Complaint·July 11, 2025

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. It was alleged that R1’s prescription for Atorvastatin changed from 20MG to 10MG, the facility received both doses from the pharmacy in February 2025, the facility gave R1 both doses for multiple days despite the 20MG dose being discontinued, and in March 2025 the bubble packs for all of R1’s medications showed that R1 had missed multiple days of their medications. LPA inspected the facility, conducted health and safety checks on residents present, and observed no health and safety issues. LPA inspected the medications for all six residents did not observe any current medication errors. LPA reviewed R1’s Medication List and did not obtain information regarding the allegation. LPA interviewed AD who denied giving R1 both doses of Atorvastatin at the same time, stating that the 20MG dose was discontinued when the 10MG dose was received, and denied that R1 missed doses of their medications. One witness stated they observed staff trying to give R1 both doses of the Atorvastatin and prevented them from doing so. R1 stated that they recall receiving two doses of the Atorvastatin, but could not recall for how many days. However, AD and two staff denied that this occurred, instead claiming that when the new dose was received the old one was put to the side and replaced by the new dose. AD and two staff also stated that residents receive all their medications as prescribed. LPA reviewed staff training records which showed four out of four staff have up-to-date medication training. LPA interviewed the five other residents and did not obtain information corroborating any other issues with medications. No information was obtained indicating that R1 suffered any effects from the alleged medication error and interviews with AD and a witness revealed that R1’s Atorvastatin prescription has since been increased to 40MG, which is higher than both previous doses combined. The information obtained is conflicting. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation 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. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.