complaint·November 18, 2025

Facility staff did not maintain complete and accurate residents' records. - SUBSTANTIATED It was reported that the facility could not locate a copy of a resident’s power of attorney (POA) and social security card when requested. LPA reviewed: Resident Move in Record for R1 which includes their social security number. Resident Move in Record for R2 does not include their social security number. Administrator stated that POA documents for the residents have not been submitted to the facility. The facility does not have a social security card on file for R1. R1’s pre-admission paperwork does include R1’s social security number but R2’s pre-admission paperwork does not. Per Title 22 regulations POA documents and social security cards are not required to be included in a resident’s file. However, it is a regulatory requirement that each resident shall have their social security number included in their resident file. 1 of 2 resident files reviewed does not include their social security number. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Nicole Braswell. Facility staff mismanaged residents’ medication. - UNSUBSTANTIATED It was reported that staff discarded a residents Norco and Oxycodone without proper authorization. LPA reviewed: Pharmacy medication list for R1 dated 01/06/2025 for which includes oxycodone 5 mg, order date and start date of 12/03/2024. Fax communication from the facility to R1’s doctor dated 02/17/2025 requesting to discontinue the oxycodone 5 mg for R1 at the POA’s request. R1’s physician signed the request to d/c. Medication Destruction Record for R1 dated 02/25/2025 which states that 15 5 mg oxycodone pills had been destructed and signed off by facility LVN and one other staff. There was no physician’s order for Norco on file for R1. Administrator stated when R1 & R2 moved in they brought a bag of medications with them but they did not have a doctor’s order for oxycodone so the facility had to dispose of the medication. It was determined there was no order for Norco on file for R1. The prescription for Oxycodone was discontinued by R1’s physician on 02/17/2025 and the facility destroyed the 15 remaining pills on 02/25/2025 which meets licensing regulation requirements. This allegation is unsubstantiated. This agency has investigated the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED. No deficiency cited. Exit interview conducted and a copy of the report was provided to administrator Nicole Braswell.