complaint·May 14, 2025

Continued from LIC9099 Review of R1’s centrally stored log and Medication Authorization Record (MAR) stated the following: · Lorazepam 1MG Tablet; take 1 tablet by mouth once daily as needed 1 hour prior to attending medical appointments · Centrally Stored Log for R1 showed that Facility received a quantity of 12 tablets. · Review of R1’s MAR shows that R1 received a dose of Lorazepam from 03/11/25-03/20/25, and on 03/24/25 and 03/25/25 Interview conducted with Marin County Mental Health Supervisor stated that the facility was to monitor and observe R1 for withdrawal and increased anxiety. If observed, facility staff were to contact 911 and ensure R1 received medical attention. Review of facility incident reports showed that on 03/30/2025, R1 was sent to the ER due to increase in anxiety and shortness of breath. Interviews conducted with facility staff confirmed that R1 does not have medical appointments every day and revealed that facility staff did not contact R1’s doctor for clarification on the medication. Based on document review and interviews conducted, these allegations are Substantiated . A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.