complaint·September 16, 2025

Interviews with residents revealed 6 out of 9 residents had no concerns regarding their medications. 3 out of 9 residents were aware the facility staff had run out of their medications a few times in the past. Interviews with staff revealed there have not been medication errors, missed medication, or mismanagement of the residents’ medications. Medication review for Resident #1-9 (R1-R9) revealed the following: 7 out of 9 residents were missing one or more of their prescribed and/or as needed medication(PRN). Missing medications were observed as follow; R1 was missing Tramadol. R2 was missing Vitamin D2, Loperamide 2mg, Milk of magnesium, Naproxen 500mg. R4 was missing Levothyroxine 50mg, Diclofenac gel, Anti-Acid and bubble pack for Oxcarbazepine 600mg was observed with the back popped/tear for 18 pills that were placed back into the pack. R6 was missing Enolose 10mg. R7 was missing Omeprazole, Acetaminophen 325mg, Milk of magnesium, Nystatin 100,000 solution. R8 was missing Acetaminophen 325mg, Docusate 100mg Loperamide 2mg, Albuterol HFA90 inhaler. R9 was missing milk of magnesium. Per wellness coordinator, they recently conducted an audit and have requested refills for the medications. LPA Flores contacted the pharmacy to verify orders were place per facility’s records dated 9/11/25 and 9/12/25. Interview with pharmacist revealed, orders have not been placed for refills for 5 residents. 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 9099D, and appeal rights were provided. R1 is no longer at the facility and was not able to be interviewed. Interviews with staff revealed there have not been medication errors, missed medication, or mismanagement of the residents’ medications. Medication review of 9 residents revealed facility staff did not have some of the residents medications. However, per the review the medications available had been provided to the residents in care. Therefore the 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.