Alta Loma Gardens Residential Care #1

Type of visit: Required - 1 Year

On 4/22/2026 Licensing Program Analyst, LaVette Farlow, (LPA) arrived at the Alta Loma Gardens Residential Care #1, Residential Care Facility for the Elderly unannounced, to conduct the Annual Inspection. LPA met with Administrator, Ana Margarita Pleitez; introduced self and stated purpose of the visit. LPA was invited inside facility and provided space to work. The current census is 6. The facility is licensed and approved for 6 non-ambulatory residents, 1 bedridden and Hospice Waiver for 4 residents. During the visit, LPA was accompanied on a tour of the facility and observed the following: Physical Plant: The facility is maintained at a comfortable temperature. Pathways inside the facility were free of clutter and obstructions. The common areas such as Living and Dining areas provide adequate seating and lighting. Resident Rooms included adequate lighting, seating, beds with required linens, night stands and appropriate storage. Resident Bathrooms contained adequate paper supplies, hand soap, non-slip materials and operable appliances. Water temperature was tested and observed at 121.3, 121.2, 126.2 and 124.2 degrees F. The facility does have a notice posted caution hot water, in the residents restroom. The facility is equipped with operating smoke detectors and carbon monoxide alarms. LPA observed two fully charged fire extinguishers. At 10:38 AM, LPA observed that the first bathroom on the right side hallway under the sink had cleaning supplies that were not secured and accessible to residents in care. A Deficiency cited. LPA did observe a lock cabinet in the kitchen under the sink with toxins, sharps, and other dangerous items kept secure inaccessible to residents in care. The facility food supply was observed in good standing and sufficient for the amount of residents in care. Dishes, cups, and utensils were also observed and stored properly. Posters such as: Facility License, Facility Sketch, Long Term Care Ombudsman, See Something Say Something, Theft and Loss Policy, Administrator Certificate, and Resident Rights were posted in a prominent place in the facility. LPA observed Medications are kept secure and inaccessible to unauthorized individuals inside the facility kitchen cabinet. Yards/Outside: One shaded patio, with sufficient number of chairs for residents in care. The backyard is free of any bodies of water. All outdoor pathways were free of obstructions. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. LPA observed that 4 out of 4 staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed 3 out of 3 resident files for admission agreements, physician reports, and needs and services plans. LPA observed 1out of 3 residents were missing the physician report. A Technical Violation issued. LPA reviewed 3 staff files for Criminal Background Clearance, Health Screening, TB test results, training requirements, and CPR/First Aid Certificate. LPA observed 1 out of 3 staff was missing a health screen, but the personnel record did have the TB test results. A Technical Violation Medications were audited at random and LPA observed the MARS is accurately maintained. Also, LPA reviewed the facility's files for insurance coverage, emergency disaster plan, infection control plan and emergency drills. LPA observed the facility is not maintaining Liability insurance coverage, and the Emergency Disaster Plan (LIC610E) was not reviewed and update. A Deficiency and Technical violation issued. During todays visit Two deficiencies, and three technical violation, were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV, and appeal rights were discussed and copies were provided to the Caregiver LaVonne Brinkley.the state’s words, verbatim · CDSS document, Apr 22, 2026

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff do not provide adequate food service Staff did not properly maintain a resident's bedroom Staff did not ensure the facility door is properly maintained

