Cottages at Palm Springs.

LPA conducted an interview with R1 who stated that it took about 30 minutes for two (2) staff members to come in and assist R1 back on their bed. R1 stated it was about 2:00 AM on an unknown date in 2025. R1 stated it was the only time when staff response time was delayed. R1 thought that was due to the incident took place at such early time of the day and the job required two (2) staff members. R1 could not remember any other incidents when staff response time was delayed. LPA's attempted interviews with additional two (2) residents were unsuccessful due to their cognitive condition. LPA conducted interviews with five (5) staff members, all of whom stated that they have not heard any complaints from residents regarding call button response time. Staff members interviewed stated that all caregivers carry radios or phone and respond to residents immediately. The facility's office has a central monitor that can display which calls were not responded. Staff's response time can vary depending on what they are working on or time of the day. Based on interviews conducted, the Department's investigation did not provide enough information to corroborate the allegation that staff do not respond to call alert system in a timely manner. LPA determined that R1's experience of delayed staff response time was an isolated incident, not an on-going problem at the facility. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.

S1 stated that the televisions were all supplied by the residents or their families, not the facility. LPA's records review revealed that R1 was admitted to the facility on March 25, 2026, and television was not offered in the admission agreement. LPA's interview with the Administrator confirmed the statement from S1. Based on observation, interviews and records review, the Department's investigation did not provide any information to corroborate the allegation that resident do not have a working television. This allegation is unfounded. A finding of Unfounded means the allegation could not have happened, is false, and/or is without a reasonable basis. An exit interview was conducted where a copy of this report was provided.

R1's admission agreement stated that community fee is to be refunded in certain proportion depending on the time of termination of the admission agreement. LPA also observed that R1's admission agreement showed the amount of the community fee and was signed by all relevant parties. LPA obtained documentation from the facility's accounting department which showed the refund processed date of May 11, 2026. The refund was processed consistent with the Department's regulation. Based on records review and interviews conducted, the Department's investigation did not provide enough information to corroborate the allegation that facility staff refused to provide refunds. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced annual required visit. Upon entry, LPA was greeted by Tammy Eddy, Executive Director, and informed them of the purpose of the visit. Currently, the facility has 79 residents in care. Facility Overview: The facility is consisted of 6 cottages and an office building. Each cottage's capacity is up to 16 residents. There are no pools or known firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility has infection control plan in file. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. The facility has laundry room in each cottage, and LPA observed them to be operational. Sharp and dangerous objects were securely locked and inaccessible to residents. LPA obtained and reviewed the annual fire inspection report dated 06-10-2025, and the facility passed the inspection. LPA reviewed the monthly water temperature logs and observed the water temperatures in each cottage were within regulatory limit. Fire extinguishers installed on the walls of each cottage, and the fire extinguishers had current inspection tags. Continued on LIC809-C.... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate. Record Review and Resident/Staff Files: LPA reviewed files for five (5) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Five (5) resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for five (5) residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 03-25-2026, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided. ***LPA left the facility at 12:00 noon and returned at 1:00 PM.

LPA attempted to conduct an interview with R1, but the interview was unsuccessful as R1 declined to answer any of LPA’s questions. LPA conducted interviews with four (4) other residents, none of whom were aware of any physical altercation in the facility. LPA conducted an interview with S1 who confirmed the information that R1 had a behavior episode, and R1 rammed into S2 on 02-04-2026. LPA conducted interviews with five (5) additional staff members, all of whom stated that they have witnessed R1’s aggressive behavior toward staff members in the past. LPA’s review of R1’s records confirmed the statements from the staff members interviewed. Based on records review and interviews conducted, the Department’s investigation did not find enough information to corroborate the allegation that staff had a physical altercation with a resident in care. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided. **LPA left the facility at 11:30 AM and returned at 12:30 PM.

