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32 | Report continued LIC 9099c...
Records show that the incident involving Resident 1 (R1) occurred on 04/18/2026. Documentation confirms that the facility submitted the UIR to CCLD via fax on 04/26/2026 at approximately 3:25 p.m. The Administrator Daily Operation Sheet further indicates that on 04/21/2026, the ED discussed the incident with O1, provided the UIR to O1.
Allegation: Resident was not able to go on an outing due to staffing issues: Unsubstantiated
During the course of the investigation, the Licensing Program Analyst (LPA) interviewed eight (8) residents, the Executive Director (ED), and three (3) staff members. The allegation indicated that a resident was unable to participate in outings due to insufficient staffing. However, interviews with the ED and staff, as well as documentation reviewed, including but not limited to the facility’s planned activities calendar and LPA observations, do not support this claim.
Resident 1 (R1) reported, “I can go on outings, but during the time that is scheduled, I don’t want to go and only want to go with S2.” This statement indicates that R1’s lack of participation in outings is based on personal preference rather than staffing limitations. Additionally, other residents and staff did not report any concerns about being unable to attend outings due to staffing shortages.
Based on the information obtained through interviews, record review, and observation, there is insufficient evidence to support the allegation that staffing issues prevented the residents from going on outings.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED.
Exit interview conducted and a copy of this report provided via email.
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