***This is an Amended report orginated on 4/3/2025*** On 04/03/2025, at 03:00 PM, Licensing Program Analyst (LPA), LaVette Farlow, conducted an unannounced visit to the facility to conclude the investigation and deliver findings to the above-mentioned complaint. LPA met with Staff, AJ Espino who was informed of the reason for today's visit. The investigation consisted of interviews with staff and clients and records review. The first allegation is Staff do not provide adequate food service. LPA Farlow interviewed R1, R2, R3, and R4, and they all indicated that the facility has an adequate amount of food. R1, stated the food was okay, just would like a different variety. R2, R3, and R4 stated they were satisfied with the meals. LPA Farlow interviewed staff S1, S2, S3, S4, S5, S6, and S7 and they all indicated that the facility does have an adequate amount of food for residents in care, and those resident with special dietary needs. ***Continued in LIC9099C*** Unsubstantiated S1 stated during his employment at the facility he would prepare a grocery list every Thursday. S1, S2, S4, S5, and S7 all stated they prepare meals for residents in care and things may run low, but they had never been completely out of food. Also, the administrator does a weekly grocery run. LPA Farlow did not find evidence to corroborate the allegation. The second allegation indicated that staff did not properly maintain a resident’s bedroom. LPA Farlow interviewed R1, R2, R3, and R4 and all residents indicated that staff come and complete the cleaning of the room several times a week and as needed. LPA Farlow interviewed S1, S2, S3, S4, S5, S6 and S7 and all staff indicated that the staff and administrator are very strict about the cleanliness of the facility. During the visit, LPA observed that the facility was clean, smelled fresh and the rooms were maintained. LPA Farlow did not find evidence to corroborate the allegation. The fifth allegation indicates staff did not ensure the facility door is properly maintained. LPA Farlow interviewed staff and the following was revealed. S1, S2, S4, S5, S6, and S7 all stated there was an issue with the door, but it was repaired immediately. S3 stated that when staff notified S3 of the door issues it was repaired the same day. LPA observed front door during LPAs visit and did not observe any problems with the front door. LPA Farlow did not find evidence to corroborate the allegation. Based on LPA Farlow’s interviews, and observation, the allegations staff do not provide adequate food service (Allegation 1), staff did not properly maintain a resident’s bedroom (Allegation 2), staff did not ensure the facility door is properly maintained (Allegation 5) are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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 at this time.the state’s words, verbatim · CDSS document, Aug 6, 2025 · control 56-AS-20241015093925

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Aug 22, 2025

87506(a)licensee shall ensure that a separate, complete, and current record is maintained for each resident...location..available to facility staff and to licensing agency staff. Based on interviews, and records review, the licensee did not comply with the section cited above due to facility staff not having access to residents complete files.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Licensee agrees to write a statement of understanding for section cited 87506(a) and when send by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Aug 22, 2025

87468.1(a)Residents in all residential care facilities.. all of the following personal rights(3)To be free from punishment, humiliation, intimidation, abuse..punitive nature, such as withholding.. interfering with daily living functions..sleeping, or elimination. Based on interviews, the licensee did not comply with the section cited above by not ensuring sufficient amount of staff are available to assist with residents needs. Also, staff was encouraging residents to go to there rooms at 5:30 PM.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Licensee agrees to make sure staff does not interfere with resident desire to stay up after 6PM. Licensee agrees to ensure there is sufficient staffing to meet the residents needs. Licensee will send a statement of understanding by POC date.

