complaint·March 18, 2026

The allegation of “Staff mismanage residents' medication.” Alleges that facility staff mismanage resident’s medications and that facility staff inappropriately administer sleeping pills to residents. LPA conducted a medication review for six (6) residents. LPA interviewed Staff #1(S1) and Staff #2 (S2). Both staff members denied administering any medications not prescribed by a physician, including sleeping aids, to residents. LPA observed two (2) resident’s Centrally stored medication and destruction record sheets (CSMDRs) to contain inaccurate records of the resident’s prescribed medications. Additionally, during the audit of resident’s medications LPA observed a total of twenty three (23) medications across six (6) residents to have errors in the medication count. LPA and S2 observed the CSMDRs for six (6) residents and confirmed that the amount of medications remaining in the bottles did not match the amount of medications that should be left based on the recorded start date and medication administration instructions. The resident interviewed did not have concerns with the administration of medications at the facility. LPA did not observe evidence of unprescribed sleeping pills being administered to residents but did observe evidence of medication mismanagement. Based on interviews and record review there is sufficient evidence to support the allegation of “Staff mismanage residents' medication.” Therefore the allegation is deemed Substantiated at this time. The facility Administrator was unable to come to the facility to sign this report but has designated S1 to sign on their behalf. This report was read to the Administrator via telephone call. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D): Exit interview conducted and copy of the report was issued and appeal rights provided