Complaint Investigation Report

107209035-11-13-2025-24-AS-SMOA-DNLNNB-20251120093629

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

11/04/2025 and conducted by Evaluator Jacques Leffall

COMPLAINT CONTROL NUMBER: 24-AS-20251104092210

Staff are mismanaging residents medications

On 11/13/25 at 9:30 am Licensing Program Analyst's (LPA) J. Leffall conducted an initial complaint visit to open and to deliver findings on above allegations. LPA met with Administrator (A1) Michelle Ramos.

The Department reviewed facility records, and reviewed resident MAR's. LPA observed from the Memory Care Med Tech Room R1's medication: Denepezil 10mg tablet/Take 1 tablet by mouth every morning. Start date 11/3/25. Count from 11/3/25 to 11/13/25 should be 11. 12 tablets were punched out total. Per medication count, 1 tablet over was punched out.

LPA observed from the Assisted Living Med Tech Room R2's medication: Montelukast 10 mg tablet/Take 1 tablet by mouth at bedtime. Start date 10/23/25. Count from 10/23/25 to 11/12/25 should be 21. 20 tablets were punched out total. Per medication count, 1 tablet short was punched out. Ferrous Sulfate 325mg (65mg) tablet/Take 1 tablet by mouth everyday in the morning. Start date 11/8/25. Count from 11/8/25 to 11/13/25 should be 6. 5 tablets were punched out total. Per medication count, 1 tablet short was punched out.

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 and civil penalty issued Per Title 22 Regulations.

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