complaint·October 20, 2025

Review of facility records revealed that facility staff had self reported this medication error for R1 to the department on September 18th, 2025. The records reviewed stated that on 09/08/2025, R1 ran out of their medication, and medication was not delivered until 09/15/2025. Interviews with staff and outside sources all corroborated that R1 had not been given medications for several days. R1 did have some emotional adverse reactions presumably due to the lack of medication. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of evidence exists to support the allegation. One deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Johnathan Thomas, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.