complaint·October 16, 2025

The investigation revealed the following: Regarding allegation: Staff did not consult responsible party regarding a resident's care. It is alleged resident’s responsible party was not contact before giving R1 a vaccination dosage during facility’s vaccination clinic day. Interviews with residents revealed 5 out of 8 residents stated facility staff either contact responsible party before medical decisions or believe that it will happen. 1 out of 8 residents did not know if the facility staff will contact their responsible party. 1 out of 8 residents is able to make decisions for self, therefore responsible party will not be contact, and 1 out of 8 residents was unable to answer due to cognitive skills. Interviews with staff revealed staff contact responsible party when offering a vaccination clinic to obtain either a release form or verbal approval from residents' responsible party prior clinic day to provide any vaccinations. Documents reviewed reveal, R1 had a durable power of attorney signed on 4/8/11 which notes that if there are other matters other than those listed on POA, the POA is able to make decisions for R1. Per R1’s physician’s report dated; 9/19/22, R1 was noted with dementia. There were no records that R1’s responsible party signed consent for vaccination clinic on 11/16/22. Therefore, this allegation is SUBSTANTIATED. Regarding allegation: Staff do not distribute resident's medication as prescribed . It is alleged resident’s medication was not distributed appropriately. Interviews conducted with residents revealed 7 out of 8 residents stated facility staff provides medications as needed. 1 out of 8 residents handles own medications. 5 out of the 8 residents stated that they are provided as needed medications when requested. Interviews with staff revealed staff centrally stored medications for residents that are on medication assistance, including medication that may be brought by the responsible party. Per staff once the medication is provided it is labeled with residents’ name and it is only used for that resident. Documents reviewed for R1 note R1 was provided with medications as prescribed between August and October of 2022. Medication review conducted on 10/16/22 revealed the following residents were missing the following as needed/routine medications; resident #2(R2) anti-acid liquid, resident#3(R3) acetaminophen 325mg and 500mg, anti-acid liquid, antifungal 2% powder, benzonatate 100mg, fexofenadine 180mg, loperamide 2mg, ondansetron 4mg. Resident #4(R4) acetaminophen 325mg, anti-acid liquid, baqsimi 3mg spray, bysacodyl 10mg suppository, fleet enema, loperamide 2mg, milk of magnesia, naloxone 4mg spray, robafen 10/100mg. Resident #5(R5) chlorhexidine 4% was observed and was noted as discontinued on medication sheet and Mucinex 1200mg observed and not listed on medication sheet, memory armor 300mg(routine medication), anti-acid liquid, ibuprofen 200mg, loperamide 2mg, milk of magnesia, quetiapine fumarate 25mg, Resident #6(R6) baza moisture cream, hydrocodone/APAP 5/235mg, senna 8.6mg, loperamide 2mg was observed and has been discontinued since 5/1/25. (CONTINUED ON LIC 9099C) Resident #7(R7) ivermectin 3mg(routine) observed and noted as discontinued on medication sheet, triamcinolone .025% cream. Resident #8(R8) anti-acid liquid, Benadryl 1-0.1 % cream, fleet enema, ondansetron 4mg, tripe antibiotic ointment, docusate sodium 2mg was observed and not listed on medication sheet. Resident #9(R9) Albuterol, geri-tussin 100mg, ibuprofen 800mg, milk of magnesia. Resident #10(R10) acetaminophen 325mg, docusate sodium 250mg, hydrocortisone 1% cream, loperamide 2mg, lubricant eye .4% drops, milk of magnesia, naloxone 4mg spray. Therefore this allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted and a copy of this report, LIC 9099C, and appeal rights was provided. The investigation revealed the following: Regarding allegation: Staff did not follow COVID protocol. It is alleged facility staff failed to review resident’s vaccination records, resulting in R1 receiving an additional COVID vaccine booster on 11/16/22. Interviews conducted with residents revealed residents received assistance and COVID protocols are followed. Interviews with staff revealed facility assist residents by offering a vaccination clinic yearly. Per staff, they did become aware R1 received the dose during the clinic. Facility staff contacted R1’s physician and was placed on alert checks that day. Facility records provided for review revealed R1’s physician’s report dated: 9/19/22 notes dementia. COVID 19 vaccination record notes R1 had 5th booster shot on 10/13/22 at local stored. On 11/16/22, R1 received a booster shot provided by Rons pharmacy. Per chart notes on 11/16/22 staff spoke with responsible party who acknowledge to provide care for R1 after becoming aware of booster shot given to R1. LPA was unable to interview R1 as R1 passed away on 11/25/23. LPA reviewed mitigation plan last updated on 10/31/24 and Infection control last updated on January 2016. There are no protocols regarding vaccination boosters. Although, facility staff failed to ensure R1 did not receive an additional booster shot within a month. There were no protocols or mandates regarding COVID vaccinations other than recommendations to followed. In addition, R1 was residing in the assisted living portion of the facility from 3/16/20 to 11/15/23 and because we are unable to determine whether R1 willingly participated in obtaining the shot we cannot said R1 was asked to obtained the vaccination shot by staff. Therefore, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was conducted and a copy of this report was provided.