complaint·August 23, 2025

The investigation revealed the following: Allegation: Staff are denying a resident from making phone calls. It is alleged that staff do not allow R1 to use the facility phone. LPA interviewed 4 residents and 3 out of 4 residents denied the above allegation and stated although they have not needed to make any phone calls they do not believe staff will restrict them of making any calls. LPA observed location of phone to be within the locked staff office that also holds all secured resident and staff files. During interviews with Staff, S2 stated that recently the phone has been relocated from the kitchen to the staff office as R1 has made unnecessary 911 calls. Interviews with 5 staff, each denied the above allegation and stated that residents are allowed to use the facility phone, however, when R1 asks to use the phone, they ask who R1 will be calling and often times staff will dial the number for R1 and give privacy for the phone call, staff added that this is done due to R1 making unnecessary 911 calls. S1 and S3 also confirmed S2’s statements. LPA reviewed R1s file and did not observe any notes of R1 making false/non-emergency 911 calls, there was no change of condition due to this being a continuous issue, there has been no reappraisal done for resident on how staff will assist resident with these new alleged behaviors and LPA reviewed Special Incident Reports (SIR’s) that have been sent to the department and there were no SIR’s received for these alleged 911 calls. LPA asked administrator for any notes on these alleged 911 calls and Administrator could not provide that information. Allegation is Substantiated. Allegation: Staff are mishandling a resident's medications. It is alleged that staff are not providing R1 with their prescribed medicine. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation and stated that residents are provided with medications that are prescribed by their physician and given per the doctors orders. LPA interviewed 4 residents and 3 out of 4 residents denied the above allegation and stated they are provided with their prescribed medications. LPA conducted a medication review and LPA observed R1’s medications to have dates that were not with complete medications (medications are prepackaged by day/time), when LPA asked staff why the dates were not matching, S2 and S3 stated that they recently took over medication administration and the medications were like that when they started and they have been pulling the correct medication but from future dates to ensure resident is still being administered the correct medication. During medication review LPA also noticed R1 to have a medication that is not listed within the doctors medication list nor the residents physician report, LPA also noticed that R5 was missing 1 routine medication and 1 PRN from their prescribed medications these medications were listed on R5’s current physician report dated 5/6/2025. Allegation is Substantiated. (Continued on LIC9099-C page) Additionally, during medication review LPA noticed that the Medication Administration Record (MAR) was not being signed for after administering medication to residents when LPA questioned staff, S3 stated that the medications have been administered they just sometimes forget to sign the MAR. Signatures were missing for 4 out of 14 medications for R1. This will be cited on a separate case management visit. Based on LPAs observations, interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview held, and a copy of this report and appeal rights were provided. The investigation revealed the following: Allegation: Staff are locking and isolating a resident inside of the facility. It is alleged that staff put R1 in a different room, isolated them and locked the door. Interview with R1 revealed that they are ambulatory, however, there have been times a chair has been left at the entrance of their room making it difficult to exit their room but the door has never been locked and they have never been confined in their room. LPA interviewed a total of 4 residents and 3 out of 4 residents denied the allegation and stated they have never been locked or isolated by staff at the facility. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation and stated they do not lock or isolate residents in their room and that R1 is ambulatory which allows them to ambulate freely throughout the facility. LPA interviewed 4 residents and 4 out of 4 residents denied the above allegation and stated that they are not locked or isolated in their rooms, when LPA questioned staff about placing a chair in front of R1’s room each staff denied doing that or witnessing other staff do that. Allegation is unsubstantiated. Allegation: Staff are not allowing a resident to file complaints. It is alleged that the facility staff does not allow residents to file complaints to the Department. LPA observed the complaint poster at entrance hallway along with ombudsman poster and residents rights signage, that is displayed clearly and in an area all residents access. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation and stated that the residents are free to file complaints and make phone calls to do so. LPA interviewed 4 residents and 3 out of 4 residents denied the above allegation and stated they have never needed to file a complaint and don’t think they would be prevented of doing so. Allegation is unsubstantiated Based on statements and interviews conducted with staff/residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.