complaint·July 11, 2025

Continued from LIC9099 06/19/2025, it was observed that 12 out of 15 bathrooms were missing items such as toilet paper, paper towels, or soap. During visit conducted on 07/11/2025, it was observed that 7 out of 15 bathrooms were missing items such as toilet paper, paper towels, or soap. Based on observations made, this allegation is Substantiated . “Staff did not distribute resident's medication as prescribed,” – Complainant alleged that R1 was not provided their medication timely, stating that they had to wait 18 hours for their medication. Interview conducted with Staff Member 1 (S1) revealed that there are usually two medication technicians each shift. On 05/15/2025, R1’s medication was delivered to the wrong house. Per S1, if a medication is received for a resident that is in a different home, it should be given to the medication technician that oversees that house and the medication technicians coming in for the next shift are to be informed of any medication received prior to their shift. S1 further stated that they found R1’s medication at the end of their shift on 05/16/2025 and therefore was able to start the medication once the medication was located. Review of R1’s file showed that their medication arrived on 05/15/2025 with instructions to be given three times a day. Review of R1’s Electronic Medication Authorization Record (EMAR) showed that R1 missed their morning dose of medication but received their afternoon and evening dosage on 05/16/2025. Based on observations made and interviews conducted, this allegation is Substantiated . Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.