complaint·April 28, 2022

discovered that the MAR document had been falsified and the medication had not been administered. Interviews conducted with staff indicate R1's medications had been sent out to the pharmacy for re-packaging and there were no medications left at the facility to administer. Pharmacy re-packaging of medications is standard practice at the facility. Four out of five staff interviewed indicated being told by facility management to sign the document after the fact. R1 was part of the "Circle of Friends" group at the facility. This group is assisted out of their rooms to meals and activities daily by facility staff. Documents provided by facility indicate that resident was being escorted to meals and activities. Dietary documents show resident was provided meals. Door key records indicate facility staff was observing R1 every 2-3 hours during daytime hours. 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, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Executive Director Ayala and a copy of this report was provided.