complaint·August 10, 2022

Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced complaint investigation visit at the facility. LPA gained access to the facility and met with Administrator, Elizabeth Najera and explained the purpose of the visit which was to deliver findings for the above allegation. The Department’s investigation consisted of record reviews, interviews with staff and outside sources. On April 28, 2020, it was alleged that during April 2020, staff did not follow the physician’s orders for Resident 1 (R1 - See Confidential Names List LIC 811). R1 was sent to the hospital and could not be given as-needed medication for agitation, as they had been actively consuming alcohol. R1 also had a heart condition which would have required surgery; however, they were not medically evaluated as a candidate because of the alcohol consumption. Interviews with staff confirmed R1 was given four ounces of alcohol by designated staff around 12:00 pm and around 5:00 pm. There were no concerns expressed by third party sources during this time. Records reviewed confirmed R1 was diagnosed with a Substance Use Disorder which affected their behavior and care needs; however, according to written notes from their primary care physician, they were still allowed to consume four ounces of alcohol two times per day. There was insufficient evidence to support the allegation staff did not follow physician’s orders. The Department has investigated the allegation listed above. Based on evidence obtained, including interviews and records reviewed, the above allegation is determined to be unsubstantiated as the Department could not meet the preponderance of the evidence standard. An exit interview was conducted with Administrator, Najera and a copy of this report, LIC 811 Confidential Names List and Licensee/Appeals Rights (LIC 9058 01/16) was provided to the Administrator.