complaint·September 1, 2021

• New Hire Initial Training Record for S1 • R1 Information Sheet • Physician's Report for R1 • Preplacement Appraisal Information for R1 • Personnel Record for S1 • Staff and Resident. The investigation revealed the following; Allegations: "Staff did not administer medications as prescribed" and "Facility has inadequate staffing for the residents while in care ". The details of these allegations state, R1 called 911 due to experiencing back pain. Once the Emergency Medical Services (EMS) arrived at the facility, S1 reported to EMS personnel that she was the only staff on duty with a census of 36 residents and she was not qualified to administer the necessary medications to R1. Based on interviews conducted and record reviews, the incident involving R1 took place on 6/27/21, between the hours of 10:35PM - 11:35PM. R1 called 911 because was she experiencing back pain and had not been provided her pain medications. After reviewing the file of S1, LPA discovered that S1 did not have the qualifications and training to administer medications to residents. Interviews conducted corroborated with the information found in the file of S1. In reference to the allegation of "Facility has inadequate staffing for the residents while in care", statements obtained confirmed that S1 was the only staff member on duty at the time of the incident and in charge of providing care and supervision to 36 residents. S2 was scheduled to be on duty with S1 but was a "no call, no show" leaving S1 alone at the facility. LPA learned that S1 failed to inform Management about S2 being a "no call, no show" in a timely manner in order to find a replacement. Based on interviews conducted and record reviews, there is sufficient evidence to support the allegations of "Staff did not administer medications as prescribed" and "Facility has inadequate staffing for the residents while in care". Allegation: " There is a strong odor of marijuana present inside the facility". During the visit conducted on 7/7/21, at 12:15PM, LPA Katrdzhyan toured the facility with the assistance of Assistant Administrator / Alexander Solorio and observed a strong odor of marijuana coming from the hallway, near the dining room area. Based on statements obtained, LPA learned that residents have been o bserved smoking marijuana in their rooms and the outside, near the courtyard area. Based on LPA's observation and interviews conducted, there is sufficient evidence to support the allegation of "There is a strong odor of marijuana present inside the facility". Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator along with the Appeals Rights.