complaint·March 11, 2026

Continued from LIC 9099 During today’s visit a brief physical plant tour of the facility was conducted. On 10/27/2025 and 02/26/2026, LPA conducted interviews with interim ED, and three (3) M ed-Techs and the Resident Service Director (RSD), Natalie Ontiveros. Additionally, LPA conducted a review of Resident #1's (R1's) file, obtained copies of pertinent documents relevant to the investigation, and conducted a medication audit. Information gathered reflected that R1 does not utilize the facility pharmacy and has Kaiser. Throughout the course of the investigation, LPA reviewed all documents obtained, conducted additional telephonic interviews with current and former residents and staff. The following was then determined: Interview with the management revealed that med techs are responsible for refilling, reordering and ensuring that residents’ medications are available at the facility before supplies are depleted. Additionally, it was noted that the community utilizes an electronic medication management system, Accuflow, which generates electronic Medication Administration Record (eMARs). These eMARs include resident information, medication details and administration schedules based on physicians’ orders. Moreover, information gathered reflected that facility utilizes Omnicare as the facility pharmacy and residents are highly encouraged to use the facility pharmacy to ensure faster service. Any resident that does not utilize the facility's pharmacy, including R1, must provide a signed and dated physician's order to the facility med-techs, who will then fax the information for entry into the Accuflow system, which can take up to 24 hour s. However, based on facility policy, med-techs are not able to administer any medication until the information is reflected on Accuflow. Therefore, a resident's family/friend of needs to assist with storing the medication and support the resident with with self-administration during that time. Due to R1 not utilizing the community's pharmacy, R1 is expected to obtain the refill independently until the facility receives and documents the updated order in the electronic medication management system. Staff interviews also revealed inconsistent responses regarding medication management practices. Some staff reported no issues with dispensing or refilling medications prior to them running out. However, other staff stated they are often overwhelmed and overworked and indicated that incoming faxes with medication changes or refill requests may occasionally be overlooked, resulting in delays. Staff acknowledged that the facility has procedures in place to ensure timely medication refills, however, it is disregarded by some staff. Continued on LIC 9099-C Continued from LIC 9099-C Regarding the required five-minute interval between administering two (2) different medications, staff confirmed that the interval is not always observed and stated that, at times, medications are administered without waiting for the full five (5) minutes for convenience or to save time. LPA Conway conducted a medication audit and reviewed supporting documentation including but not limited to, Medication Administration Records (MAR), physician orders and the Centrally Stored Medication & Destruction Record (LIC 622) for R1. Record reviewed revealed the facility failed to properly administer at least two (2) mediations as prescribed. During the medication audit on 10/27/2025, LPA observed a faxed physician’s order dated 10/21/2025, directing that Fosamax be administered on Monday mornings instead of Sunday mornings. Review of the eMARs indicated the medication had been administered correctly prior to the change, however, after receipt of the updated order, the medication was administered on Sunday 10/26/2025 and not on Monday 10/27/2025 as prescribed. Additionally, review of medication records revealed discrepancies in documentation. The medication RX# on the open box label did not match the medication RX # recorded LIC 622. Further review of the physician’s order for Brimonidine Tartrate 0.2% indicated the medication was to be administered three (3) times daily. However, the MAR and Med Techs initials reflected the medication was administered only twice (2) daily (8 AM and 8 PM), rather than three (3) times daily as prescribed. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “ Staff mismanaged resident's medication” has been SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. LPA informed the RSD that this is a repeat violation of the same regulation within a twelve (12) month period. LPA informed the Administrator that a civil penalty in the amount of $250 is being assessed on today’s date (03/11/2026) for a repeat violation. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.