Complaint·December 24, 2025

In May 2025, Melatonin was not given on five different dates 5/25/25, 5/26/25, 5/27/25, 5/28/25,5/30/25 and 5/31/25. In June 2025, Melatonin was not given for 11 days in a row (6/1/25, 6/2/25, 6/3/25, 6/4/25, 6/5/25, 6/6/25, 6/7/25, 6/8/25, 6/9/25, 6/10/25 and 6/11/25 In July 2025, it was not given for 9 days in a row. 07/01/25, 07/02/25, 07/03/25, 07/04/25, 07/05/25, 07/06/25, 07/07/25, 07/08/25 and 07/09/25. Melatonin was not given on the following dates as evidence by the absence of staff initials and/or check marks used to indicate medications was given to R2. During a medication review and interview on 7/30/2025 with LPA Arvin Villanueva and Designated Facility Administrator, Valesia Cole it was noted that the Melatonin on hand was 5mg tablets (photo taken), reported cutting the tablets in half, making the dose 2.5mg. The prescription records do not show an order to cutting the medication. Staff member also admitted they were not sure if the medication was given on the days left blank on the MARs. Staff explained that sometimes R2 did not receive Melatonin if R2 was already too sleepy from other medications, and that a family member instructed staff to hold the Melatonin under those conditions. However, the prescription order dated 4/18/25 does not state that the medication may be held for any reason. LPA Hayes attempted to interview R2, the resident was not cognitively available to participate in an interview. The evidence shows staff did not consistently follow the physician’s order for R2’s Melatonin, and medication was either missed or altered without physician’s authorization. Therefore, the allegation is SUBSTANTIATED. This facility is being cited per Title 22 CCR Section 87465(c)(2 ). An exit interview, appeal rights and a copy of this report was left with Valesia Cole.