Complaint·February 11, 2026

On 11/21/2025, the department obtained an Unusual Incident Report dated 07/16/2025. On 09/25/2025, the department conducted interviews with Staff #1 – #5 (S1–S5) and Residents #2 – #4 (R2–R4). An attempt to interview Resident #1 (R1) was made, but R1 was unavailable because they had passed away prior to the initial visit. LPA toured the facility with Administrator Mona Alcaraz and found the facility to be clean and in good repair. The investigation revealed the following: Allegation: Staff did not provide resident medication as prescribed It was alleged that staff did not provide resident medication as prescribed. 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 because R1 moved out of the facility on 07/20/2025 prior to the visit. The department asked the residents if staff provided them with their medication as prescribed by their physician. Of those interviewed, 3 out of 3 residents denied the allegation. 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. A1 stated, “We don’t give any medication without a prescription; it must be 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). The department asked staff if they assisted residents with their medication as prescribed by their physician. Of those interviewed, 5 out of 5 staff denied the allegation. On 09/25/2025 between 10:09 AM – 04:48 PM, the department obtained and reviewed the Centrally Stored Medication Destruction Records (CSMDR), which showed that all residents interviewed received their medication as prescribed by their physicians. The department requested Medication Administration Records (MAR), but the Administrator informed the department that the facility only documents medication administered to residents via the CSMDR. A thorough review of the CSMDR showed that the dates and times of distribution for each resident were current at the time of the visit. Based on the information gathered, interviews conducted, and review of records, the department found no evidence to support the allegation. 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 was alleged that staff restrained a resident in a chair using a band of some sort to keep the resident from falling out of the chair. On 09/25/2025 between 10:09 AM – 04:48 PM, LPA Watson conducted interviews with Residents #2 – #4 (R2–R4). Per Administrator Mona Alcaraz, the facility was informed on 07/20/2025 that R1 would not be returning. On 11/21/2025 at approximately 03:20 PM, LPA Watson conducted an interview with the Administrator Mona Alcaraz (A1). A1 was asked about the allegation regarding staff restraining a resident in a chair. A1 stated that this practice does not occur in the facility and staff have not received in-service training in restraining residents. On 09/25/2025 LPA Watson interviewed Resident#2-Resident#4 (R2-R4) and asked them if staff ever restrained them or another resident 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 denied the allegation. On 09/25/2025 between 10:09 AM – 04:48 PM, the department conducted interviews with Staff #1 – #5 (S1–S5). The department asked staff if they restrained a resident in a chair at the facility. Of those interviewed, 5 out of 5 staff denied the allegation. On 09/25/2025 between 10:09 AM – 04:48 PM, LPA Watson obtained and reviewed R1’s Physician’s Report, which showed that no resident residing in the facility is required to be restrained. The department toured the facility with Administrator Mona Alcaraz and found no evidence of restraining devices that could have been used as restraints to secure residents in chairs. Based on the information gathered, interviews conducted, and review of records, the department found no evidence to support the allegation. 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 Administrator Mona Alcaraz, and a copy of this report was provided.