Complaint Investigation Report

075600757-11-4-2024-15-AS-KHOS-DCWLLW-20250114075149

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 1515 CLAY STREET, STE. 310

This is an official report of an unannounced visit/investigation of a complaint received in our office on

09/06/2023 and conducted by Evaluator Grace Luk

COMPLAINT CONTROL NUMBER: 15-AS-20230906160133

Staff did not dispense medication as prescribed by physician

On 11/4/2024 at 11:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegation above. LPA met with Administrative Assistant, Lenie Ibe and explained the purpose of the visit.

During the course of investigation, LPA interviewed 3 residents, 3 staff, and complainant. LPA obtained and reviewed documents including physician's report, centrally stored records, MAR (Medication Administration Record), and medical records. R3's medical records and MAR revealed that R3 had a doctor's order for Clonazepam. However, R3's urine screens in June and August of 2023 indicated no Clonazepam presence.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.