complaint·March 12, 2025

Allegation: Staff did not provide medication assistance to resident in care. The details of the complaint alleges staff did not provide resident with their medications. During LPA’s visit on 03/12/2025, LPA reviewed medications with Staff S7 and S8. LPA reviewed the medications for seven (7) residents, LPA observed seven (7) out of seven (7) residents’ medications were not consistent with documentation of medication administration. LPA observed three (3) out of seven (7) residents have medications that are not listed on the eMAR. Additionally, LPA observed three (3) out of seven (7) residents have medication that is listed on the eMAR but there are no medications. During file review, LPA received and reviewed the eMAR for seven (7) residents and observed medications were not properly documented when taken (initialed by Med Tech), refused, or out of the community. During interviews, on 03/04/2025 and 03/12/2025, with Staff S1-S9, were asked if residents are provided their medication as prescribed, ten (10) out of ten (10) stated they provide residents with their medications as prescribed. During interviews, on 03/04/2025 and 03/12/2025, with Residents R1-R10, were asked if staff provide them their medications as prescribed, one (1) out of ten (10) stated they do not receive their medications as prescribed. Allegation: Staff falsified resident’s records. The details of the complaint alleges staff indicated on the Medication Administration Record that a medication was administered to a resident when it was not. During LPA’s visit on 03/12/2025, LPA reviewed the eMAR and medications for seven (7) residents, LPA observed three (3) out of seven (7) residents had medications that were signed off as provided but were still in the bubble pack. During file review, LPA received and reviewed the eMAR for seven (7) residents and observed medications were not properly documented as taken (initialed by Med Tech), refused, out of the community, or other. During interviews, on 03/04/2025 and 03/12/2025, with Staff S1-S10, were asked if staff had signed off that a medication was provided by a Med Tech and it was not provided, four (4) out of nine (9) stated there was an occasion when a Med Tech signed that a medication had been provided by them and it was not. During the course of the investigation, LPA was able to find evidence to support the allegations. 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 A civil penalty was assessed for a repeat violation within the last 12 months. LPA, Executive Director, and Wellness Director discussed a referral to the Technical Support Program regarding medication management. An exit interview was conducted with Executive Director, Fabiola Marciano, and a copy of this report and the Appeal Rights were provided. Allegation: Staff did not safeguard resident’s personal belongings. The details of the complaint alleges a residents responsible party has seen their Resident’s clothing is missing and being worn by other residents. During LPA’s visit on 03/04/2025 and 03/12/2025, LPA observed a resident on the third floor leave personal belongings in the common room and staff took the item to the resident. During file review, LPA received and reviewed Resident’s R1-R8’s Client/Resident Personal Property and Valuables (LIC621), LPA observed eight (8) out of eight (8) indicated and signed on the form they decline to have their items inventoried. Additionally, LPA received and reviewed the Theft and Loss Policy provided to the Residents that states it is encouraged for residents to fill out the Resident Personal Property and Valuables form. During interviews, on 03/04/2025 and 03/12/2025, with Staff S1-S9, four (4) out of nine (9) stated sometimes residents clothing get mixed up or a resident will take another residents belongings. During interviews, on 03/04/2025 and 03/12/2025, with Residents R1-R10, were asked if they have had any personal belongings that have gone missing, four (4) out of ten (10) stated they have had some of their personal belongings go missing. 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 and a copy of this report was provided.