Complaint·April 4, 2025

Medication Administration Records (Dated: 10/01/2024-12/31/2024), and current Physician’s Orders (Dated: 12/31/2024) were also obtained from the facility. This complaint was referred to the California Department of Social Services Investigation Bureau for investigation and was assigned to Investigation Bureau Investigator, Olivia Spindola. As a part of the investigation, Investigator Spindola subpoenaed copies of College Medical Center medical records for resident (R1) which included: progress notes, physicians orders, psychological exam, lab results, and medication list. Additionally, the investigator conducted interviews with staff (S1-S4), witness (W1), and residents (R1-R3). The investigation revealed the following: Allegation-Resident had unknown exposure to fentanyl while in care. It is alleged that resident had exposure to an illegal drug while living at the facility. On 12/18/24 the resident was admitted to College Medical Center where they tested positive for the illegal drug Fentanyl. On 01/15/25, from 11:30am-1:00pm, the department interviewed staff (S1-S3); On 2/11/25, from 11:00am-3:30pm, the department interviewed residents (R1-R3) and staff (S4), and on 3/18/25, from 4:00pm-4:30pm, the department interviewed witness (W1) about the complaint allegation. 4 of 4 staff denied the allegation that the Resident had unknown exposure to fentanyl while in care. Staff denied knowing how the resident tested positive for the illegal drug. Staff also stated the resident resides in a locked area and cannot leave without supervision or assistance from staff. They further deny that the resident had access to illegal narcotics inside the facility or that anyone would provide the resident with Fentanyl. The department interviewed residents (R1-R3) about the allegation and 2 of 3 residents denied the allegation, while one resident was unable to participate in the investigation due to poor health. The residents that were interviewed stated that they have not witnessed any illegal drug use in the facility and was not aware of anyone providing illegal narcotics to residents. The department reviewed medical records from College Medical Center for R1 and observed that (R1) tested positive for Fentanyl on 12/18/2024, and 12/31/2024, when hospitalized at College Medical Center (CMC). The CMC records revealed that (R1) was hospitalized on an involuntary psychiatric hold for reported increased aggression and combativeness. Although the medical records indicated (R1) tested positive for Fentanyl during both hospitalizations, the department did not uncover any evidence or obtained any witness statements indicating that (R1) had access to Fentanyl or any other illegal narcotics, as (R1) resides in the Memory Care Unit of the facility, which is a locked area. The CMC records also indicated that (R1) takes several psychotropic medications to treat schizoaffective disorder, which included Olanzapine, Risperidone, Lorazepam, Quetiapine, and Trazadone. According to www.pubmed.ncbi.nlm.nih.gov , antibiotics, analgesics, and antidepressants medications such as Quetiapine and Risperdal are known to give false-positive for Fentanyl in laboratory testing. The nurse assistant (W1) stated that Quetiapine and Risperidone are drugs known to give false-positive for Fentanyl. Page 2 of 3 LIC9099-C Based on records reviewed and interviews conducted, there is insufficient evidence to support the allegation that the Resident had unknown exposure to fentanyl while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . No citations were issued for this complaint. An exit interview was conducted, and a hard copy of this Complaint Investigation Report was provided to Suzette Johnson, Administrator . Page 3 of 3 LIC9099-C