Complaint·February 4, 2026

(Cont. from LIC 9099) Regarding the allegation that staff did not provide a written incident report to the resident's responsible person within seven days, interviews with staff corroborated the allegation. By admission, staff reported that they called Resident 1 (R1)'s responsible party the day R1's incident occurred on 01/10/2026, however they had not sent a written report within seven days. Staff reported that R1's responsible party requested the written incident report and received it on 01/29/2026. Regarding the allegation that staff did not dispense medications as prescribed, interviews with staff corroborated the allegation. Staff #2 (S2) reported that they attempted to administer an as-needed pain medication in a method that was not consistent with the prescribed method, due to R1's condition. S2 stated that hospice staff came to the facility to demonstrate the correct administration technique for R1. By admission, staff also reported that they administered a discontinued medication to R1 on 01/23/2026. R1's Medication Administration Record revealed that the administered medication was placed on hold on 01/23/2026. Records review of R1's discharge paperwork dated 01/22/2026, revealed a discontinuation of three (3) medications, one of which was given to R1 on 01/23/2026. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are 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 Marquette Corbett, whose signature below confirms receipt of these rights.