Incident investigation·March 11, 2025

On 03/11/2025 at 1:20pm, Licensing Program Analysts (LPAs) Haner-Tomasko and Jeffries conducted an unannounced Case Management visit. LPAs arrived at the facility, met with Administrator Adam Bramwell, and announced the purpose of the visit. During the investigation, LPAs reviewed relevant documents and interviewed staff and resident. On 03/03/2025, Community Care Licensing received a self-report from the facility regarding missing medication. On 03/03/2025, Resident #1(R1) reported medications missing from their self-managed medications to Administrator Adam Bramwell. On 03/03/2025, Adam reported the incident to Community Care Licensing, the Local Long-Term Ombudsman, local law enforcement, and opened an internal investigation. R1 is able to self-administer their medication, and keeps their medications locked in their apartment. It was alleged the narcotic Norco was missing, due to R1 keeping records of the number of pills in the bottle. The report states R1 believed 35 pills went missing in February 2025. On 2/27/2025, R1 left 3 Norco pills in a bottle at their bedside, went to dinner, and returned to find only 1 pill left. The facility was notified of the missing medications on 3/3/2025. On 3/8/2025, Administrator submitted a supplement incident report with additional details. After discussion with R1 and R1’s responsible parties, a Ring camera was placed in R1’s room to view only the drawer where the medications were kept and posted a camera in use sign outside resident room. On 3/5/2025 around 4:20pm, R1 left their room to go to dinner. At 5:25pm, the Ring camera detected movement in the room. The video footage revealed Staff 1 (S1) open the drawer, appear to take pills from the bottle, and exit the apartment within 20 seconds. The Administrator viewed the footage and contacted law enforcement. Once law enforcement was on-site, the pill bottles were collected and examined, and was found to be missing 2 Norco pills. Law enforcement questioned S1, who initially denied taking the pills. (Continue 809-C) S1 emptied their pockets and the 2 Norco pills were found on their person, along with 28 other pills of varying shapes, sizes, colors, and imprint codes. S1 refused to state where the other pills came from. S1 was arrested by law enforcement. S1 was terminated by the facility and administrator submitted documentation to remove S1's associated clearance from facility roster. Administrator stated they conducted an additional audit to ensure all residents who self-store medication had proper locking boxes. LPA recommended conducting an audit of all resident self-stored and administered medications with residents present. LPA conducted a medication audit of 9 centrally stored residents’ narcotic medications and found (no errors/errors). Administrator conducted full medication audit of all residents’ centrally stored medications on 3/6/2025. The following deficiencies were observed and cited from the California Code of Regulations, Title 22. Personal Rights of resident, property was not safeguarded by the facility. Exit interview conducted. A copy of the report and appeal rights issued at the time of the visit.