complaint·December 30, 2025

On 04/08/25, LPA Ngo-Castaneda conducted an initial complaint visit at which time, at approximately 10:19 AM, LPA conducted a physical plant tour of the facility. From 12:30 PM – 1:30 PM, LPA interviewed three (3) staff members present in the facility and five (5) residents. At 11:00 AM, LPA requested copies of pertinent information which included, but not limited to Physician’s report, Admission Agreement, Staff Training, LIC 500, resident roster, needs and service plan, and other relevant documents to the investigation. Before this visit on 4.7.2025, LPA reviewed the documents previously gathered from the facility. Allegation #1: Staff over medicated a resident contributed to resident’s death. It was alleged that facility staff over-medicated resident #1 (R1), resulting/contributing in their death. LPA interviewed five (5) residents on 4.8.2025, and it was revealed that residents do not have any issues with staff over medicating anyone at the facility. During interviews with staff, it was revealed that all medications are given as prescribed. LPA reviewed R1’s medical records, which revealed that on 3.21.2025, no drug overdose was found in R1's system. R1’s death was due to ‘cardiac arrest’ on 4.1.2025. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation #2: Staff did not keep the facility free of an illegal substance. It was alleged that the facility kept an illegal substance that R1 took and consumed. During LPA Ngo-Castaneda facility plant tour, medication review, and observation, LPA did not observe any ‘illegal substance’ in the facility. During interviews with staff, it was revealed that all medications are given as prescribed. All of the staff confirmed that no one uses or sells drugs in the facility. During interviews with residents, all interviewed residents stated that they were given their medications as prescribed. Residents revealed no occurrences of illegal drug use or sales in the facility. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Continue to LIC 9099-C Allegation #3: Staff placed a resident on hospice without authorization. It was alleged that R1 was placed on hospice care without their consent. LPA phone interview with R1 family at 12:15 PM on 4.8.2025 revealed that R1’s family was aware of what they signed and was advised on the services that hospice will provide. LPA interview with staff revealed that R1 was admitted at the facility on 1.17.2025. Before being admitted to the facility, R1's family signed and agreed to R1 to receive hospice care. R1’s hospice care was approved by Circle of Life Hospice coverage on 1.01.2025. Based on the information provided and record review, the allegation is deemed to be UNSUBSTANTIATED at this time. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Copy of this report provided.