Licensing Program Analyst (LPA) Seo Jeon arrived unannounced to the facility to conduct a case management visit to check on the health, safety, and welfare of residents in care. A report was received by the Department from the facility on 08-25-2025 regarding Resident #1 (R1) and Staff #1 (S1). LPA met with Tammy Eddy, Administrator, who allowed LPA entry. The LPA conducted a tour of the interior/exterior areas of the facility, conducted a review of records, obtained, and requested copies of pertinent documentation. LPA's interview with the Administrator and records review revealed S1 was removed from the facility staff schedule as of 08-15-2025. LPA's review of staff schedule confirmed S1 was not scheduled to be at the facility at the time of LPA's visit. LPA did not observe any health and safety concerns. No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted where a copy of this report was discussed with and provided to Tammy Eddy, Administrator.

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced annual required visit. Upon entry, LPA was greeted by Tammy Eddy, Executive Director, and informed them of the purpose of the visit. At the time of the visit, there were fifteen (15) staff members and sixty eight (68) residents present. Facility Overview: The facility is consisted of six (6) cottages for residents and one (1) main office building. There is no swimming pool on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. There is laundry room in each resident building. LPA observed inspection report from fire marshal dated 10-1-2024 which showed passing inspection of all fire extinguishers, smoke detectors, and carbon monoxide detectors. The facility has total of 14 fire extinguishers. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Continued on LIC809-C..... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Care & Supervision/Administration: LPA reviewed staff schedules and observed there were sufficient staff coverages to provide care for the residents. Record Review and Resident/Staff Files: LPA reviewed files for five (5) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Six (6) resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked in med cart in med room. LPA reviewed medications for eight (8) residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 3-21-2025, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided.

traumatic wound to left lower dorsal leg. In the same discharge assessment date 12/23/24 R1 is noted to have new skin tears, and it is unknown as to how R1 sustained “so many new skin tears”. Per a file review conducted of Unusual/Incident/Injury report review there were no reports of any falls. Per the home health progress note revealed that R1 requires max assist when transferring from their bed to wheelchair. Home health services commenced on August 8, 2024. Home health is noted to come out to the facility every seven days (7). The third party wound care agency commenced services on 11/8/24 -12/17/24 and was coming out every six (6) days. On 11/8/24 R1 was observed to have a wound to their lower left anterior leg that was not healing despite measures taken such as topical antibiotics, Santyl, Medi honey, and Collagen. The wound is described as being a result of venous insufficiency, resulting a procedure was performed to remove slough and necrotic tissue. Per records reviewed of home health agency progress notes, “R1s left leg wound was noted to make no improvement and had worsened with drainage without significant improvement”. R1 is noted to have sustained additional wounds and the recommendation was to have skin grafting procedures completed”. Further notes reviewed revealed R1 is noted to have sufficient nutrition as well as normal oxygen level, the recommendation as noted in the home health progress notes was to reposition R1 every two (2) hours. Per R1s narrative charting the third party wound care specialist agency states in the notes for R1s dressing to be changed every 2-3 days as needed. Per an interview with Executive Director Tammy Eddy “facility staff were provided wound care training as well as the status of R1s condition was reviewed in regard to any applicable changes”. “Further due to the facility being non-medical, any wounds are reported to the primary care provider, and they refer out to Home Health for wound care”. Tammy further stated that the staff did not see the wounds as they were covered. Per additional staff interview conducted training was conducted which consisted of reporting observations of any wounds observed, and to apply basic first aid if applicable. Basic first aid consists of cleaning the wound with a wound solution spray and applying a bandage or gauze. Staff denied that the dressings were to be changed by facility staff, as home health or any other agency is involved, the responsibility is to report to the Primary Care Physician and keep following up until the resident has been seen by the necessary party. Despite efforts taken little to no improvement was made and a Hospice recertification was completed, and R1 received hospice services from 12/23/24 -1/31/24. Per a record review on R1s narrative charting, R1 is 12/23/24 R1 was admitted to a local hospital with the diagnosis of chronic wounds. On 1/31/24 R1 passed away and was unable to be interviewed in regard to the complaint allegation. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on interview and record review the allegation of Staff neglect resulted in a resident sustaining multiple pressure injuries is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted and a copy of this report, LIC811-Confidential names list was reviewed and provided to Patricia Russell, Resident Services Director.

