complaint·March 30, 2025

Allegation: Staff stealing resident medication. The allegation alleges that staff is stealing residents’ medication. During record review, LPA reviewed the Medication Administration Records (MAR) and Physician’s Orders for 10 residents. During the facility tour LPA inspected the medication room and reviewed the MAR and medications for 10 residents. LPA observed eight (8) out of ten (10) resident medications are consistent with properly documented records. LPA reviewed 15 residents Controlled Drug Administration Record and conducted a Narcotic Drug pill count. LPA observed fifteen (15) out of fifteen (15) Controlled Drug Administration Record and pill count are consistent with properly documented records. During interviews with Staff S3-S10, were asked if they suspect, seen, or heard of staff stealing medications, three (3) out of eight (8) stated they had heard a while ago that a staff might be stealing resident’s narcotics, but nothing recently. During interviews with Residents R3- R12, were asked if they had any concerns if staff were stealing their narcotics, ten (10) out of ten (10) stated they have no concerns of staff taking their narcotics. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . An exit interview was conducted with Memory Care Director, Melissa Sigala, and a copy of this report was provided. Allegation: Staff does not keep an accurate medication log. The allegation alleges that staff changes the medication count on the medical log and they not accurate. During Staff File review, LPA reviewed a Separation Form for S1, indicating an Involuntary Termination for Violation of company Policy effective 09/13/2024. Additionally, LPA reviewed a Suspension Notice for S1 dated 09/10/2024, pending an investigation. LPA reviewed an Employee Counseling Report dated 01/09/2024 for an incident that occurred on 12/05/2023. On 12/05/2023 there was a report of a discrepancy in the Controlled Substance count. The count sheet noted 10 pills and the bubble pack had 9 pills. During record review, LPA reviewed the Medication Administration Records (MAR) and Physician’s Orders for 10 residents. During the facility tour LPA inspected the medication room and reviewed the MAR and medications for 10 residents. LPA observed eight (8) out of ten (10) resident medications are consistent with properly documented records. LPA reviewed 15 residents Controlled Drug Administration Record and conducted a Narcotic Drug pill count. LPA observed fifteen (15) out of fifteen (15) Controlled Drug Administration Record and pill count are consistent with properly documented records. During interviews with Staff S3-S10, were asked if they have observed any discrepancies on the Controlled Drug Administration Record , four (4) out of eight (8) stated they have observed discrepancies on the Controlled Drug Administration Record. During interview with Residents R3-R12, were asked if they believe staff keep accurate documentation of their medications taken, ten (10) out of ten (10) stated they believe staff keep accurate records of their medications taken. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Memory Care Director, Melissa Sigala, and a copy of this report and the Appeal Rights were provided.