complaint·November 19, 2025

Regarding the allegation: 1.) Staff did not assist resident with self-administration of medications as prescribed. On 11/14/2025, the Department received a complaint alleging staff did not assist Resident #1 (R1) with R1’s PRN medications as prescribed. Interview with the ED and WD revealed that R1 is no longer residing at the facility. Due to R1 not residing at the facility, the LPA was not able to do a medication audit for R1, however the LPA conducted a random medication audit for four (4) residents. During today’s visit, between 10:13 a.m. and 10:55 a.m., the LPA conducted a review of medication and medication documentation with staff for four (4) residents and observed the following: Resident #2 (R2’s) Bedtime Melatonin 5MG tablet had 9 tablets remaining, however the medication was started on 11/05/2025 and with the quantity listed as 30, meaning there should be a total of 16 tablets remaining instead. R2’s Morning Atorvastatin Calcium 80MG had 15 tablets remaining, however the medication started on 11/04/2025 and with the quantity listed as 30, meaning there should be a total of 14 tablets remaining instead. R2’s Morning Lisinopril 5MG had 15 tablets remaining, however the medication started on 11/04/2025 and with the quantity listed as 30, meaning there should be a total of 14 tablets remaining instead. Resident #3’s (R3’s) Bedtime Senna 8.6MG had 11 tablets remaining, however the medication was started on 10/29/2025 and with the quantity listed as 30, meaning there should be 9 tablets remaining instead. R3’s Bedtime Trazodone HCL 100MG had 14 tablets remaining, however the medication started on 11/01/2025 and with the quantity listed as 30, meaning there should be 12 tablets remaining instead. Resident #4’s (R4’s) AM Aspirin EC 81 MG had 12 tablets remaining, however the medication was started on 11/01/2025 and with the quantity listed as 30, meaning there should be 11 tablets remaining instead. Based on observation and record review, the preponderance of evidence standard has been met, therefore the above allegation, “Staff did not assist resident with self-administration of medications as prescribed” is deemed Substantiated at this time. Regarding the allegation: 2.) Staff did not accept resident back from hospital. On 11/14/2025, the Department received a complaint alleging facility staff refusing to accept Resident #1 (R1) back to the facility from the hospital. Interview with the ED and WD revealed that R1 was admitted to the facility on 11/13/2025 and on 11/13/2025, R1 was hospitalized due to behaviors. The ED and WD explained that R1 was throwing items at staff in which staff did not feel safe for themselves and other residents. Once R1 was hospitalized, the ED wanted to reevaluate R1 to ensure that R1 was a correct fit for the facility. The ED explained that she assisted the hospital and referred them to a placement agency to assist R1 with placement. The ED said that on 11/18/2025, she followed up with the hospital and confirmed that R1 is going to be placed at a different facility that better fits their needs. Continued on LIC 9099-C. The LPA explained to the ED and WD that if they felt that R1 was endangering the health and safety of residents and staff or if R1 required a higher level of care, that a proper eviction notice and procedure is required. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation, “Staff did not accept resident back from hospital” is deemed Substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided.