Complaint·April 20, 2026

On 02/24/2026, LPA Marrufo interviewed staff S1, who stated that there were no issues with distributing M1 and M2 to R1 as prescribed. S1 stated there was a doctor’s order to increase R1’s dosage of M1 from a quarter tablet to a full tablet. R1’s Admission Agreement indicates R1’s admission date is 02/25/2025. R1’s Medication Administration Record (MAR) indicates R1 was prescribed a whole tablet of M1 from 02/25/2025 to 03/04/2025. R1’s MAR states R1 was assisted with the administration of a full tablet of M1 from 02/25/2025 to 03/04/2025. R1’s MAR indicates R1 was prescribed a quarter tablet of M1 from 02/25/2025 to 03/07/2025. R1’s MAR indicates R1 was assisted with the administration of a quarter tablet of M1 from 03/04/2025 to 03/07/2025. The boxes for 03/01/2025 to the morning of 03/04/2025 have an “x” in them, meaning the resident was not present at the facility when the medication was prescribed to be given. On 03/25/2026, LPA Marrufo received a copy of a prescription order for R1. The prescription order called for a quarter tablet of M1. The prescription order did not have a date on it. Allegation: Staff did not ensure that resident was provided a signal system specific to living unit During visit on 08/12/2025, LPA Marrufo toured the bedroom that R1 lived in when R1 lived at the facility. LPA Marrufo pushed the Emergency Call Button which was installed on the bedroom wall near the bed. Within 3 minutes, a staff member came to the bedroom to check on the emergency call. LPA Marrufo then went into the kitchen area where there was a panel that showed the emergency call came from R1’s former bedroom. LPA took photographs of the Emergency Call Button in the bedroom and the panel in the kitchen area. Page 2 of 3. During visit on 03/24/2026, LPA Marrufo obtained a copy of a document titled “Call Button Room Numbers.” The document was placed in a plastic sheet protector pinned to the wall near the call button panel in the kitchen area. The document listed R1’s first name as the resident in R1’s bedroom. During visit on 03/24/2026, LPA Marrufo interviewed Licensee Saaj Kaiyom and staff S1. During interview, Licensee stated the emergency call system does not have a log. During interview, S1 stated that R1 could not independently trigger his/her emergency pendant. S1 stated R1’s private care giver would trigger R1’s pendant. S1 stated whenever R1’s emergency pendant was pressed, the emergency pendant would cause R1’s room number to show up on the emergency panel on the kitchen area wall. S1 stated there was never a time when R1's pendant was pressed and a staff went to the wrong room in response. Based on information from interviews conducted with staff, records reviewed, and observations, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. No Deficiencies were cited under California Code of Regulations Title 22. This report was reviewed with Saaj Kaiyom and a copy of this report was provided. Page 3 of 3. END REPORT During interview, Licensee Saaj Kaiyom stated that R1 had a gluten free diet. Licensee stated that facility staff served R1 gravy made with Campbell Cream of Mushroom soup while R1’s family member was visiting R1. Campbells.com states Cream of Mushroom Soup ingredients include wheat. Licensee stated that R1’s family member prevented R1 from consuming the gravy made from Campbell Cream of Mushroom soup. During interview, S1 stated to have notified the rest of the staff, including the cooks, that R1 was not to have anything with lactose. S1 stated the facility cooks did not realize Campbell Cream of Mushroom soup contained lactose. S1 stated staff served R1 Campbell Cream of Mushroom soup, but R1’s private care giver notified staff and the soup was removed. Based on records review and interviews, there is preponderance of evidence to prove the alleged violation did occur. Therefore, the allegation is substantiated. See LIC9099-D for deficiencies cited per the California Code of Regulations, Title 22. This report was reviewed with Saaj Kaiyom and a copy of this report and appeal rights were provided. Page 2 of 2. END REPORT