complaint·January 29, 2026

Page 2. Staff are not meeting the needs and services of the residents. On the allegation that staff are not meeting the needs and services of the residents; it is the concern of the reporting party (RP) that on 05/13/2025, R1 was found and observed to be altered and bed bound, incontinent with strong smell of urine, rapid respirations and hyperglycemia. At the time of the RP’s observation, the staff present did not speak English, was unable to locate any paperwork or information regarding the R1’s medical history, recent illnesses or baseline mental status. LPA Urena interviewed staff (S1) about the condition of R1 on 05/13/2025. The staff stated that they did not notice any urgent changes in R1 prior to leaving the facility briefly due to a personal emergency. The S1 stated that the cleaning person stayed to keep watch over the residents while the S1 was gone. However, this is when the incident occurred, and the EMT personnel arrived. The Administrator denied knowing that S1 had left the cleaning person to watch over the residents while they were gone. LPA was unable to interview the cleaning person. Based on information obtained through interviews, the staff did not meet the needs and services of the residents when they left residents under the care of a person who did not provide care and supervision to R1 when R1 was found to be in an altered state, rapid respirations and with a strong smell of urine. Therefore, the allegation is deemed Substantiated at this time. Staff provided expired medication to a resident. On the allegation that staff provided expired medication to a resident; it is the concern of the reporting party (RP) that untrained staff provided EMT personnel with a box full of R1’s medication, and upon observation of the medication, EMT personnel observed an expired (03/06/2025) insulin bottle which was prescribed to R1 (a picture of the insulin bottle found at the facility was provided by credible sources). It is not clear if the staff had administered the expired insulin to the R1. To investigate the allegation, the LPA requested a copy of the LIC 622 (Centrally Stored Medication and Destruction Record). The LIC 622 was observed to have outdated entries at the time of the visit, with the last entries made as ‘medication received on 03/10/2025’. No record of the insulin was found on the LIC 622. No medication was available to review on the day of the visit. Continues on LIC 9099C...page 3. Page 3. Based on the record review in addition to the RP’s report, credible witnesses and pictures, the preponderance of the evidence supports that the staff provided expired medication to a resident. Therefore, the allegation is deemed Substantiated at this time. Staff are unable to provide proper documentation for the residents while in care. On the allegation that staff are unable to provide proper documentation for the residents while in care; it is the concern of the RP that staff were unable to provide EMT personnel with the resident’s medical information at the time they arrived to transport R1 to the hospital. To investigate the allegation, LPA Urena conducted an initial visit on 05/15/2025; at this time the LPA requested records pertaining to R1 pertinent to the investigation and interviewed the staff, administrator and residents. The Administrator’s interview revealed that they were not sure why the staff did not provide the R1’s medical records. The Administrator provided to the LPA the following records: LIC 602 (Physician’s Report dated 03/21/2025) and LIC 622 (Centrally Stored Medication and Destruction Record). The LIC 622 was outdated at the time of the visit. The interview with staff revealed that at the time of the EMTs arrival they had stepped out of the facility to attend to a family emergency, consequently they left the cleaning person at the facility for a short period, and the cleaning person did not have access to the residents’ records. Based on the information obtained through credible sources, and interviews with staff, the staff present at the time of the incident were unable to provide proper medical information for the residents while in care. Therefore, the allegation is deemed Substantiated at this time. Continues on LIC 9099C... page 4 Page 4. Unqualified staff is providing care and supervision. On the allegation that unqualified staff is providing care and supervision; it is the concern of the RP that staff present at the facility on the day of the incident were not qualified to provide care and supervision to the residents in care. To investigate the allegation, the LPA interviewed the staff and Administrator. The Administrator denied knowing that staff (S1) left the cleaning person to watch over the residents while S1 attended to a personal emergency. S1 confirmed that they left briefly, and left cleaning person at the facility. S1 claimed they were gone for maybe 15 minutes and when they came back the EMTs had taken the R1 to the hospital. The LPA confirmed via Personnel Report that cleaning person was not associated with the facility at the time of the incident. Based on information obtained via Personnel Report and interviews, unqualified staff were present providing care and supervision to residents in care. Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted. A copy of the report and Appeal Rights were issued.