R1 was admitted to a local hospital with hip pain. After further assessment the diagnosis given was mechanical function also known as “painful ortho hardware failure” due to a previous procedure. The mechanical function is not associated with a fall as it was also believed that was how R1 sustained the injury. Based on observations, interviews and records review the allegation of staff neglect resulted in a resident sustaining an unexplained injury while in care is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted and a copy of this report, 9099C, LIC811-Confidential names list was reviewed and provided to Tammy Eddy, Executive Director.

At this facility, there are multiple buildings identified as cottages. Within R1’s cottage, there are multiple apartment-like bedrooms with their own bathroom. Each cottage also has common areas which include kitchens shared by all residents. During staff interviews, it was reported that on 04/17/2024, R1 was assisted by staff to toilet in their apartment. Staff assisting R1 left R1 on the toilet, exited R1’s apartment, and went to the cottage’s kitchen to get water for R1. It was further reported the staff told R1 to stay seated on the toilet. It was estimated the staff was gone approximately 1-2 minutes. As staff made their way back to R1’s apartment, they heard R1 yelling for help. R1 was found on the floor. Staff called for medical attention. Charting notes dated 04/17/2024 with a time entered as 8:51pm revealed the following note: R1 had unwitnessed fall in their bathroom. R1 reported they wiped themselves with no caregiver present and fell. R1 refused for 911 to be called. The Serious Incident Report (SIR) dated 04/17/2024 revealed the date of the incident was 04/17/2024 and the time of incident was 6:55pm. It reads R1 got up to wipe themselves with no caregiver present and fell. R1 had red mark on their forehead. R1 refused for 911 services to be called. In the interview with R1, R1 reported experiencing a medical event and was administered their prescribed medication (M1). Charting note dated 04/17/2024 with a time entered of 3:55pm revealed the following note: R1 experienced the medical event and was given M1. R1 reported being especially concerned about being left alone in the bathroom that day. R1 said the medication “puts me out like a light.” R1 added the sedating effects M1 can last 5-7 hours, depending on how well R1 slept the night before. Because of the sedation, R1 was unable to estimate how much time had passed between the medical event and when R1 escorted to the bathroom by staff. Once R1 was positioned on the toilet, R1 reports they told S1 to stay with them. R1 added they had to remind all caregivers about staying with R1 after M1 is provided. R1 reported staff assisting them, left the room completely and did not say anything to R1 about why staff was leaving, how long they would be gone, nor did staff ask R1 to wait on the toilet until staff returned. When staff did not return after a period of time, R1 decided to try to wipe on their own. R1 can generally wipe on their own but tends to need help from the staff to get their pants and briefs pulled up. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 While attempting to wipe, R1 fell forward into the shower directly in front of the toilet. R1 landed on their left arm on the slightly raised lip/edge of the shower entrance. R1 estimated they were down on the bathroom floor for about 20 minutes until a staff member came to assist. Interviews revealed R1 was complaining of pain on 04/18/2024 and R1’s POA arrived and transported R1 to the hospital. Medical records were reviewed. Discharge paperwork dated 04/18/2024, revealed an x-ray of R1’s left arm was taken on 04/18/2024. X-ray revealed a distal humerus shaft fracture. In regards to the allegation that Staff did not ensure medications were dispensed to residents as prescribed. It was alleged that a medication was discontinued without a formal physician’s order. R1 was scheduled for a biopsy on August 15, 2022. Instructions were given for R1 to terminate the medication five days prior to the surgery. During the interview with Administrator, the facility provided R1’s Medication Administration Records (MAR) for the period May-August 2022. The August MAR shows the medication Clopidogrel (Plavix) was discontinued from August 11th to August 15th, 2022. An entry states the medication was suspended due to a procedure. . Staff could not find any formal physician’s order for this discontinuation. The Administrator confirmed that such a stoppage or discontinuation of a medication should not be done without a formal order. Resident Service Director, Patricia Russell indicated that she could not find a copy of the note from the neurologist to stop the medication. Information obtained from staff members stated that a request for a stop order was never requested from the neurologist. It was revealed that the physician did not send an order to the facility because the physician was not informed to terminate the order. Facility staff made a note in R1’s chart that the medication was terminated on August 10, 2024 and was suspended until the August 15 