complaint·April 23, 2025

Regarding the allegation: Staff mismanaged resident's medication. It is being alleged that staff #1 (S1) was trying to over medicate and poison Resident #1 (R1). LPA received an Unusual Incident/Injury Report that states R1 was sent out to the community due to a 5150 hold on March 04, 2024 due to being a danger to self and others. Additionally, LPA obtained confirmation via the Medication Administration Record that R1 refused four (4) days of a medication that deals with treating schizophrenia prior to the incident on March 04, 2024. Two (2) staff confirmed that R1 was not taking their medication at the time of the incident and as a result their behavior had became worse. Four (4) staff confirmed that R1 would yell and scream from time to time. Eleven (11) residents were interviewed that confirmed they receive their medication and it is not mismanaged by staff. One (1) out of the eleven (11) residents that was R1's friend confirmed that R1 had episodes of yelling and screaming when they would not take their medication. Let it be noted, R1 had a bipolar disorder, anxiety and depression and was supposed to be taking several types of medication for these conditions. LPA obtained R1's Centrally Stored Medication and Destruction Record, Physician's Report, Preplacement Appraisal and Resident Appraisal, Appraisal Needs and Services Plan and the Medication Administration Record. Therefore, based on the LPA's record review, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not safeguard resident's personal belongings. It is being alleged that staff discarded Resident #1 (R1)’s personal belongings. During LPA's interview with R1, R1 stated that their belongings were taken to the Skilled Nursing Facility where they were staying. LPA interviewed two (2) of the staff that confirmed R1's belongings were taken to the Skilled Nursing Facility because R1 did not want to return to the above facility. LPA also interviewed R1's social worker and the social worker confirmed that R1's belongings were brought to the Skilled Nursing Facility and the belongings that were brought were in several boxes and were put in the basement for R1 until their transfer to another facility. LPA also obtained R1's Client/Resident Personal Property and Valuables that confirmed R1 did not entrust any values to the above facility signed by R1. Therefore, based on the LPA's record review, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Illegal eviction. It is being alleged that the facility administrator illegally evicted Resident #1 (R1) and was transferred to a Skilled Nursing Facility. LPA interviewed R1 and R1 confirmed that they were not illegally evicted. R1 chose to not come back to the above facility because they felt they were being mistreated and the administrator had taken their belongings to the Skilled Nursing Facility. Furthermore, R1 confirmed that they asked their social worker not to bring them back to the above facility and instead look for a new place for them to live. Therefore, based on the LPA's resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not treat resident with dignity and respect. It is being alleged that staff #1 (S1) did not treat Resident #1 (R1) with dignity and respect. LPA interviewed eleven (11) residents that confirmed S1 and/or other staff have treated them with dignity and respect. Furthermore, while interviewing residents, one (1) out of the three (3) residents that knew R1 stated that R1 told them they were going to burn the building down. Three (3) out of the eleven (11) residents confirmed that R1 yelled and screamed at them. Two (2) staff confirmed that they saw R1 walking down the hallway without clothes. Therefore, based on the LPA's resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to Maria Chengcuenca, Medical Technichian.