Complaint·October 1, 2025

The investigation revealed the following : Allegation #1- Staff are not providing residents with medication management. The details of the complaint alleged that the facility has a centralized location to give residents their medication but if a resident forgets or oversleeps, then a dosage is missed. On 10/1/2025, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R7) regarding the allegation. 4 of 4 staff denied the allegation that Staff are not providing residents with medication management. All staff (S1-S4) stated that the facility has a centralized location to give residents their medication, which is on the third floor in the medication room. They stated that those who are not able to come to the medication room to get their medication, it is taken to them by the medication technician, so it is not missed. They state further that they utilize Medication Administration Records (MAR) to chart medications given to residents and any missed or refused doses are written in the MAR and reported to their primary physician and family. The department interviewed residents (R1-R7) about the allegation and 7 of 7 residents that were interviewed stated that they have not missed any medications due to the location in which they receive their medication. Additionally, they stated their medication has not been mismanaged by the staff. The department reviewed a random sample of Medication Administration Records (Dated: 8/1/2025-9/30/2025) and did not observe any irregularities or deficiencies in the medication management of the residents’ records. Based on observation, interviews, and records reviewed, there is insufficient evidence to support the allegation that Staff are not providing residents with medication management. 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 . Allegation #2- Staff are not abiding by the terms and conditions of Admission Agreement. The details of the complaint alleged that the facility is not providing activities for the residents (such as trips to the beach) or providing the residents with cable in their room per their admission agreement. On 10/1/2025, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R7) regarding the allegation. Report Continued on LIC9099-C 4 of 4 staff denied the allegation that Staff are not abiding by the terms and conditions of Admission Agreement. All staff (S1-S4) stated that the residents are provided with daily activities to take part in at the facility and that each resident has access to cable in their room and it is a part of the basic services provided in the admissions agreement. Staff further state that activities provided by the facility include bingo, exercises, board games, trivia, outings to the park/beach, shopping trips, and arts and crafts just to name a few. Staff also stated that the admissions agreement states that the facility has a planned activity program but does not list which activities because the list changes often. The department interviewed residents (R1-R7) about the allegation and 7 of 7 residents that were interviewed stated that the facility does have a planned activity calendar and offers these activities daily. They further state that they are satisfied with the activities provided by the facility and enjoy them. The department reviewed the Admissions Agreement (Dated: 03/25/2021) and the Activity Calendar (September 2025, October 2025) and observed that each day the facility provides activities such as exercises, board games, walks to the beach, arts & crafts, trivia games, and religious discussions throughout the month of October 2025. Most of these activities were provided in the prior months, though some activities were due to change. The department also reviewed the admissions agreement, and cable is provided to all residents as part of the basic services provided by the facility. Additionally, the admissions agreement states that a planned activity program including arrangement for utilization of transportation to local community resources such as senior centers, parks, shopping malls, and other recreational venues will be offered to the residents. Based on observations, interviews, and records reviewed, there is insufficient evidence to support the allegation that Staff are not abiding by the terms and conditions of Admission Agreement. 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. An exit interview was conducted with Jesus Chavez, Assistant Administrator, and a hard copy of this Complaint Investigation Report was provided.