complaint·December 22, 2025

LPA interviewed the Regional Vice President/Administrator (RVP/ADM), stated that former ED/ADM and RSD resigned, RVP took over the daily operation of the facility the day after ADM vacated the position. RVP stated there was no gap of supervision for 3 months. When RVP is attending to other duties and responsibilities, he/she assigns directors and managers to supervise and manage facility operation. LPA observed RVP to be present at the facility during unannounced investigation visits on 09/05/25, 09/11/25, 09/18/25 and 10/07/25. LPA observed that a manager of the day is posted at the front desk. LPA interviewed 8 staff (S2 to S9). 8 out 8 staff stated that RVP/ADM is at the facility 3 to 5 days in a week and comes in at random times, in addition 8 out of 8 staff stated an interim RSD was assigned and an RSS was hired to fill in the position expeditiously. 8 out of 8 staff stated there was no gap for 3 months that staff were not supervised. This agency has investigated the complaint allegations that facility Administrator is not consistently present to supervise and direct the facility's daily operations and facility staff did not have direct supervision for 3 months causing delays in medication administration. We have found that the complaint was unfounded , meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Executive Director/ Administrator (ED/ADM) Maddalena Chavez. A copy of the report was provided. page 2 of 4 According to responsible party (RP), R1s medication was put on hold on 03/22/25 when the medication technician (MT1) trainee inadvertently administered the incorrect medication. A senior medication technician (MT2) was with MT1 while in training. R1 was observed for 24 hours for possible adverse reaction. MT2 reported the incident to R1s medical team, and responsible party (RP), former ADM, RSD and CCLD expeditiously according to the policy and procedure of the facility. RP stated that there was no adverse effect on R1, and the error was correctly handled. Based on document review and interviews that facility staff did not administer resident’s medication correctly due to lack of supervision while in training may have happened or is valid, there is not a preponderance of evidence to prove the allegation did or did not occur, therefore the allegation is unsubstantiated . No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with Executive Director/Administrator (ED/ADM) Maddalena Chavez and a copy of the report was provided. page 4 of 4 end of report