Complaint·February 5, 2026

Based on resident interviews, one (1) out of five (5) corroborated the allegation. One resident explained they were provided a nighttime medication twice, wen they are supposed to be provided it only once, on accident by facility staff approximately two (2) weeks ago. No other residents corroborated the allegation. In interviews with staff, none of them corroborated the allegation. The staff stated that they are providing medications to all residents according the physician orders and that there has not been any discrepancies. During medication or R1's medication, it was observed that their morning medication for Furosemide 20 MG is supposed to be given twice, however only one (1) was distributed and the second was found still in the bubble pack. In addition, Nystatin cream and Triamcinolone is indicated as cycle medications and were not present. Facility staff stated that they have been discontinued but their is no discontinue order. In addition C2's Azithromycin 250 MG medication was not being given due to being put on a hold by a nurse according to staff, however there is no order for this. C2 also had Ensure and Ketaconazole orders that were said to have been discontinued, however there are no discontinue orders, and C2 was also out of their Vitamin A & D ointment. In regards to the allegation that " Staff does not provide resident with oxygen," it is alleged that R1 is supposed to be on continued oxygen, however they were not given oxygen for two (2) days in the month of January 2026, and that staff turn off the oxygen machine due to concerns about setting off the facility smoke alarm. During interviews with the residents, none of them corroborated the allegation. All residents denied there had been any issues with oxygen administration. During interviews with staff, none of them corroborated the allegation as well. Staff stated that R1 that they do not turn off the oxygen for any resident, and that they are not sure what R1's oxygen order is however they believe it is not 24/7. Another staff stated that R1 only ceases to use their oxygen when using the restroom and for meals. During LPA's interview with R1 in the living room of the facility, R1 did not have their oxygen machine turned on. In addition, the facility staff were not able to provide a physician order for R1's oxygen use. Based on LPA observations, interviews conducted, and record review, 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 LIC9099D. Exit interview was held, and a copy of the report along with appeal rights were provided.