complaint·February 13, 2026

Allegation #2: Staff falsified a resident's records while the resident was in care. Regarding the allegation, “ Staff falsified a resident's records while in care ,” The complaint alleged that staff are initialing medications they do not have or that have been discontinued. During the department visit on 11/12/25, the department interviewed six residents, #1-6 (R1-R6), who denied the allegations. The department also interviewed three staff members, #1-3 (S1-S3). Two of the three staff members stated they mishandled R1’s medication while in care. The department reviewed the QuikMAR system and the medications for Resident #1 (R1). It was noted that two medications for R1 were marked as administered; however, one medication, Fluoxetine HCl 10 mg capsule, had been discontinued on July 7, 2024, but still appeared as administered in May 2025. Additionally, a new prescription for Fluoxetine HCl 40 mg capsule was issued on July 7, 2024, but it was also discontinued in May 2025. The Department reviewed QuikMAR for Resident #1 and found the documentation for medication administration insufficient. Medications intended for oral administration as a single tablet every 12 hours were not accurately recorded. Med Tech did not initiate some entries; some medications were not documented when they were refused or when residents were out of the community; and others should not have been initiated for various reasons. Additionally, these medications should not be included on the list for administration by Med Tech for Resident #1 (R1). Regarding the allegation, “ Staff falsified a resident's records while in care ,” based on record reviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated . The California Code of Regulations (Title 22, Division 6 & Chapter 8) is cited in the attached LIC 9099D. A civil penalty was assessed for a repeat violation within the last 12 months. Allegation: #3: Staff mishandled a resident's medications while in care Regarding the allegation that “Staff mishandled a resident's medications while in care,” it is alleged that the staff is not dispensing medications as prescribed. A review of R1’s April 2025 QuikMAR showed that several medications scheduled for twice daily were not administered correctly. For example, the Sodium Chloride 1GM Tablet prescribed by the doctor on April 8 was intended to be taken twice daily, in the morning and evening. The department's April 2025 QuikMAR records indicated that R1 did not receive the medication from April 8 to April 13. Later, in May 2025, the QuikMAR record showed the medication was given from May 1 to May 15, 2025, except for the morning of May 16 and the afternoon of May 17. The Department interviewed three staff members, #1-3 (S1-S3). Two of the three staff members suggested that medication handling was mishandled during R1's care. The Department also interviewed the Executive Director (ED), who stated that QuikMAR identified inconsistencies in the administration of R1’s sodium tablets and other medications. However, the facility staff provided quality care to residents. Additionally, the Department interviewed MP, who was unable to confirm whether the medication mishandling caused R1’s hospitalization. The Department also interviewed R1, who said R1 liked living there. During interviews on 11/12/2025, six residents (R1-R6) were asked whether staff had signed off and whether Med Tech had provided medications; all six confirmed that Med Tech had given them their medications as prescribed. During the investigation, the Department found evidence supporting the allegations. Based on the Department 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 Regulations (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC 9099D. Deficiencies were cited. A copy of this report and the appeal rights were provided to the Executive Director, Jakini Robert. Allegation: #1: Staff neglect resulted in a resident to be hospitalized The complaint alleged that, due to their negligence in managing R1's medications, sodium chloride was not administered to R1, who had recently been prescribed it by an emergency room physician (ER). R1 ended up in the hospital for a week with severe hyponatremia. On 06/13/2025, the Department interviewed the Executive Director (ED) and the three staff members #1-3 (S1-S3), who acknowledged a possible error in documenting medication administration. On 08/01/2025, the Department interviewed the Medical Physician (MP), who stated that it is difficult to determine whether any lack of medications caused the hospitalization of resident #1 (R1). They also stated that R1's declining health could be a factor. On 11/12/2025, the department interviewed six residents, #1-6 (R1-R6), all of whom denied the allegation and stated that facility staff helped them with their medications. R1 also stated that R1 likes living at the facility and receiving medication as prescribed. Regarding the allegation, “Staff neglect resulted in a resident being hospitalized,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have occurred or be valid, there is not a preponderance of evidence to prove whether the alleged violation did or did not occur; as a result, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of the report was provided to the Executive Director Jakini Robert.