complaint·September 23, 2025

The investigation revealed the following: Regarding allegation: Staff did not re-order resident’s medication timely. It is alleged Resident #1(R1) was not provided with medication when needed because it was not available at the facility. Interviews conducted revealed 4 out of 10 residents stated medication is provided as prescribed and as needed medication when needed. 2 out of 10 residents are not assisted with medication, however facility staff have assisted with obtaining their medication. 2 out of 10 residents stated that medication was not provided when needed as it was not available at the facility on one occasion. 2 out of 10 residents were unable to be interviewed due to cognitive skills. Interview with staff revealed facility ensures to have a 30 supply of medication for residents in care for all routine and as needed medications. Administrator stated that R1’s lorazepam was not available on the morning of 4/24/22 and the resident was sent to the hospital to obtain the medication as a refill had not come in. Per documents reviewed R1 had a prescription order for Lorazepam. Per pharmacy’s email dated: 4/26/22, an initial request from the facility for the medication was submitted on 4/15/22 to refill the lorazepam. The pharmacy followed up on the request with the facility and physician and the medication was refilled on 4/25/22. LPA was unable to review medication sheets for April 2022 as the facility uses QuickMar system, which did not allow them to go that far to obtain the records. On 9/22/25 LPA Flores conducted a medication review and observed R1 has an order for lorazepam .5mg as needed and observed the medication available. LPA observed resident #2(R2) did not have routine Aspirin 81mg available, resident #3(R3) did not have as needed medication Clonidine HCL .1mg, and resident #4(R4) did not have hyoscyamine .125mg and senna 8.6 mg. LPA contacted hospice agency who stated facility is to contact hospice to reorder medication for R4. Although, facility attempted to obtain the lorazepam days before it run out and there is not enough evidence to say that the facility is at fault for the medication not being available when R1 needed. During the visit of 9/22/25 LPA observed routine and as needed medication was not available for R2,R3, and R4. Therefore the 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 9099D, and appeal rights were provided. The investigation revealed the following: Regarding allegation: Insufficient staffing. It is alleged emergency responding agency was not able to enter the facility at night as there was no staff in the front desk. Interviews with residents revealed 8 out of 10 residents stated there is night staff available. 2 out of 10 residents were not able to answer due to cognitive skills. Interviews with staff revealed there is 2 caregivers and 2 medication technicians during the night shift. Documents reviewed revealed Staff Calendar for April 2022 notes there was a floor manager and 2 caregivers on the night of 4/23/25 scheduled to work from 10:00pm to 6:00am. Staff roster reviewed on 9/22/25 notes there are a total of 4 staff scheduled to work the night shift from 10:00pm to 6:00am. Per administrator, the Executive Director, Health and Wellness Director, Journey Director, and Maintenance Director Sales Director, and Business Office Director area available over the phone during the night. Based on documents reviewed 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.