Complaint Investigation Report

On the allegation " Staff are not reporting incidents to proper agencies." LPA reviewed charting notes and available unusual incident reports for R1. Based on a review of charting notes LPA identified over 35 incidents between March 2025 and November 2025 that required submitting an unusual incident report and/or SOC341 report of suspected abuse to the required parties and agencies. LPA observed that the facility submitted 1 unusual incident reports and 5 SOC341 report of suspected abuse during this time period. LPA observed that all required incidents where not reported as required by Title 22 therefore the allegation "Staff are not reporting incidents to proper agencies." is Substantiated.

On the allegation "Staff are mismanaging resident's medications." LPA reviewed R1's MAR, charting notes, and correspondences with R1's physician and responsible party. LPA identified 9 occasions where R1 was administered their as needed PRN for agitation. R1 was a memory care resident and was unable to determine their need for the PRN and unable to communicate their symptoms clearly. LPA observed that there was not a record of the Facility staff contacting the resident's physician prior to each dose, describing the resident's symptoms, and receiving direction to assist the resident in self-administration of that dose of medication as required by Title 22 therefore the allegation "Staff are mismanaging resident's medications." is Substantiated.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted with Executive Director, San Sor. Appeal rights and copy of this report provided.