complaint·June 3, 2025

In regard to the allegation Staff mismanaged resident's medication, based on interviews conducted and information gathered Staff S1 confirmed that an error did occur on 02/08/2025. Stated that Resident R2 was given R1's medication after she had left the room to get water. Administrator stated that Resident 1's medication was given to Resident R2 and that it was a mistake. Said that Staff S1 notified her immediately of the error. San Gabriel Pomona Regional Center on an unannounced visit during a review of resident's medication observed there to be an error. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Per Title 22, deficiencies are cited. In regards to the allegation Staff did not administer resident's medication as prescribed, based on interviews conducted and information gathered Staff S1 confirmed that Resident R2 did miss evening medication. Administrator stated that per physician's advice Resident R2 was asked to skip medication Mapa 500MG Tablet, Atorvastatin 20MG Tablet for the evening and resume with medication as prescribed the following day 2/09/2025. San Gabriel Pomona Regional Center's unannounced visit revealed the medication error and in the Corrective Action Plan dated May 19, 2025 a substantial Inadequacy and citation was issued for failure to administer medication as prescribed. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Per Title 22, deficiencies are cited.