Complaint Investigation Report
Allegation: Staff mismanaged resident’s medications
During investigation, LPA interviewed reporting party (RP), facility staff (ADM, S1) and reviewed resident’s (R4) documents. Review of R4’s admission agreement, centrally stored medication logs and medication administration records showed he was first admitted at the facility on 09/11/25 coming from a skilled nursing facility (SNF). On 09/16/25, staff informed R4 that his prescribed medication had run out. Staff (ADM, S1) confirmed with LPA that they failed to follow up with R4’s primary care physician on his prescription refill requirements. Based on interviews and observations which were conducted, the preponderance of evidence standard has been met and the above allegation(s) that staff mismanaged resident’s medications is substantiated.
Allegation: Staff did not attend to resident’s call for help
During investigation, LPA interviewed reporting party (RP/ Ombudsman (OMB)), facility staff (ADM, S1) and residents (R1, R2). On 09/17/25, RP/Ombudsman witnessed a resident (R1) in Room #207 shouting for help at 3:10PM. RP/OMB informed housekeeping who was cleaning a room on the 2 nd floor who called the front desk for help with no staff response. At 3:53PM, RP/OMB informed staff on the 1 st floor that R1 needed assistance. RP/OMB stated staff finally arrived around 3:55PM and helped R1. On 09/24/25, ADM confirmed with LPA that residents do not have a call button device available to alert staff for assistance when needed. Based on interviews and observations which were conducted, the preponderance of evidence standard has been met and the above allegation(s) that staff did not attend to resident’s call for help is substantiated.
Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties .
Exit interview conducted. Appeal rights and a copy of this report provided .
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction