complaint·February 27, 2025

The investigation revealed the following: Allegation : Resident did not receive medication as prescribed. It was alleged there are multiple medication errors including some residents are not receiving their medications. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 denied being aware of any residents not receiving their medications. On 12/16/2024 between 11:45am - 1:00 pm and 1/21/25 2:48pm and 1/24/25 at 9:05 am, LPA/LPM interviewed Staff #1-7 regarding the allegation, 3 of 7 staff interviewed denied the allegation; 3 of 7 staff interviewed were unable to answer the questions since they do not administer medications and 1 out of 7 staff confirmed the allegation. On 12/16/2024 between 10:00am - 11:30am and 1/22/2025 8:47am - 9:38am and 1/21/25 8:47am, LPA/LPM interviewed Residents #1-10. 6 of 10 residents denied the allegation; 3 of 10 residents confirmed the allegation and 1 of 10 residents stated they sometimes don’t receive medications. LPA/LPM reviewed 9 residents Medication Administration Records (MAR) and medications, 9 out of 9 reviewed had medication errors. 8 of 9 medications were not in the medication was not in the bubbled pack and the MAR was not signed;1 of 9 residents MAR is not signed from 12/1/24-12/16/24 for routine medications; 3 of 9 residents medication was still in the bubble pack (not given) and the MAR was not signed. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided to Rafael Silva, Quality Assurance Director. The investigation revealed the following: Allegation: Unqualified staff is administering insulin injections to residents. It is alleged appropriate skilled professionals are not administering insulin injections to diabetic resident on the weekend when the LVN is not working. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 stated LVN administers insulin Monday-Friday and med tech administer insulin hand over hand to residents. On 12/16/2024 between 11:45am -1:00 pm and 1/21/25 2:48pm and 1/24/25 at 9:05am, LPA/LPM interviewed Staff #1-7 regarding the allegation, 2 of 7 staff interviewed stated the LVN administers insulin and med techs prepare the medication and the resident self administers; 2 of 7 state the LVN administers insulin and comes in to assist as needed on the weekend; 2 of 7 state they have witnesses the LVN and med techs administer insulin and 1 of 7 state the LVN administers insulin and they have never witnessed med techs administer insulin. On 12/16/2024 between 10:00am-11:30am and 1/21/2025 8:47am - 9:38am, LPA/LPM interviewed Residents #1-10. 9 of 10 residents stated the LVN administers insulin and 1 of 10 stated the LVN and med techs administer insulin. Allegation: Facility staff are stealing residents medication. It is alleged staff are stealing residents Narcotic medications. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 denied being aware of staff stealing medications. On 12/16/2024 between 11:45am - 1:00 pm, 1/21/25 2:48pm and 1/24/25 at 9:05am, LPA/LPM interviewed Staff #1-7 regarding the allegation, 7 of 7 staff interviewed denied the allegation. On 12/16/2024 between 10:00am - 11:30am and 1/21/2025 8:47am-9:38am, LPA/LPM interviewed Residents #1-10. 10 of 10 residents denied the allegation. Report continues on LIC 9099-C page. Allegation: Illegal Eviction It was alleged R8 was issued, and eviction notice and was put outside the facility on the streets. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 denied R8 was issued an eviction notice but stated the facility intends to issue one. On 12/16/2024 between 11:45am-1:00 pm,1/21/25 2:48pm and 1/24/25 at 9:05am, LPA/LPM interviewed Staff #1-7 regarding the allegation, 4 of 7 staff interviewed denied the allegation; 2 of 7 staff are aware of residents being evicted in the past. 1 out of 7 staff stated R8 was talked to about his behavior but was not issued an eviction notice. On 12/16/2024 between 10:00am-11:30am and 1/21/2025 8:47am - 9:38am, LPA/LPM interviewed Residents #1-10. 9 of 10 residents denied the allegation; 1 out of 10 residents confirmed receiving a verbal eviction. LPA/LPM conducted a file review and did not observe and eviction notices on file for R8. Allegation: Facility charging residents for services without consent. It is alleged facility does weekly COVID testing and residents insurance is being billed without consent from the residents or responsible parties. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 denied the allegation and stated the facility pays for COVID testing. On 12/16/2024 between 11:45am-1:00 pm, 1/22/25 2:48pm and 1/24/25 at 9:05am, LPA/LPM interviewed Staff #1-7 regarding the allegation, 7 of 7 staff interviewed denied the allegation. On 12/16/2024 between 10:00am-11:30am and 1/21/2025 8:47am-9:38am, LPA/LPM interviewed Residents #1-10. 8 of 10 residents denied the allegation; 2 out of 10 residents confirmed the allegation. LPA/LPM conducted a review of records and did not observe any evidence that residents are being charged for COVID testing. Based on the records reviewed, interviews conducted and Observations the allegation are Unsubstantiated : Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Rafael Silva, Quality Assurance Director and a copy of this report was provided.