complaint·April 30, 2026

...Continued from 9099 For resident R2, the MARS for medication R2M1 was not initialed on the following dates: 1/5/2026, 1/6/2026, 1/7/2026, 1/8/2026, 1/15/2026, 1/29/2026, 1/30/2026, and 1/31/2026. For resident R2, the MARS for medication R2M2 was not initialed on the following dates: 9:00 AM medication pass – 1/5/2026, 1/6/2026, 1/7/2026, 1/8/2026, 1/15/2026, 1/29/2026, 1/30/2026 and 1/31/2026. 5:00 PM medication pass - 1/29/2026, 1/30/2026 and 1/31/2026. For resident R3, the MARS for medication R3M1 was not initialed on the following dates: 1/8/2026, 1/30/2026 and 1/31/2026. For resident R3, the MARS for medication R2M2 was not initialed on the following dates: 1/8/2026, 1/30/2026 and 1/31/2026. California Health and Safety Code (HSC) 1569.69 (g) states that Residential care facilities for the elderly licensed to provide care for 16 or more persons shall maintain documentation that demonstrates that a consultant pharmacist or nurse has reviewed the facility's medication management program and procedures at least twice a year. Consonus Pharmacy conducted reviews of the facility’s medication management program on 9/15/2025 and 12/17/2025. Both reviews noted that there are a “High Number of Holes” in the MARs for the quarter under review. “Holes” indicate that staff initials have not be entered when medications are administered. Based on LPA’s record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. ...Continued from 9099-A In reference to resident R2, witness W1 stated that on 1/20/2026 they received their morning medications late. LPA reviewed Medication Administration Records (MARs) for resident R2 for 1/20/2026 and observed nothing to indicate that R2’s medications were not administered at the prescribed times. In reference to resident R3, witness W1 stated that the facility is swapping out resident R3’s medication and replacing them with an over the counter (OTC) medication. A photograph of pills in a bottle was provided by witness W1. The photograph did not show prescription labels or any evidence that could tie the photograph to resident R3’s prescribed medications. In reference to resident R4, witness W1 stated that R4’s medication was being kept in a black lock box in staff member S2’s office. LPA inspected S2’s office and found no evidence of a black lock box containing medications. LPA observed the PRN medication in question to be centrally stored, secure and with proper documentation. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Complaint alleges that the Facility Staff are Not Properly Trained in Medication Management. During the course of the investigation there were six (6) staff members designated as Med Aids who were responsible for administering medication to residents. California Health and Safety Code (HSC) 1569.69 states that in facilities with sixteen (16) or more residents, each employee of the facility who assists residents with the self-administration of medications shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction. Additionally, employees who continue to assist with the self-administration of medications shall also complete eight hours of in-service training on medication related issues in each succeeding 12-month period. LPA reviewed training documentation and course materials for the facility’s six (6) Med Aides. LPA observed that the Med Aides had taken all required initial training and continuing training. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. Copy of LIC 9099, LIC 9099D, LIC 9099S and Appeal Rights discussed and provided to Administrator Lua. Signature on form confirms receipt of documents.