complaint·February 12, 2026

Allegation: Facility did not administer residents’ medications in a timely manner Investigation Finding: Substantiated On 02/12/26 at 3PM, LPA interviewed staff (ALD, Director of Nursing, S1) who stated that residents’ (R1, R2) medications were not administered in a timely manner because of S1’s failure to prioritize timely medication administration to residents on 02/01/26 because of two emergencies that happened around 10:30AM. S1 stated the other Med Tech on duty was busy helping other residents with their medications and could not assist her. Review of email documents dated 09/30/25, 10/02/25, 01/20/26 and 02/01/26 showed staff failed to administer R1 and R2’s medications in a timely manner and R1 had to call staff to give R2’s medications. 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 facility did not administer residents’ medications in a timely manner is substantiated. . Allegation: Facility missed resident’s blood pressure checks Investigation Finding: Substantiated During investigation, LPA interviewed reporting party (RP) and staff (ED, ASL Director, S1). RP stated that R2’s twice daily blood pressure checks (one in the AM and another in the PM) were not being done by staff. ALD stated staff failed to perform R2’s blood pressure checks daily due to a lack of better training to fulfill residents’ care requirements. 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 facility missed resident’s blood pressure checks is substantiated. Continued on next page, LIC 9099-C pg1 Allegation: Facility did not follow up with resident’s primary care physician on discontinued medication and refills in a timely manner Investigation Finding: Substantiated Review of email documents dated 09/30/25, 10/01/25, 10/02/25 and 10/03/25 showed R1’s ER discharge instructions to a skilled nursing facility (SNF) on 08/13/25 stated to stop taking Lisinopril. The 08/25/25 discharge notes from SNF to the facility did not have Lisinopril on R1’s medication list. Staff continued to administer Lisinopril to R! and failed to timely follow-up with his primary care physician (PCP) to remove Lisinopril from his medication list. Also, review of email dated 01/26/26 showed staff gave RP a package of his medications dated August 2025 which RP stated dosage was never received. Ba sed 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 facility did not follow up with resident’s primary care physician on discontinued medication and refills in a timely manner is substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates 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.