Type of visit: Office

Community Care Licensing (CCL) staff met with licensee representative, Ana Margarita Pleitez. The meeting was held with CCL staff, Regional Manager Leslie Mendiveles, Licensing Program Manager Nedra Brown, and Licensing Program Analyst Lavette Farlow. The purpose of the meeting was to discuss final judgements issued by the Department of Industrial Relations (Labor Commissioner’s Office) as a result of Labor Code Violations by Licensee. CCL staff inquired with licensee as to what has been done to remedy the judgements. According to the licensee, the judgments have not been paid, nor arrangements have been made with the Labor Commissioner’s Office. Licensee agreed to contact the Commissioner’s Office and provide CCL with update/status of remedy by 8/22/2025. In addition, Licensee was requested to submit by 8/22/2025, the Plan of Corrections due following the Annual inspection completed by CCL on 4/3/2025. Licensee reviewed and signed this report and copy was provided.the state’s words, verbatim · CDSS document, Aug 6, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst, LaVette Farlow, (LPA) arrived at the Alta Loma Gardens Residential Care #1, Residential Care Facility for the Elderly unannounced, to conduct the Annual Inspection. LPA met with Administrator, Margarita Pleitez; introduced self and stated purpose of the visit. LPA was invited inside facility and provided space to work. The current census is 6. The facility is licensed and approved for 6 non-ambulatory residents, 1 resident may be bedridden and Hospice Waiver for 4 residents. During the visit, LPA was accompanied on a tour of the facility and observed the following: Physical Plant: The facility is maintained at a comfortable temperature. Pathways inside the facility were free of clutter and obstructions. The common areas such as Living and Dining areas provide adequate seating and lighting. Resident Rooms included adequate lighting, seating, beds with required linens, night stands and appropriate storage. Resident Bathrooms contained adequate paper supplies, space, hand soap, non-slip materials and operable appliances. Water temperature was tested and observed at 117.4 and 121.5 degrees F. The facility does have a notice posted caution hot water, in the residents restroom. The facility is equipped with operating smoke detectors and carbon monoxide alarms. LPA observed two fully charged fire extinguishers. 1 of the 2 fire extinguishers did not have tag of last inspection, which was dated 4/2024. LPA observed that items such as cleaning supplies, toxins, sharps, and other dangerous items were kept secure inaccessible to residents in care. The facility food supply was observed in good standing and sufficient for the amount of residents in care. Dishes, cups, and utensils were also observed and stored properly. Posters such as: Facility License, Facility Sketch, Long Term Care Ombudsman, See Something Say Something, Theft and Loss Policy, Administrator Certificate, and Resident Rights were posted in a prominent place in the facility. LPA observed Medications are kept secure and inaccessible to unauthorized individuals inside the facility kitchen. During the tour LPA observed medication in the garage that was not centrally stored and locked. The administrator stated it was medication from a resident that is no longer in the facility. Although the medication was inaccessible to residents it was not properly destroyed. A technical violation was issued. Yards/Outside: One shaded patio, with sufficient number of chairs for residents in care. The backyard is free of any bodies of water. All outdoor pathways were free of obstructions. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. LPA observed that 3 out of 4 staff members working in the facility have criminal record clearance through the department. One staff member background clearance is in process and not cleared. A deficiency with civil penalty was cited. Record Review: LPA reviewed 3 out of 3 resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed 2 out of 3 residents were missing the physician report, and needs and service plans. LPA requested 4 staff files. LPA was reviewing the files for First Aid/CPR certification, criminal record clearance, training, and health screenings. LPA observed the administrator did not have a file available for review. Also, 2 out of 3 staff were missing health screening, TB test, application an job description. Medications were audited at random and LPA observed the MARS is not accurately maintained. LPA reviewed the record and observed missing signatures, and date medication was issued, and facility did not have accurate records of which medication are being dispensed by staff. The review of the records revealed medications were not listed on the MARS. LPA observed the facility does not maintain an accurate file for 3 out of 3 residents. Also, LPA reviewed the facility's insurance coverage, emergency disaster plan, infection control plan and emergency drills. LPA observed the facility is not conducting quarterly fire and emergency drills. A deficiency was cited. Five deficiencies, two technical violation, one technical advisory, and one civil penalty were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV, LIC9102TA, LIC421BG, and appeal rights were discussed and copies were provided to the Caregiver AJ Espino.the state’s words, verbatim · CDSS document, Apr 3, 2025

The state marks this report as 9 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to this facility to initiate an investigation of complaint number: 56-AS-20241015093925. LPA met with Caregiver, Raymond Munsayac. During today's visit, LPA conducted interviews with residents, staff, obtained and reviewed facility records, and did a walk-through of the facility. LPA found the following issues: Staff Personnel record not accessible and readily available for review. These pose an potential health and safety risk to residents in care. Refer to LIC 809D for deficiencies cited. An exit interview was conducted where this report, LIC809D, and appeal rights were discussed with and provided to Caregiver, Raymond Munsayac.the state’s words, verbatim · CDSS document, Oct 16, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87755(c) · Plan of correction due date: Oct 29, 2024

