complaint·October 27, 2025

Relevant party reported to the department that facility staff were not monitoring resident (R1's) blood sugar as often as they were supposed to, causing R1's blood sugar to increase and resulting in R1's hospitalization. Interview with witness indicated that R1 is Type 1 diabetic. Witness stated that R1 is not capable of administering their own insulin or able to perform their own glucose testing. Witness stated that facility staff did not inform R1's authorized representative timely regarding insulin not working and blood sugar levels increasing. Interviews conducted with Administrators Raluca Solovyev and Alena Tripadush, as well as staff member (S1), indicated that R1 administered their own insulin and performed their own glucose testing. Administrator Tripadush indicated that R1 was tested for blood sugar levels three (3) times a day, while Administrator Solovyev and S1 stated that R1 was tested for blood sugar levels four (4) times a day. LPA reviewed R1's records at the facility, including Admission Agreement, Medical Assessment, Doctor's Orders, and Blood Sugar Record. R1's Doctor's Orders indicate that R1 is to use a glucose meter, test, strip, and Softclix lancet "to test blood sugar 3 times per day with meals and once nightly as directed." Doctor's Order was dated April 20, 2025. Medical Assessment for R1 dated April 18, 2025 indicates that R1 is not able to administer their own injections and is not able to perform their own glucose testing. R1 was admitted to the facility on May 22, 2025. LPA observed Blood Sugar Record showed that R1 did not receive testing until September 7, 2025. Interview with Administrator Tripadush indicated that the facility started tracking R1's blood sugar in September as they just started using the forms at another facility. Administrator Solovyev stated that the facility started documenting R1's blood sugar levels because they had an appointment and wanted to know what the results were. LPA did not observe any days listed on Blood Sugar Record indicating that R1 received four (4) tests in one (1) day. LPA observed multiple days on R1's Blood Sugar Record in which R1 was test once or twice in one (1) day. LPA observed that there was no restricted health care plan on file for R1. Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.