Complaint Investigation Report

126803939-3-3-2026-21-AS-KMOA-DSBLVA-20260319090515

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SANTA ROSA RO , 1450 NEOTOMAS AVENUE, STE. 100

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

01/25/2026 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20260125210427

Staff left resident's medication accessible to another resident in care

Staff do not ensure that resident's prescriptions are taken as prescribed

At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Administrator Nadia Roop and reviewed records. Based on records reviewed and interviews conducted, LPA found evidence to support the allegations listed above. The investigation revealed, staff left a small cup of medication containing pills in a different residents room. The cup was discovered by a residents family member and given to staff. Based on records reviewed, the morning medication on 01/23/2026 was documented as given, but interviews conducted showed R1 refused the medications and they were put in a plastic baggy and given to the bus driver to take to the day program. Staff of the day program were not given any documentation for the pills and did not administer. The pills were properly destroyed.

Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Nadia Roop and Appeal rights were given.