87755(c) The licensing agency shall have the.. audit...resident or..facility..demand during normal business..requirements in Sections 87412(f), 87506(d), and 87508(b). This requirement is not met as evidenced by: Based on observation, and interviews the administrator did not comply with the section cited above by not maintaining personnel records and having them accessible for LPAs review which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: Administrator stated she will update the personnel record and ensure they are accessible for upon request. Administrator stated she will review the regulation cited and submit a statement of understanding to LPA via email by 10/29/2024.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to complete the Annual Inspection from April 3, 2024. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 121.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects that were observed unlocked on April 3, 2024. LPA verified there is a telephone working at this location. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Two (2) Fire extinguishers observed and do not have tags attached. LPA was unable to verify if the facility is conducting emergency disaster drills, documentation was requested but not able to view. (Continued on Page 2) (Continued from Page 1) LPA allocated time to prepare this report for delivery. Based on the information received during this visit today, there are four (4) deficiencies is being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with and a copy provided to the facility representative. Appeal Rights were also provided at the time of the exit interview.the state’s words, verbatim · CDSS document, Apr 12, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to conduct a case management visit to clear deficiency. LPA was greeted at the door by facility staff and Administrator Ana Stark Pleitez was present. Currently there are six (6) residents in care. The following documents were requested to be viewed for staff and residents; records such as, Physician's Reports, Needs and Services, Admissions Agreements, Verification of Required Staff Training's, Proof of Fingerprints/Background Checks/Facility Associations, Health Screenings. These records or proof their of were to be submitted to Community Care Licensing by March 13, 2024. LPA Delgado requested and reviewed five (5) of six (6) residents files and all documents requested were not in files. There is no file for 6th Resident. LPA requested to review five (5) staff files and three (3) of five (5) files were available to be reviewed and all documents requested were not in files. Based on the information received during this visit today, civil penalties assessed are $2100 and will be issued for Failure to Correct per Title 22, Division 6 of The California Code of Regulations. This LIC 809 report, LIC811, LIC421FC, and Appeal Rights was reviewed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Apr 3, 2024

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card. Resident record review began. Five (5) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is not meeting documentation requirements. LPA began review of employee records. Five (5) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have not been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is current and has not been issued as of yet however Administrator showed LPA pending on the website. Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. (Continued on next page) (Continued from page 1) Due to insufficient time, LPA Delgado will need to return to complete the Annual and address the deficiencies observed on this day. Based on the information received during this visit today, deficiencies will need to be cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with and a copy provided to the facility representative.the state’s words, verbatim · CDSS document, Apr 3, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Alta Loma Gardens Residential Care #1, Residential Care Facility for the Elderly unannounced, to conduct the Annual Inspection. LPA met with Caregiver, Alvin John, Espino; introduced self and stated purpose of the visit. LPA was invited inside facility and provided space to work. Mr. Espino informed LPA the Administrator was not available at the time of the visit, but notified of LPA's visit. The current census is 6. The facility is licensed and approved for 6 non-ambulatory residents, 1 resident may be bedridden and Hospice Waiver for 4 residents. During the visit, LPA was accompanied on a tour of the facility and observed the following: Physical Plant: The facility is maintained at a comfortable temperature. Pathways inside the facility were free of clutter and obstructions. The common areas such as Living and Dining areas provide adequate seating and lighting. Resident Rooms included adequate lighting, seating, beds with required linens, night stands and appropriate storage. Resident Bathrooms contained adequate paper supplies, space, hand soap, non-slip materials and operable appliances. Water temperature was tested and observed between 105-114 degrees F. within regulation. The facility is equipped with operating smoke detectors and carbon monoxide alarms. LPA observed two fully charged fire extinguishers. The two fire extinguishers did not have tags of last inspection. Staff maintains the fire extinguishers were inspected in June 2023. LPA observed that items such as cleaning supplies, toxins, sharps, and other dangerous items were kept secure inaccessible to residents in care. The facility food supply was observed in good standing and sufficient for the amount of residents in care. Dishes, cups, and utensils were also observed and stored properly. Posters such as: Facility License, Facility Sketch, Long Term Care Ombudsman, See Something Say Something, Theft and Loss Policy, Administrator Certificate, and Resident Rights were posted in a prominent place in the facility. LPA observed Medications are kept secure and inaccessible to unauthorized individuals inside the facility kitchen. LPA requested to review facility files for staff and residents. LPA was informed that only select staff have access to such records. LPA unable to reach Administrator on file during the visit. LPA was unable to review and records during the visit which poses a potential risk to residents in care. Based on observations, deficiencies will be cited to address concerns for the facility records and accessibility. An exit interview was conducted, this report was reviewed, discussed then provided to facility representative.the state’s words, verbatim · CDSS document, Feb 13, 2024

Type of visit: Office

Licensing Program Analyst (LPA) Bernadette Allen met with Ana Pleitez Stark Administrator at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 11/08/2023 at 10:50 AM to initiate a Case Management Office Visit. LPA Allen requested that Ana Pleitez Stark come to the office to sign an amended complaint investigation control number 18-AS-20210430090536 that was conducted on 10/28/2023. The report was missing an allegation and investigation information. An exit interview was conducted where this report was discussed, and a copy was provided to Ana Pleitez Stark at the conclusion of the visit.the state’s words, verbatim · CDSS document, Nov 8, 2023

Allegation investigated: Staff are mismanaging medications. Staff do not have appropriate training.

