complaint·August 14, 2025

Licensee did not ensure that staff are properly trained. - SUBSTANTIATED It was reported that Staff 1 (S1) did not complete training videos and was allowed to administer medications. Executive Director could not provide LPA with documentation to prove that S1 had completed their required medication training. Executive Director stated S1 should have received video training and 20 hours on the floor shadowing and hands on training. ED did not have proof that S1 took their medication training test. It was determined that the facility could not supply proof that S1 had completed their required medication training. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to Executive Director Stacey Baxter. Staff did not administer medication as prescribed.- UNSUBSTANTIATED It was reported that Staff 1 (S1) gave the incorrect dosage of medication to Resident 1 (R1). LPA reviewed Medication Administration Record (MAR) for R1 for the months of June 2025 when the error was reported to have been made. There were no medication errors listed for R1 on this document. 1 of 5 staff that were interviewed stated that S1 had dispensed the wrong medication to R1. This staff could not provide details concerning which (medication name, date) was dispensed incorrectly to R1. 4 other staff who were interviewed stated they had no knowledge that S1 had dispensed medication incorrectly to R1. Executive Director stated they had not heard that R1 had been administered the wrong medication dosage. This allegation is unsubstantiated. Licensee did not store an adequate amount of food for residents in care. – UNSUBSTANTIATED It was reported that that there is not enough food stored at the facility and the residents are not given enough food. LPA reviewed Sysco grocery receipts for the delivery date of 06/03/25 amount $2,410.91, 06/10/25 $1,552.60, 06/17/25 total $1,312.23, 06/24/25 total $1,269.67 Kitchens staff stated that the quantity and quality of the food items that are purchased are good. Kitchen staff stated they follow the menu but occasionally have to substitute some items or ingredients. Care staff stated that the kitchen follows the menu but has to substitute some items because they run out. Executive Director stated they purchase groceries every Thursday from Sysco. They follow the menu and purchase all supplies for three meals a day and also order supplies for snacks and sandwiches. Sysco delivers the weekly order every Tuesday. The monthly food budget is based on the census, and as the census grows the food budget increases. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to Executive Director Stacey Baxter.