complaint·October 15, 2025

Allegation: Facility staff are mismanaging resident’s medications. The allegation alleges that they have witnessed incidents of medication mismanagement and staff have destroyed narcotic records. During the facility inspection and file review, LPA participated in a narcotic count for nineteen (19) residents. LPA observed nineteen (19) out of nineteen (19) residents narcotic medications are consistent with properly documented records. Additionally, LPA reviewed Centrally Stored medication and the Medication Administration Record (MAR) for eight (8) residents. LPA observed seven (7) out of eight (8) residents Centrally Stored Medications are not consistent with documented records. LPA did not observe notations of missed or refused medications, or resident out of community. During record review, LPA received and review the training logs for Medication Technicians (Med Tech), and observed they have all completed 32 hours of shadowing and 8 hours of medication instruction provided on Relias. During interviews with Staff S1-S9, were asked if residents receive their medications as prescribed, nine (9) out of nine (9) stated yes residents are provided with their medications as prescribed. Additionally, Staff S1-S9, were asked if they have knowledge of medication mismanagement, nine (9) out of nine (9) stated they have no knowledge of medication mismanagement. During interviews with Residents R1-R8, were asked if they receive their medications as prescribed, eight (8) out of eight (8) stated yes, they receive their medications as prescribed. Additionally, Residents R1-R8 were asked if there was a time they did not receive their medications, three (3) out of eight (8) stated yes, there have been times they did not receive their prescribed medication. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Executive Director, Nestor Eligio and Brenda Myers , and a copy of this report ant the appeals rights were provided