Licensing Program Analysts (LPA) Bernadette Allen arrived at the facility unannounced to deliver the findings for the allegations listed above. LPA met with Administrator Ana Pleitez Stark who left during the visit and gave her care staff Lavonne Brinley approval to sign report. The investigation consisted of interviews with two (2) staff members who stated that they have not been documenting the MAR for the clients in care.The administrator has also confirmed that accurate documentation has not been conducted per CCL requirements. The interviews also revealed that the licensee has not been conducting any quarterly or annual training for the staff and proof of training could not be provided at the time of the visit. Based on the evidence gathered during the investigation, the above allegation is found to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is being cited on the attached LIC 9099-D. Substantiatedthe state’s words, verbatim · CDSS document, Oct 28, 2023 · control 18-AS-20210430090536

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(2)(B) · Plan of correction due date: Nov 4, 2023

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual... (2) This training shall be...(B) Importance and techniques of personal care... This requirement is not met as evidenced by: Based on observations, interviews and record review, the Licensee did not comply with section cited above by having S2 and S3 worked at the facility without the required initial/annual training which poses immediate health, safety, and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 28, 2023

Plan of correction: Licensee has agrred to submit Proof of Required Trainings of all staff to LPA Allen by POC due date. Licensee has agreed to submit a Signed Statement of Understanding on CCR 87411(c)(2)(B) by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: Nov 4, 2023

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications...(6) The licensee shall be responsible for assuring that a record... This requirement is not met as evidenced by:Based on observations, interviews and record review, the Licensee did not comply with section cited above by not document in R1-R5 Medication Administration Record (MAR) the administration of any residents’ medications at the time they were given all pages were blank. This poses a potential health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 28, 2023

Plan of correction: The licensee has agreed to train all staff on CCR 87465(h)(6) and submit Training Log to LPA Allen by POC due date. Licensee also agrees to submit a signed Statement of Understanding on CCR87465(h)(6) to LPAllen by POC due date.

Allegation investigated: Residents sustained pressure injuries while in care. Staff are not assisting residents with ADLs. Administrator is not fulfilling management duties. Facility does not have sufficient staffing.

Licensing Program Analysts (LPA) Bernadette Allen arrived at the facility unannounced to deliver the findings for the allegations listed above. LPA met with Lavonne Brinley Support Staff who left during the visit and gave her care staff Lavonne Brinley. The investigation consisted of interviews with the administrator, two (2) staff members, four (4) residents and review of five (5) residents files. LPA interviewed two staff members who stated there was only one resident at the facility in the past who was diagnosed with a pressure injury but was being treated by hospice three times a week. LPA also observed documentation that confirms there was one resident with a pressure injury and was being treated by hospice. The interviews with the staff were asked if staffing was sufficient, and they stated they would like to have additional staff at night, but they manage with who they have. LPA also reviewed staff schedule that reflect there is sufficient staff for night shift. The interviews with the four (4) residents stated that their (ADL’s) activities of daily living were being met daily by staff members. The interviews with staff and administrator all stated the administrator is at the facility daily. During the visit LPA observed that there was sufficient staff, residents ADL’s appeared to be met and the administrator was at the facility upon arrival. Based on interviews, documentation, and observations the allegations are Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and provided with appeal rights to Lavonne Brinley Support Staff at the conclusion of the visit. Unsubstantiated LPA was unable to interview resident 1(R1) because they are deceased. LPA observed the facility files for Resident 1(R1) and their file did confirm that they were being treated by a hospice Agency off and on from 2019 through 2023. Based on the interviews and file review the above finding is Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and provided to Lavonne Brinley at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Oct 28, 2023 · control 18-AS-20210430090536