Complaint Investigation Report

107209035-10-21-2025-24-AS-SMOA-DMVM3W-20251028091548

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

10/20/2025 and conducted by Evaluator Jacques Leffall

COMPLAINT CONTROL NUMBER: 24-AS-20251020113818

On 10/21/25 at 1:00pm Licensing Program Analyst's (LPA's) J. Leffall and B. Miranda conducted an initial complaint visit to open and to deliver findings on above allegations. LPA met with Administrator (A1) Michelle Ramos.

The Department conducted interviews with staff, reviewed facility records, and reviewed resident files. LPA observed Acetaminophen 325 mg take 2 tablets by mouth every 12 hours as needed for pain administered as a daily medication per the MARS, Docusate SOD 100MG Gel CAP Take 2 tablets by mouth every morning: Count should be 22 punched out from 10/11/25. 19 tablets punched out. 3 tablets short. Levothroxine 50MCG Tab Take 1 tablet by mouth every day at 6:00pm: Count should be 15 punched out from 10/16/25. 14 tablets punched out. 1 tablet short.

Based on observation, record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The following deficincies are being cited Per Title 22 Regulations.

Exit interview conducted. A copy of this report was distributed to Administrator which confirms signature of this report.