complaint·January 23, 2025

Interview with R1 was attempted which revealed R1 was not a reliable historian. Interview with R1’s family member revealed they had been informed R1 had been seen by a medication chart that had an applesauce cup. It was reported staff redirected R1 from the cart. The family member could not recall what staff had relayed this information LPA conducted a walk through of the facility on 9/12/2023 and 9/29/2023 and did not observe unattended or unlocked medication. LPA conducted (3) staff interviews who revealed they did not recall R1 taking medications that were not their own. LPA conducted a review of the incident reports for R1, and found none reported for medication errors. Therefore, the allegation that R1 took another resident’s medications is unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided. As of 07/19/2013 the facility is approved for delayed egress and locked perimeters. Interview with R1 was attempted which revealed R1 was not a reliable historian. Interviews with (3) staff members where conducted. (2) of (3) staff did not recall if R1 had ever left the facility. (1) of (3) staff interviews revealed R1 had wandering into the parking lot of the facility and had been found (15) minutes later. Staff revealed an incident report was submitted to the department. LPA reviewed the incident report dated 8/6/2021 revealed R1 was unable to be located in the facility which prompted a head count, rooms checks and check of monitoring alarms. It was documented R1 was not located in the facility, and was found in the parking lot when a check was conducted outside. No time period on R1’s absence was documented. Based on interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations Title 22 is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided.