complaint·January 15, 2026

Medication Management Program verification, med tech Certification of Completion in Basic Medication Training, and med tech Basic Medication Shadow Training Logs. The following additional documents were requested and are to be emailed to LPA Unusual Incident Reports (URI), Physician’s Orders, Needs and Service Plan, and Medication Administration Records (MAR). The investigation revealed the following: Allegation: Staff are not following resident’s diabetic needs The allegation alleges that med techs are giving residents their insulin. During the facility visit, LPA observed residents going to the Medication Room to see the trained LVN, to have their blood sugar level checked, and to receive their insulin injections. During the visit, LPA observed insulin secured in a locked refrigerator, in the medication room. During record review, LPA reviewed the training and in-service logs for the LVN and medication technicians and observed they have received training regarding medication administration. LPA reviewed the Plan of Operation that indicates a licensed skilled professional can assist with self-administration of injections. LPA received and reviewed Resident R2-R 11’s Medication Administration Record (MAR) and observed glucose testing and insulin injections signed off by the LVN. During interviews with Staff S1-S8, were asked who checks residents’ sugar and provides insulin injections, eight (8) out of eight (8) stated the LVN is who tests residents’ sugar and gives insulin injections. During interviews with Residents R1-R11, were asked who provides them with their insulin shots and tests their sugar, eight (8) out of eleven (11) stated the nurse gives them their shots and tests their sugar. One resident stated they do their own sugar testing, and the nurse is there to document the numbers, and they do their own injections with the nurse watching. Two residents stated they do not require glucose testing or insulin injections. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . Allegation: Staff are not providing adequate food service The allegation alleges that residents are unable to get a second serving of food during mealtimes due to the kitchen running out of food. During the facility inspection, LPA observed lunch being prepared and served. LPA observed staff preparing residents plates using scoopers measuring half (1/2) a cup for mixed vegetables, fruit, and stuffing. Soup was measured using an 8 fluid ounce ladle. Residents were provided with one to two pieces of chicken with gravy. LPA observed a resident who wanted an alternative meal, and they were provided with either a turkey or ham sandwich, fruit, vegetables, soup, and stuffing. LPA observed multiple residents served a second serving of lunch. After all residents were provided with their meals, LPA observed an ample supply of prepared food still in the kitchen. Additionally, LPA inspected the food supply in the kitchen and observed a two (2) day supply of perishable foods and a seven (7) day supply of nonperishable foods. During record review, LPA received and reviewed invoices from Sysco listing food deliveries on the following dates 12/03/2025, 11/28/2025, 11/25/2025, 11/21/2025, 11/18/2025, 11/14/2025, 11/11/2025, 11/07/2025, 11/05/2025, and 11/04/2025. The food delivered consisted of dairy, meats, poultry, canned goods, frozen goods, dry goods, and condiments. Additionally, LPA received and reviewed the Sanitation and Food Safety Checklist for Assisted Living dated 09/25/2025 and 11/07/2025. On both forms, indicates the facility has a “one week of nonperishable food and 2 days perishable are available.” During interviews with Staff S1-S8, were asked if residents are able to have a second serving during mealtimes, eight (8) out of eight (8) stated residents are able to have a second serving of food during mealtimes. During interviews with Residents R1-R11, were asked if they are provided with enough food throughout the day, eleven (11) out of eleven (11) stated yes, they are provided with enough food throughout the day. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . Allegation: Staff are eating the food for the residents The allegation alleges that staff are eating all the food resulting in there not being enough food for residents. During the facility inspection, LPA observed lunch being prepared and served. LPA observed staff preparing residents plates using scoopers measuring half (1/2) a cup for mixed vegetables, fruit, and stuffing. Soup was measured using an 8 fluid ounce ladle. Residents were provided with one to two pieces of chicken with gravy. LPA observed a resident who wanted an alternative meal, and they were provided with either a turkey or ham sandwich, fruit, vegetables, soup, and stuffing. LPA observed multiple residents served a second serving of lunch. After all residents were provided with their meals, LPA observed an ample supply of food prepared in the kitchen. LPA did not observe any staff eating the food that was served from the kitchen. During review of an Admission Agreement, LPA observed a resident’s guest may purchase a meal and eat with the resident they are visiting. During interviews with Staff S1-S8, were asked if staff eat the food served to the residents, six (6) out of eight (8) stated they have eaten or seen staff eating the food served to the residents. Additionally, four (4) out of eight (8) stated meals are available for purchase and some staff eat the food for quality testing. During interviews with Residents R1-R11, were asked if there has been a time they wanted a second serving and it was not available due to the kitchen running out of food, eleven (11) out of eleven (11) stated no, the kitchen has not run out of food. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . An exit interview was conducted with Catherine Dacara, and a copy of this report was provided. Medication Management Program verification, med tech Certification of Completion in Basic Medication Training, and med tech Basic Medication Shadow Training Logs. The following additional documents were requested and are to be emailed to LPA Unusual Incident Reports (URI), Physician’s Orders, Needs and Service Plan, and Medication Administration Records (MAR). The investigation revealed the following: Staff are mishandling the residents medications The allegation alleges residents are not getting their medication because the medication is missing. During the facility inspection, LPA conducted a medication review for eight (8) residents. LPA observed three (3) out of eight (8) residents had medications that were unable to be located in the medication cart and medication room. Additionally, LPA observed two (2) out of eight (8) resident’s medications were not consistent with documented records. During interviews with Staff S1-S8, were asked if there have been any medication errors or missing medications in the past, five (5) out of eight (8) staff stated yes, there was recently a medication error that was documented and reported. During interviews with Residents R1-R11, were asked if there have been any medication errors or missing medications in the past, four (4) out of eleven (11) stated yes, they have had missing medications that the staff did not know what happened to them. 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 Assistant Administrator, Catherine Dacara, and a copy of this report and Appeal Rights were provided.