Complaint·October 17, 2024

On 02/16/2024 LPA Wesley conducted an unannounced complaint visit and met with Assistant Elizabeth Martinez. LPA requested a copy of resident roster, staff roster, interviewed staff and residents. Additional 05/03/24 LPA Wesley conducted an unannounced subsequent visit and met with Administrator Rachelle Reves. LPA requested a copy of the resident roster, staff roster, interviewed staff, interviewed residents, and reviewed the medication. On 08/27/24 LPA Reyes superseded the licensing reported created on 05/03/24. The licensing report was redelivered due to additional interviews that were conducted and further information that was obtained. The investigation consisted of: On 08/27/24, LPA Reyes conducted interviews with Administrator Rachelle Reyes, Staff #1 (S1- S8), and Residents #1 (R1-R3 and R6-R12). Residents # 4, 5, and 13-15 were not available to be interviewed. LPA Reyes collected copies of Staff and Resident Rosters, Physician’s Order Routine Medication and Physician Report for R1- R11, Exit forms for R13-R15, and Training for S1, S6, and S8. Regarding the allegations Staff mismanaged residents' medication and Staff did not provide a safe and comfortable environment for residents. It is alleged residents are not receiving their medication. Residents’ medication is being left on dressers, on the dining room tables, or in the resident’s trash cans in their room. In addition, Med Techs are not ensuring the residents are taking their medication. (6) of (8) staff interviewed confirmed the allegation. Staff indicated that medication had been found in hallways, resident’s rooms, and dining room tables. Staff acknowledge that medication found unattended was reported. Staff members have also confirmed awareness of medication being reported and delivered by other staff. Therefore there is evidence that residents at the facility are not receiving their medications as prescribed. (9) of (12) residents could not corroborate the allegation. During a tour of the dining room on 8/27/24 at 12:09 PM LPA Reyes observed a dining room of residents having lunch near a unlocked, unattended, and accessible med cart **Continued-LIC 9099-C** LPA Reyes observed S8 with the med cart near the kitchen door of the dining room preparing to deliver medications to residents in the courtyard. S8 was then observed by LPA Reyes from exiting the dining room and on the other end of the courtyard with residents. During this time LPA Reyes did not view any other staff monitoring the med cart or present in the dining room. LPA Reyes positioned himself near the med cart while S8 was assisting residents outside in the courtyard. When S8 returned from the courtyard LPA Reyes opened the cart and confirmed with S8 that med cart was unlocked and accessible to residents. S8 apologized and acknowledged they failed to lock the medication cart. LPA Reyes explained to S8 the importance of locking the med cart. The preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interviewed conducted with Administrator Rachelle and a copy of this report was provided with appeal rights.