Complaint·December 20, 2022

Additional outside source interviews revealed witnessing R1 measure their insulin incorrectly on multiple occasions as well as unable to check their own blood sugar. The facility manages R1’s medications, they do not log R1’s blood sugar checks. The administrator’s interview revealed not being aware of a change in condition or that staff were assisting with injections. Staff interviews revealed R1 was observed drawing the incorrect dose of insulin on multiple occasions and shakes a lot, which makes it difficult for R1 to administer their own injections safely. The facility does not have a skilled professional on staff to administer the injections. Staff stated they were not aware the resident must administer their own injections, or it must be conducted by a skilled professional. Staff admitted R1 is unable to manage their blood sugar checks or administer their insulin independently and agreed R1 required a higher level of care due to the facility not having a skilled professional on staff to assist. Facility staff interviews revealed denial or R1 having a change in condition but admitted R1 shakes a lot and does not draw the proper amount of insulin. R1 is unable to administer their own insulin injections and check their own blood sugar, independently. R1 requires a higher level of care, where a skilled professional can administer R1’s insulin and blood sugar checks. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Administrator, Rocio Granda whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]