complaint·July 16, 2025

Allegation: Staff mismanaged resident’s medication Investigation Finding: Substantiated During investigation, staff (ADM) and reporting party (RP) confirmed with LPA that staff failed to timely pick-up resident’s prescribed medication (Mavyret) and timely administer the medication to the resident (R1). Review of R1’s centrally stored medication logs dated October 2023 showed R1’s prescribed medication started on 02/23/24 and was discontinued on 04/19/24. Witness (W1) also stated that facility staff failed to timely pick-up and administer R1’s prescribed medication (Mavyret). Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff mismanaged resident’s medication was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties . Exit interview conducted. Appeal Rights and a copy of this report provided. Allegation: Staff threatened resident in care Investigation Finding: Unsubstantiated During investigation, LPA interviewed staff (ADM), responsible party (POA) and resident (R1). ADM denied threatening R1 with eviction. Review of R1’s 30-day eviction notice dated 07/01/24 showed that R1 was given written notification of the 30-day eviction due to failure to comply with facility guidelines wherein he walked into the medication office, took a staff’s wallet, removed money, credit cards/ driver’s license and then bragged to other residents about it. Responsible party (POA) stated that she convinced ADM to rescind R1’s written 30-day eviction in July 2024 and let R1 stay at the facility. During unannounced visits on 12/10/24, 06/05/25 and 07/16/25, LPA observed (R1) still residing at the facility. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff threaten resident in care is unsubstantiated. Allegation: Staff did not provide proper transportation services to resident in care Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with staff (ADM), reporting party (RP). resident (R1) and reviewed R1’s documents. Review of R1’s signed admission agreement dated 11/11/22 showed the facility is not responsible for R1’s transportation requirements. LPA also reviewed R1’s medical records which showed his audio appointment on 01/08/25 was rescheduled at a later date due a scheduling conflict with his oncology radiation treatments. ADM confirmed with LPA that R1’s transportation was provided by a third party as arranged by R1’s case manager and R1’s family member to and from his doctors’ visits. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not provide transportation services to resident in care is unsubstantiated. Exit interview conducted and a copy of this report provided.