Complaint Investigation Report

075601320-8-22-2022-15-AS-KHOS-CMKNUN-20221229094637

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

08/03/2021 and conducted by Evaluator Grace Luk

COMPLAINT CONTROL NUMBER: 15-AS-20210803160230

Facility staff mismanaged resident's medication.

On 8/22/2022 at 12:45PM, Licensing Program Analysts (LPAs) G. Luk and J. Sampair arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegation above. LPAs met with Administrator, Rosa Junsay.

During the course of investigation, LPA G. Luk interviewed 3 staff and complainant. LPAs obtained and reviewed documents including physician's report, medication administration records, centrally stored medication list, hospice nurse contact information, and list of medications from the doctor. Record review indicated that R1's current medication list for Metoprolol was prescribed to take 1 tablet once daily. However, MAR (Medication Administration Record) dated February 2022 states that Metoprolol was given twice a day.

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.