Complaint·April 22, 2026

The investigation revealed the following: Allegation: Staff did not distribute resident's medication as prescribed The detail of complaint alleges on 6/21/23 staff gave R1 more medication than prescribed by R1’s physician. On April 9, 2026 at 10:52 am, the Department interviewed Administrator A1 via telephone regarding the allegation who did not deny allegation. When asked if R1 was given more medication than what was prescribed, A1 responded “Yes, but we were following the RN’s instructions, and she said it was okay to give medication like that.” On April 9, 2026 at 11:00am, The department interviewed S1, regarding allegations S1 admitted that she has made a mistake. S1 went on to explain the following to the Department: R1’s medication is (Metoprolol 25 mg) to be given 3 tablets in morning and 2 tablet in the evening (totaling 5 tablet in a day) but "I made the mistake of giving him all 5 tablets at once because he demanded it. so I gave it to him." S1 stated that she called his RN from the VA, and notified R1's family, and called 911. S1 further stated, “I know it was my fault that I made a mistake…I have learned from it, I go by doctor instructions only.” On 4/7/26, the Department spoke with Officer Austin (W1) of the Escondido PD who stated that he does remember going out on a call to facility with the Mental Health Clinician because it was reported that R1 was given “way too many meds that what was allowed” by the doctor. W1 further stated that R1 was refusing any medical attention and had a vague threat of suicide that is why the PD became involved. On 4/9/26 the Department attempted to interview R1 via telephone, there was no answer. Page 2 of 3 On 4/8/26 the Department obtained and reviewed police report # 230044925 which stated: “Subject was mistakenly given copious amounts of medication by the care giving staff. When he [R1] was told about the side effects of the medications, he [R1] made a vague Suicidal Ideation (SI) statement about, "not caring." Subject had his daughter in law present and has no access to means to harm himself. Denied SI just having a difficult time with the upcoming anniversary of his wife's passing. Subject connected to mental health services and has 24 hour care. Subject was alert and oriented and refused transport. Advised staff to monitor for medical issues and call 911 should he need assistance.” On April 9, 2026 The department obtained a copy R1 Physicians report (dated 6/17/25), R1's physician's order/Pharmacy list (dated 6/30/23), R1's Appraisal Needs and Services Plan (dated:4/9/25). R1’s physician order : Metoprolol Succinate 25mg tabs: take three tablets by mouth morning and take two tablets every evening for arrhythmia (heart rhythm) Based on the information gathered and reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title twenty-two (22), Division six (6), is being cited, please see attached LIC-9099D. An exit interview was conducted with Jo Estepa and A copy of this report and appeals rights were provided. Page 3 of 3