Complaint Investigation Report

Allegation: Staff administered unauthorized medication to a resident while in care

During investigation, the department conducted interviews of facility staff (ED, S1) and reviewed assisted living resident (R1) documents. S1 confirmed with LPA that she administered unauthorized medication belonging to another staff to R1 while in care because R1's prescription refill from the pharmacy was delayed. Review of R1’s medication administration records showed R1 received unauthorized medication on 04/16/25 at 12PM. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff administered unauthorized medication to a resident while in care was found to be substantiated.

Allegation: Staff disclosed personal information about a resident

During investigation, the department conducted interviews of facility staff (ED, S1) and reviewed resident (R1) documents. S1 confirmed with LPA that she publicly discussed R1's medication with another staff on 04/16/25 in the open area close to the medication room which was adjacent to the visitor's living room/gaming area. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff disclosed personal information about a resident was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted, appeal rights and copy of report provided.