complaint·May 19, 2025

department on April 06, 2025, of the medication error. Record review reflects that R1 was given R2’s medication the night of April 5, 2025, and R1 had no adverse reaction to the medication. The complaint alleged that staff did not involve resident in the care plan. Review of resident’s records revealed that R1 move in the facility on September 22, 2024. A care plan dated September 24, 2024, reflect on page 3 document to be signed only by the community, residents and/or family/responsible party/POA is missing. Care plan dated October 28, 2024, reflect on page 3 no signature from any parties. Records for care plan reflect a care plan with no effective date but signature page reflects September 21, 2024, with an electronic signature for both community and resident. Interview with R1 stated that they did not attend any of the care plan meetings and have not signed any documents because of this. Based on the information gathered the preponderance of evidence standard has been met, therefore, the allegations, facility gave resident wrong medication and resident was not involved with care plan are found to be SUBSTANTIATED. Based on this inspection, deficiencies were observed at this time in the areas evaluated per Title 22 Division 6 Chapter 8 of the California Code of Regulations. See LIC9099-D for deficiencies. This report was reviewed with facility representative and a copy of this LIC9099, LIC9099-D report was provided and left at facility. Appeal rights reviewed, and a copy provided. states able to leave community unassisted is marked no and furthermore stated patient cannot leave unassisted due to MCI. Physician’s report dated October 9, 2024, page 3 number 14m states able to leave community unassisted is marked no. Interview with 2 of 2 staff stated that R1 did not have a change of condition upon admissions to the facility R1’s physician’s report stated R1 could not leave the facility unassisted and R1 did not agree with the information that was provided. Staff stated they have not observed any incidents that would indicate that R1 has had a change of condition. Based on the information gathered during the investigation, interviews and review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. This report was reviewed with facility representative and a copy was furnished to the facility.