Complaint·November 19, 2025

The investigation revealed the following: Allegation: Staff mismanaged resident medication It was alleged that for the last 3 months a resident medications have been passed out late. On 11/13/2025 between the hours of 11:12am - 11:22am, LPA interviewed A1 who denied the allegation and stated the facility uses a medication cart for medtech to administer the medication to the residents. A1 also stated the facility just suspended two (2) medtech for lack of performance and Technical Support Program (TSP) provided by the Department of Social Service Community Care Licensing came to the facility about two weeks ago to assist with medication training. On 11/13/2025, between 9:15am - 1:21 pm, LPA interviewed 9 staff: 2 of 9 staff confirmed the allegation and stated due to short staff  and or stopping to help assist another resident there have been challenges with timely medication administration 2 of 9 staff denied the allegation and stated not rushing to administrator medication quickly to avoid making a mistake while another staff stated it's no there hasn't been any challenges with timely medication administration 5 of 9 staff were unaware and or have no knowledge of the allegation due to their assigned job roles such a receptionist, caregiver, and activities director. On 11/13/2025, between 8:29am- 2:00pm, LPA interviewed 10 residents: 4 of 10 residents confirmed and stated by R1 that medication were for 3 months while other residents such as R3, R7 and R9 stated their medication being given late or missed once before. 3 of 10 residents denied and stated never experienced receiving their medication being given late nor missed. 3 of 10 residents did not confirm nor deny the allegation due to R6 stating no comment while R8 stated not remembering and R10 have not having any knowledge of their medication being give late or missed. On 11/19/2025, between the hours of 9am - 11am, LPA conducted medication review for 10 residents (R1 - R10) and observed the following: Medication Administration Record (MAR) for November 2025 indicated the medtechs administered medication by initial & timestamp. However medication is still observed to be in the bubble for Resident 1 (R1) 8pm Pregabalin 150mg on 11/1, 11/04, 11/1/11 and 11/18 Resident 1 (R1) 6:30am Pantoprazole SD DR 40 on 11/01 Resident 5 (R5) 8pm Rosuvastatin Calcium 10 MG  on 11/09 Resident 5 (R5) 6:30am Pantoprazole SD DR 40 MG  on 11/01 Resident 9 (R9) 8pm Atorvastatin 40 MG on 11/13, 11/14 and 11/15 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 is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was provided with appeal rights. The investigation revealed the following: Allegation: Facility does not have a certified Administrator It was alleged that the facility does not have a certified Administrator since Michael Mendoza. On 11/13/2025 between the hours of 11:12am - 11:22am, LPA interviewed A1 who stated Melissa Flores is currently acting as the facility Administrator and is not sure how long she's been in the position. A1 stated she has a Administrator certification. On 11/13/2025, between 9:15am - 1:21 pm, LPA interviewed 9 staff: 9 of 9 staff denied the allegation and stated Jennifer Rivas has been acting as the facility Administrator for a couple months. On 11/13/2025, between 8:29am- 2:00pm, LPA interviewed 10 residents: 1 of 10 resident denied the allegation and stated Jennifer Rivas is the current Administrator of the facility 9 of 10 are unaware of the allegation. On 11/17/2025, between the hours of  2:20pm - 2:30pm, LPA conducted a records review and observed the following: The previous Administrator for the facility was Michael Mendoza. Upon the departure of Michael Mendoza, the facility had Melissa Flores acting as the Administrator who held a Administrator Certification effective 08/11/2023 - 08/11/2025. On 11/7/2025 LPA received an email from Jennifer Rivas who provided her Proof of Completion for Certification Program for 740 - Residential Care Facility for the Elderly effective as of 02/23/2024 - 02/23/2026. Unfounded: This agency has investigated the complaint alleging (for the allegation above). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. Exit interview conducted with Jennifer Rivas (Administrator) and a copy of this report was provided.