complaint·August 21, 2025

(Continued from LIC 9099) Based on LPA observations, record review and interviews the allegations that alleged Staff did not ensure the residents emergency pull button was properly operating and staff did not ensure the resident’s outlets were properly operating are Substantiated. It was alleged that Staff mishandled a resident's medication. Facility progress notes from January 5, 2025 at 8:54pm document that a personal caregiver showered R1 and found three medication patches on R1’s right side; one on the shoulder and two on the bottom. This was reported to the Health and Wellness Director (HWD). Personal caregiver notified family of the three patches found on R1. HWD notified hospice and on January 10, 2025 a new patch was applied and former patches removed. A photo was submitted to the Department of multiple patches on R1. Per physician’s report dated December 12, 2024 one medication patch was to be applied daily. Therefore, the allegation that Staff mishandled a resident's medication is Substantiated. This was cited on June 18, 2025 for Control # 22-AS-20250416144122 with the allegation that: Staff are mismanaging residents medications. The Plan of Correction documentation was submitted to the Department that the staff received medication storage and destruction trainings on June 24th and June 30, 2025. Based on LPA's observations, interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations: Staff did not ensure the residents emergency pull and button was properly operating, Staff did not ensure the resident's outlets were properly operating and Staff mishandled a resident's medication are found to be Substantiated. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Cynthia Figueroa, Executive Director (ED) and a copy of this report was given to the facility along with a copy of the LIC 811, LIC 859; LIC 9099-D and Appeal Rights.