 5 stated that no resident had reported to them that they had been threatened with a knife. 4 out of 5 stated that they have never found a knife in the facility. 1 out of 5 stated that she saw a knife in a residents’ room but not recently. She went on to state that as soon and the staff saw a knife, they immediately took it.

On August 6, 2026, between 11:00am and 12:00pm, the department interviewed 5 residents (R2-R6). Of those interviewed, 5 out of 5 stated that they have never been threatened with a knife. 5 out of 5 stated that they feel safe and well cared for at the facility.

Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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.

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The detail of the complaint alleges that “the facility did not give R1 Personal & Incidental (P&I) due to R1 owing the facility.” It was also alleged that the facility was paying R1’s phone bill out of R1’s money, but they allegedly stopped paying, and as a result R1 doesn’t have a working phone.

On August 6, 2026 at 10:00am, the Department interviewed Assistant Administrator (A1), who denied the allegation stating that the facility handled R1’s P & I funds, however no funds were withheld from R1. A1 further stated that there is no record of R1 owing the facility money. Lastly, A1 stated that “We were paying for R1’s cell phone bill while R1 was a resident, but it did not come from R1’s P & I, our facility paid for it as service to the resident. When R1 moved out (2/21/26) the payment for the phone stopped.

On August 6, 2026, the department reviewed and evaluated the following documents: R1’s admission agreement (dated 10/2/24), signed personal rights (dated 10/2/26), and R1’s P & I log (2025-2026).

Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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.

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The detail of the complaint alleges that when R1 lived in the facility “there were cockroaches all over the bathroom and despite the services through pest control company Orkin the roaches allegedly kept coming back.

On August 6, 2026, at 10:00am, the Department interviewed the Assistant Administrator (A1) who denied the allegation of a cockroach infestation. A1 stated that “we have Orkin pest control come in to do maintenance inspections and we have been cleared.”

On August 6, 2026, the Department interviewed 5 staff (S1-S5) regarding the allegation. 5 out of 5 denied the allegation of a cockroach infestation, they stated that they have seen 1 or 2 roaches, but Orkin comes out often to do treatments.

On August 6, 2026, the Department interviewed 5 residents (R2-R6) who also stated that they have only seen 1 or 2 roaches and denied that there is an infestation.

On August 6, 2026, the department reviewed the Orkin Service report (dated 7/24/26). The report is a maintenance report and according to the report, mild activity was observed and documented. Previous service dates were as follows: 7/10/26, 6/12/26, 3/27/26, 11/7/25, and 10/10/25.

The document confirms that the facility is maintaining pest control.

On August 6, 2026, the Department toured the facility and observed that it was clean, safe and sanitary.

Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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.

Exit interview conducted with Assistant Administrator Nicole Lozano. No deficiencies cited during todays visit. Copy of report provided.

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