Complaint·July 30, 2025

LPA reviewed an Unusual Incident/Injury Report (SIR) for resident (R4) dated March 27, 2025 for an incident that occurred on March 22, 2025 regarding a medication error. SIR states that, on March 22, 2025, staff gave R4 a cup of their morning medications and set a cup of their spouse's medications on the counter of their apartment while preparing a patch for application. R4 picked up their spouse's cup and started to take their spouse's medications by mistake. R4 ingested five (5) of their spouse's medications. R4 was reported tired but with no adverse side effects. SIR states R4 was monitored and follow-up training with med-techs was scheduled. On May 15, 2025, LPA conducted a medication count for residents R1, R2, and R3, comparing each resident’s Centrally Stored Medication Form (CSM) and Medication Administration Record (MAR) with medications centrally stored for the resident. LPA observed one (1) medication for R1 that had three (3) tabs over the amount documented. R1's MAR did not indicate any refusals or missed passes of medication. LPA observed three (3) medications for R3 that were either over or under the amount documented. Documentation for R3 did not indicate any refusals or missed passes and did not provide an explanation for medications under the amount documented. Allegation: Staff do not meet the qualifications to administer residents' medications. LPA reviewed the facility's Plan of Operation on file with the Department. Regarding training for medication aides, the facility's Plan of Operation states the following: "The annual medication training includes 8 hours of in-service training on medication-related issues in each succeeding 12-month period." LPA observed training documentation kept at the facility for staff members S1, S2, and S3. LPA observed S2 and S3 to have documentation showing that they received necessary training in accordance with Title 22, the Health and Safety Code, and the facility's Plan of Operation. LPA observed that S1 started at the facility as a Medication Aide starting 2019 and received initial training in accordance with Title 22, the Health and Safety Code, and the facility's Plan of Operation. LPA observed that S1 did not complete annual medication training in accordance with the facility's Plan of Operation for the years of 2020, 2022, 2023, and 2024. LPA observed that S1 was in the process of successfully completing their annual medication training for the year of 2025. ** Report continued on 9099-C ** Based on a medication count and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. A civil penalty in the amount of $250 was assessed for the date of July 30, 2025 for a repeat violation within 12 months of a prior violation of a statutory or regulatory provision designated by the same combination of letters or numerals per Health and Safety Code §1548. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.