complaint·March 23, 2026

The investigation revealed the following: Regarding: Staff did not dispense medications as prescribed. It is alleged that the facility is not properly administering medication to resident during the 4:00 p.m. and 7:00 p.m. shifts by missing doses for days in a row. Interviews with S1-S5 indicated that medication is dispensed as prescribed to residents in care. Interviews with S1 and S5 revealed that physician orders are followed to properly administer medication to residents; however, medication for R1 had not been administered as prescribed due to R1 seeming intoxicated particularly during the P.M. medication pass. S5, who works during the P.M. shift, indicated that S5 had not been giving R1 their medication which was scheduled to be given to R1 with dinner which takes place around 4:30 p.m. S5 stated that S5 did not give R1 their medication because R1 would be observed drinking alcohol down the street outside of the building and R1 seemed intoxicated when returning to the facility. S5 further indicated that the medication which was not given to R1 was the P.M. set. S5 stated that they could not recall how long R1 has gone without their P.M medication, but although it wasn’t a daily occurrence, it was missed several times a week for the past few months (exact dates could not be recalled by S5). Interview with S1 revealed that S5 acknowledged not dispensing R1’s mediation as prescribed due to R1 “being drunk.” During record review, the facility could not provide LPA with missed medication documentation, contact with physician regarding R1 missing doses or new physician orders indicating changes to current medication or discontinue orders for R1. Review of R1’s January 2026 medication sheet revealed that R1 should have been receiving (5) mediations which include medication to manage their glucose level and control their blood pressure. LPA reviewed medication for (7) residents and observed that R4 has a NovoLog Flex Pen (insulin injection)/100 units Sub-Q to be administered before meals and at bedtime per sliding scale received by the facility from the pharmacy on 1/30/2026. Review of R4’s medication revealed that R4’s insulin injections have not been dispensed to R4 by staff. LPA observed that the box in which the injection pen was sent out by the pharmacy was sealed and unused. Interview with S2 indicated that R4 has not received any injections from this prescribed pen since it was sent out by the pharmacy on 1/30/2026. S1 and S3 further indicated that R4’s insulin injections are to be administered on a “sliding scale” which means R4’s glucose level must be measured before their meals to determine if insulin is needed. However, the facility could not provide the Daily Blood Sugar Readings log for R4 which the facility uses to track resident's blood sugar checks and the levels before administering insulin. ***Continues on LIC 9099-C Interviews with (7) out (8) residents indicated that their medication is dispensed as prescribed and have no concerns with their medication needs. Interviews with staff, observations and record review corroborate the allegation that staff did not dispense medications are prescribed. The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated . California Code of Regulations (Title 22), is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided. Exit interview was conducted with Rosalie Sandova, Director, and a copy of this report, LIC 9099D and Appeal Rights was provided.