complaint·August 23, 2024

Based on interview, multiple facility staff interviewed denied ever giving R1 Fentanyl. Moreover, R1 denied the facility staff ever giving R1 Fentanyl. R1 denied knowing taking Fentanyl. R1 admitted to smoking Marijuana at the facility. R1 smokes outside in a designated area specifically for smoking Marijuana. R1 stated the day R1 went to the hospital R1 met a “friend” who gave R1 a “baggie” full of Marijuana. R1 stated that R1 believes the baggie the friend gave R1 might have been “laced” with Fentanyl and that is why R1 tested positive at the hospital. This agency has investigated the complaint alleging " residents consumed illegal drugs (Fentanyl) while in care". We have found that the allegation is unfounded , meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to the facility. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited. A copy of this report was provided alone with the LIC 811, the Confidential Names List. Exit interview. R2 returned to the facility and the same treatment was continued which initially worked but again ultimately the rash got worse. R2 was sent to UC Davis again on 07/09/2023 and then discharged back to the facility. On 07/15/2023, R2 was sent to UC Davis again for the rash. This time, R2 was admitted into the hospital. R2 was released to a rehab center for approximately one month. When R2 returned to the facility, the rash was gone. The rash has not returned. Per staff interviewed, R2 is completely bedbound as R2 has sustained a few falls and R2 is now afraid to get out of bed. R2 is given complete showers twice a week. R2 requires assistance with all ADLs. When the rash presented under R2 breast, staff would clean R2’s breast area daily with warm water, soap, and a rag. Staff continued to clean R2 daily and apply the cream and ointments per the doctors’ orders. Based on records and staff statements, staff were aware of the rash and continued treatment per the in-house doctor’s orders. There were gaps in R2 being seen in person by a physician which may have resulted in a different outcome. Facility staff attempted to have doctor treat R2 in person, but the doctor was “unavailable” or “hard to reach” resulting in the staff sending R2 to the hospital on three different occasions. Based on evidence in this report, the case is unsubstantiated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED . A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited. A copy of this report was provided, along with the LIC 811, the Confidential Names List. Exit interview.