Complaint Investigation Report

Staff do not ensure residents room is kept in clean sanitary conditions

On 08/22/2025, LPA and S1 toured C1’s room. LPA observed a red solo plastic cup filled with an unknown substance that attracted what appeared to be a swarm of gnats, two of the drawers in Chester of Drawers were missing, the white wall light fixture was covered with what appeared to be dust, and an unknown substance that was textured and brown in color was splattered on two of the walls in multiple places. Although S1 stated the facility was undergoing repairs, the licensee did not ensure maintenance of C1’s room for furniture, equipment and hygiene.

Staff do not ensure resident receives medications as prescribed

C1’s Medication Administration Record (MAR) dated 08/01/2025 report that C1’s Olanzapine medication was not administered at 08:00 AM. due to hospitalization; however, C1’s progress notes at 02:30 PM revealed C1 was transported to Alta Bates Hospital in Berkeley, CA. and at 07:59 PM Alta Bates Hospital Emergency Room contacted the facility inquiring about C1’s medication; Olanzapine was due at 05:00 PM.

Based on the above observation, interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights were provided to James Alegre, ADM.