th , 2024. Information obtained from interviews with Administrator stated that on 08/13/22, S1 gave R1 their nasal spray and it appeared to be working. She stated that family R1’s POA would visit and observed R1 resting for the first hour or so post- seizure. R1’s POA was concerned that R1 was not snapping back from the medication effects and the RP had the evening shift med tech send out R1. R1 was admitted for testing and observation. The Administrator stated that S1 did not observe any unusual behavior different from R1’s typical seizure activity, which is why she did not call 911 promptly. The previous Resident Services Director, Melissa Polendo confirmed that the RP did request permission to put up signs to educate staff about stroke signs to watch for. Polendo was not certain if staff had additional training on stroke recognition after this incident. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 In regards to the allegation that the Staff did not seek medical treatment for resident in care. The incident that occured on 04/17/2024. The resident was on M1 and had a history of strokes. The staff should have taken into account the R1's medical history and possibility of closed head trauma should have been the deciding factor and the facility should have taken the initiative and called 911 to have R1 sent out. It was reported that staff did not seek medical treatment for resident in care. Charting dated 8/13/22 shows R1 was seen by the med-tech after showing signs of weakness and slurring words. R1 was treated at 1443 hours for a seizure and monitored the rest of the day. R1 reported feeling better around 9 PM. R1’s POA came to the facility at 10:03 PM because the POA felt R1 did not sound good when the POA spoke to her by phone. The POA observed slurring, dizziness and poor balance, leading the POA to send R1 out by ambulance. On 8/14/22, facility records reported that tests were ongoing for a suspect stroke/TIA and a UTI. R1 was going to be transferred to an in-patient rehab facility for 1-2 weeks. Though R1 was displaying signs consistent with a stroke, staff failed to consider this possibility and did not send R1 for timely medical evaluation. R1 was eventually diagnosed with a stroke. Interview with the Administrator stated R1 was being actively monitored after the seizure. Staff indicted that they went into check on MJ every 30 minutes, even if R1 did not activate her pendant. The Administrator added that R1’s high cognitive functioning level and answering “no” to hitting R1’s head and being in pain was the deciding factor in not sending R1 out. The Administrator indicted that if the resident is competent, then the resident’s wish to go to the hospital or not go, is honored. Interviews with staff members which are corroborated by the facility’s charting dated 8/13/22 shows R1 was seen by the med-tech after showing signs of weakness and slurring words. R1 was treated at 1443 hours for a seizure and monitored the rest of the day. R1 reported feeling better around 9 PM. R1’s POA came to the facility at 10:03 PM because the POA felt R1 did not sound good when the POA spoke to R1. R1’s POA observed slurring, dizziness and poor balance, leading the POA to send R1 out by ambulance. Interview with other pertinent parties indicted that S2 correctly recognized that R1 was suffering symptoms consistent with a stroke. Staff 2 (S2) informed Staff (3). S3 then incorrectly determined R1 was suffering a seizure and treated R1 with Valium nasal spray medication. Next, S3 failed to contact the POA for five hours, even though the POA was supposed to be notified right away if there is a seizure. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 By the time the POA got to the facility, R1 was silently sleeping though a stroke due to the M1 that had been given inappropriately. R1’s POA immediately called 911 to get R1 to the hospital. Due to the delay by S3, it was too late for the physicians at the hospital to administer tPA, a clot-dissolving drug. R1 was ultimately diagnosed with a stroke in the same area as a previous ischemic stroke and spent about four weeks at Desert Regional’s in-house rehab center. R1’s POA said this second stroke undid all the progress R1 made recovering from R1’s first stroke. The hospital discharge paperwork dated 08/23/2022 on stated Chief Complaint: stroke, patient diagnosis: 1- Seizure, Page 17 out of 83. Page 31 of 83 stated that the patient was discharged in stable condition and to follow up with the PCP neurology and cardiology. Based on interviews and records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Based on records review and interviews, there was no information found to show that the facility made changes or attempts to change their care and supervision for the resident, based on her fall history. An exit interview was conducted where a copy of this report was discussed and provided along with copies of the LIC811, LIC9099D and appeal rights. In addition, an immediate civil penalty of $500 is being assessed. The LIC 421 was also reviewed, provided along with appeal rights. In accordance with H&S Code Section 1569.49(e), the determination of additional ci

