Complaint·November 21, 2025

On 08/01/2025 between 04:36 PM - 5:00PM the department requested, reviewed, and obtained copies of the Staff Roster, Client Roster, Physicians Report. On 09/25/2025 between 10:09 AM – 04:48 PM the department requested and obtained the foll(owing: Centrally Stored Medication Destruction Record (CSMDR). On 11/21/2025 the department obtained an Unusual Incident Report dated 07/16/2025. On 09/25/2025 (10:09 AM – 04:48 PM) the department conducted interviews with Staff #1 - #5 (S1-S5) and Resident #2-#4 (R2-R4). An attempt to interview Resident #1 (R1) was made but R1 moved out of the facility on 07/20/2025 prior to the visit. LPA toured the facility with Administrator Mona Alcaraz. The investigation revealed the following: Allegation: Staff did not provide resident medication as prescribed It is being alleged that staff are over-medicating residents and not providing medication as prescribed. Three out of three residents (R2 – R4) indicated staff provided them with their medication as prescribed by their physician. On 11/21/2025 at approximately 03:20 PM the department conducted an interview with the Administrator (A1). A1 was asked if staff provided residents with medication as prescribed, and A1 said we don’t give any medication without prescription if it is not prescribed by their doctors. On 09/25/2025 between 10:09 AM – 04:48 PM the department conducted interviews with Staff #1- #5 (S1-S5). Five out of five staff interviews indicated (S1-S5) they assisted residents with their medication as prescribed by their physician. On 09/25/2025 between 10:09 AM – 04:48 PM the department obtained and reviewed the Centrally Stored Medication Destruction Record (CSDMR’s) and it showed that all residents interviewed received their medication as prescribed by their physicians. The department requested Medication Administration Records (MAR’s) from the facility but was informed by the administrator that they only documented medicine administered to residents via the Centrally Stored Medication Destruction Record (CSMDR’s). A thorough review of the CSMDR’s showed that all medicines including R1 were current at the time of visit. Based on the information gathered, interviews conducted, and review of records, the department found no evidence to support the allegation mentioned above. 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. CONTINUED ON LIC9099-C Allegation: Staff restrained a resident in a chair. It is being alleged that staff restrained Resident #1 (R1) in a chair using a band to keep the resident from falling out of a chair. On 09/25/2025 between 10:09 AM – 04:48 PM the department conducted interviews with Residents #2- #4 (R2-R4). An attempt to interview Resident #1 (R1) was made but R1 was not present at the time of visit. The department obtained and reviewed an SIR report that showed R1 was transferred to An interview with the Administrator (A1) revealed that R1’s Responsible Party later called the facility on 07/20/2025 and said that R1 was not returning back to the facility. On 11/21/2025 at approximately 03:20 PM the department conducted an interview with the Administrator (A1). A1 was asked about the above allegation, did staff restrain a resident in a chair. A1 stated that it is not practiced in the facility, nor has A1’s staff received in service training in restricting patients. The department asked the residents if staff ever restrained them or another resident at the facility in a chair using a band of some sort to keep them from falling out of the chair. Of those interviewed, 3 out of 3 residents (R2-R4) denied the above allegation. On 09/25/2025 between 10:09 AM – 04:48 PM the department conducted interviews with Staff #1- Staff #5 (S1-S5). On 09/25/2025 the department asked the staff if they restrained a resident in a chair at the facility. Of those interviewed, 5 out of 5 staff denied the above allegation. The department toured the facility with the Administrator Mona Alcaraz and found no evidence of devices that could have been used as restraints. Based on the information gathered, interviews conducted, and review of records, the department found no evidence to support the allegation mentioned above. 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 deficiencies were cited. An exit interview was conducted with the Administrator Mona Alcaraz and a copy of this report was given.