complaint·June 6, 2025

The investigation revealed the following: Allegation: Staff did not ensure medications were dispensed as prescribed On 6/6/25, LPA Felisa Shirley observed an email from R1’s doctor regarding administering medication changes forwarded to the facility’s Administrator instructing the caregivers to follow the directions of the doctor and to document and monitor for changes. LPA Shirley reviewed the email dated 5/31/25, from facility’s owner informing R1’s responsible party that R1 was may have been given the wrong medication. On 6/6/25, during the course of the investigation, LPA Shirley received a copy of the Special Incident Report dated 6/6/25 stating that there was a medication error that occurred May 19 thru 30, 2025. LPA interviewed staff, staff 1 – staff 3 (S-1 – S-3). LPA asked, does staff ensure that medications are dispensed as prescribed. Of those interviewed 3 out of 3 stated yes. LPA interviewed Resident 1 – Resident 5 (R-1 – R-5). LPA asked residents, does staff give you your medications as prescribed. Of those interviewed, 5 out of 5 answered, yes. Based on observations, information gathered and reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Based on CCLD staff's observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6), is being cited, please see attached LIC-9099D. Deficiencies were cited during today's visit. An exit interview was conducted, and plans of corrections were developed with the Administrator, Marhlyn Sapugay . A copy of this report and appeals rights were provided. The investigation revealed the following: Allegation: Staff did not ensure planned activities were conducted for residents in care On 6/6/25, LPA Shirley observed the activities calendar that was posted on the refrigerator. On 6/6/25, LPA Shirley observed, Dominos, the board game Scrabble and crossword puzzles. LPA observed 2 videos of residents doing chair yoga and exercises. On 6/6/25, LPA Shirley spoke with a visitor, W1 was visiting with a relative at the facility at the time of the investigation. W1 stated that she loved the facility because the staff had a genuine concern for the residents. W1 stated that staff helps the residents celebrate birthdays and different holidays. LPA interviewed staff, staff 1 – staff 3 (S-1 – S-3). LPA asked, does staff ensure that planned activities are conducted for residents in care. Of those interviewed 3 out of 3 stated yes. LPA interviewed Resident 1 – Resident 5 (R-1 – R-5). LPA asked residents, does staff offer activities for the residents in care to enjoy. Of those interviewed, 5 out of 5 answered, yes. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Administrator, Marhlyn Sapugay .