Complaint·January 5, 2026

An interview with the reporting party reflected that the resident (R1) requires a higher level of care than what the facility can provide, however resident (R1) has denied the need for a higher level of care. The resident requires diabetic care, including injectable insulin administration, which exceeds the facilities scope of care. The facility does not employ licensed medical staff authorized to administer injectable medications. An interview with R1’s Home Health nurse confirmed that facility staff lack the skill and authorization to properly meet the resident’s diabetic needs. Resident (R1) has been hospitalized on multiple occasions due to complications related to diabetes management. Despite glucose monitoring by facility staff, the facility is unable to ensure care and supervision appropriate to the resident’s identified health care needs, as required by Title 22 regulation 87628(a), therefore the allegation is substantiated. Allegation: Staff are not ensuring that skilled professionals are taking resident's blood pressure It was alleged that Staff are not ensuring that skilled professionals are taking resident's blood pressure. This investigation consisted of interviews with facility staff, the reporting party, and resident (R1) Home Health nurse. On 12/17/2025 LPA Hughes conducted a visit to the facility and spoke with 2 facility staff. Facility staff (S1) stated that they are responsible for assisting resident (R1) with glucometer testing and reported having received additional training related to glucose monitoring. Despite training, staff remain unauthorized to administer injections. An interview with the reporting party indicated that (R1) requires a higher level of care than the facility can provide due to additional health concerns contributing to elevated glucose levels. An interview with resident (R1) Home Health nurse indicated that facility staff are unable to perform injectable medications and are limited in providing skilled medical care due to the facilities scope of care limitations. The Home Health nurse further stated that resident (R1) is legally blind and unable to self administer diabetic injections. Based on the investigation, the resident is legally blind and requires diabetic injections the facility does not employ licensed or trained medical professionals to administer injectable medications. This was observed not in compliance with Title 22 regulation Diabetes 87628(a). The citation was previously cited to the facility, Therefore, the citation will not be reissued at this time. As a result, the allegations are SUBSTANTIATED . A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Veniana and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility. Interview with facility staff (S1) and (S2) reported that residents have freshly prepared meals. Interview with residents 2 out of 2 residents in care stated that they have no concerns about meals being prepared and served in the facility. LPA attempted to speak with resident (R1) but was unable as the resident was hospitalized at the time of the visit. LPA spoke with (R1) Home Health nurse, who stated that they are unsure of meals provided to resident is a direct result of an increased concern for (R1) health needs. There is not enough evidence to corroborate this allegation, therefore the allegation 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 violations occurred.