complaint·July 22, 2025

Continued from LIC 9099 Regarding allegation of “Staff are not dispensing medication as prescribed” it was alleged that resident medications were not being delivered on time. During the course of the investigation, LPAs conducted a medication audit and reviewed the Medication Administration Records (MARs) for two residents. The review revealed that Resident #1 (R1) had discrepancies with two medications. The PRN medication Lorazepam 0.5 mg, 1 tablet up to 2 times per day as needed, was filled on 06/05/2025 with a quantity of six (6). At the time of the audit, only two (2) pills remained in the medication container for Lorazepam and the MARs log for June and July 2025 did not reflect any documentation of administration. Also, Quetapine (generic for Seroquel) 50 mg, 1 tab every morning, 2 tabs in the afternoon and 4 tabs at bedtime, with a start date of 07/03/2025 containing 100 pills had 17 pills left, however if administered as prescribed, should have been empty as of 07/17/2025. MARs log from 07/15/2025-07/22/2025 was incomplete. The absence of MedTech initials on the MAR indicates that medication was not recorded as having been dispensed to the resident. LPAs observed that medications for all residents were being stored in two (2) medication carts positioned against the wall adjacent to the file room. At 1:19 P.M., LPAs observed several loose pills on the floor between the two (2) medication carts. When the carts were pulled away from the wall, LPAs and Med-Techs present discovered several unidentified pills scattered on the floor. Med-techs stated they were unaware of those pills and were unable to identify which resident(s) the medications belonged to. Based on interview and record review, the preponderance of evidence standard has been met; therefore, the allegations above are deemed SUBSTANTIATED at this time. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 9099-D). Failure to correct the deficiencies may result in additional civil penalties. A $250 civil penalty is assessed today for the citation related to CCR 87465(a)(4) for repeat violation within 12 months. The Administrator Monica Reyes was informed that additional civil penalties might be assessed based on health and safety code 1569.49(f). Exit interview conducted. A copy of the report and appeal rights were provided.