Complaint·July 2, 2025

Page 2 of 2. Facility staff did not administer resident's medication as prescribed by physician. It was alleged that resident R1 was not being administered Medication #1 as prescribed by physician. On 3/19/2025, the Department interviewed 2 staff (S1-S2). S2 stated R1 did not have physician’s order for facility to administer Medication #1, which was not a routine medication but as need (PRN) medication. S2 stated the Hospice RN was able to administer the medication but they only had orders signed by a nurse and not a physician. S2 stated Hospice agency was aware of this and they would administer the medication #1 as it was a PRN medication. On 3/19/2025, the Department interviewed 2 residents (R1-R2). Two out of two residents were not able to answer the questions requested at the time of the visit. On 3/19/2025, the Department interviewed 1 witness (W1). W1 stated that they did not see or hear any issues with facility staff not administering medications to the residents. Based on review of resident R1’s file, R1’s Hospice medication orders for Medication #1 was signed by a nurse and not a physician. Based on review of R1’s hospice visit log, R1’s nurse stated medication #1 order, but order was signed by nurse and not physician. Facility staff installed a security camera in resident's room without resident's consent. On 3/19/2025, the Department interviewed 2 staff (S1-S2). Two out of two staff stated resident’s responsible party was aware of security camera and signed consent forms to have camera in resident’s room. On 3/19/2025, the Department interviewed 2 residents (R1-R2). Two out of two residents were not able to answer the questions requested at the time of the visit. Based on review of resident R1’s Admission Agreement, page 35 out of 36, R1’s responsible party signed to have non-recording video monitors in the resident’s living space. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided. Page 2 of 3. Facility staff is not meeting resident's needs due to lack of staffing. On 3/19/2025, the Department interviewed 2 staff (S1-S2). Two out of two staff stated there was enough staffing to meet the resident’s needs. S1 stated there were two residents and 1 staff assisting both resident. S1 stated there were available staff from the next facility, which also belongs to the Licensee, and they can always come to assist residents in an emergency. S2 stated there are enough staff to meet the resident’s needs. S2 stated they will help assist S1 when there were only 2 residents at the facility to cover breaks and assist with other duties at the facility. On 3/19/2025, the Department interviewed 2 residents (R1-R2). Two out of two residents were not able to answer the questions requested at the time of the visit. On 3/19/2025, the Department interviewed 1 witness (W1). W1 stated they did not hear or see any issues with the facility staff not meeting the resident’s needs at the facility. W1 stated the staff are always available when requested. Based on review of staff schedule from January 2025 to March 2025, there are 1 to 2 staff assigned throughout the day, along with 1 administrator on shift throughout the day. Facility staff did not follow resident's care plan. It was alleged that the resident wasn’t having a consistent sleep pattern, where the staff did not ensure the resident was sleeping in the night and awake in the day. On 3/19/2025, the Department interviewed 2 staff (S1-S2). Two out of two staff stated the R1 had a hard time adjusting to the new facility and was restless at night. S2 stated the night shift staff would do safety checks at night with the other residents and stay in R1’s room to ensure R1 was comfortable to sleep. S2 stated R1’s hospice team had initiated medication which they was administer when facility staff would report R1 being restless at night. On 3/19/2025, the Department interviewed 2 residents (R1-R2). Two out of two residents were not able to answer the questions requested at the time of the visit. Page 3 of 3. On 3/19/2025, the Department interviewed 1 witness (W1). W1 stated they have not seen or heard facility staff not following resident’s care plan. W1 stated they are present in the facility in the day time and have not observed facility staff’s night time activities. W1 stated when they are present in the facility, the residents are awake and doing activities Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.