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that seventy-two (72) clients live at this facility. There was twenty (20) staff members present. The Executive Director, Tammy Eddy came to conduct and completed the facility tour. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Ten (10) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration : LPA reviewed employee records. Ten (10) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a location for sharps in the kitchen. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 75 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 107.0 degrees F. Laundry is done in the designated laundry room in each cottage. There is a locked closet for storing laundry soap, cleaning supplies and chemicals in the closet located in the housekeeper’s closet. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA dialed the facility’s landline number, which rang and was operable. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There are seven (7) secured fireplaces at this facility, located in each cottage and the main office. There is not a pool at the facility. There is one (1) main secured gate that leads into the facility, that has a self-latching lock. LPA observed emergency supplies and seven (7) first aid kits, additionally one is found to be located in each cottage. The last emergency drill was done on 01/18/2024. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training. Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed that they were dispensed accurately. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed smoke detectors and carbon monoxide detectors throughout the facility. There were twenty-eight (28) fire extinguishers on site, date serviced was 08/15/2023. The last fire inspection was 08/28/2023 done by the State Fire Marshal. The facility is monitored 24 hours by Desert Fire Extinguisher Co INC. Pursuant to Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to Executive Director, Tammy Eddy.

Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an unannounced case management visit to the facility. LPA met with Resident Service Director (RSD), Patricia Russell, LPA explained the nature of the visit and was granted entry into the facility. The purpose of today's visit is to conduct a follow up visit for an Immediate Exclusion letter for an ex-employee named Adriana Silva. Adriana Silva was not present during today’s visit. LPA was informed by the RSD that Adriana Silva has not worked at the facility since June 25, 2021. LPA conducted a tour of the facility. There was no health and safety concerns at this time. No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed with and provided to the Resident Service Director, Patricia Russell.

When R1 left the facility, there were still personal items in the room such as a hospital bed, and a bedside table; therefore not completely moving from the facility until May 30, 2023. Admission Agreement indicated that "Leaving the community is defined as moving from the Community and removing your furniture and all other personal belongings." R1's Power of Attorney signed an Admission Agreement stating that it was understood that if notice was given in the first month, that refund compensation would be at 80%. LPA received documentation that the facility provided the 80% refund on June 28, 2023. Per the Admission Agreement, the facility had 30 days to issue the refund. Document, and interview revealed that the refund was issued as agreed upon. Thus this allegation was Unsubstantiated. It was then alleged that R1's personal belongings were not safeguarded. R1 was alleged to have had their pair of glasses which were found on R1's roommate's bed. R1 was further reported to have been on R1's roommates bed. Staff interview revealed that R1's glasses were reported to have been moved, but not lost. Confidential interview revealed that R1 had all of their belongings when they moved from the facility, and none were claimed damaged, lost or stolen. Thus, this allegation was Unsubstantiated. A finding of UNSUBSTANTIATED means that 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. An exit interview was conducted where a copy of this report was discussed with and provided to ED Melissa Polendo.