Complaint·December 23, 2025

The RSD explained on 12/05/25 their Maintenance Director was contacted to break open the medication cart, so they could dispense medications. The maintenance director was able to open the medication cart. However, it was not prior to resident’s first AM dose. Therefore, morning medications were not dispensed on 12/05/25. A review of facility Progress Notes dated 12/04/25 indicated the medication cart was locked and/or staff could not open the cart. The RSD explained once the lock was broken on the cart, the cart was stored in a locked room for safety. Medication technician explained Ron’s Pharmacy came out over the weekend and fixed the lock. The RSD explained the lock was not broken open initially on 12/04/25 to obtain the medications, as the facility did not want to damage Ron’s Pharmacy medication cart. Residents were interviewed and stated they were no adverse reactions to not receiving their medications. LPA was advised by staff that the Executive Director was out of the building today. However, The Executive Director was present but did not meet with LPA regarding the compliant investigation. Towards the end of the visit the Executive Director made LPA aware they were out sick when the incident occurred and it was the responsibility of staff to report the issue. Based on interviews and record review, 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 03/22) were provided to Resident Service Director whose signature below confirms receipt of these rights. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Resident Service Director whose signature below confirms receipt of these rights.