Complaint Investigation Report
157203395-9-10-2025-24-AS-SPIY-DLTPL2-20250924112400
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
05/21/2025 and conducted by Evaluator Melinda Medina
COMPLAINT CONTROL NUMBER: 24-AS-20250521115419
Facility staff did not properly dispose of resident's medications upon termination of services
Facility staff did not dispense medications to residents as prescribed
On 09/10/25, Licensing Program Analyst (LPA) M. Medina conducted an unannounced subsequent complaint visit. LPA introduced self, stated purpose of visit, and allowed entrance. LPA met with Executive Director (ED)/Administrator (ADM), Jeffrey Toomer to conduct visit.
This department investigated the above allegation, during the investigation, facility was toured, interviews
conducted and records reviewed. Based on information gathered during interviews and incident report received by department on 5/23/2025, R1 was administered medication belonging to both R2 and R3. R1 and R2 were current residents and R3 last resided at facility on 3/30/25 and medication was still at facility as of date of complaint.
The preponderance of evidence standard has been met, therefore the allegations of facility staff did not properly dispose of resident's medication upon termination of services and facility staff did not dispense medications to residents as prescribed are found to be SUBSTANTIATED.
Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D.
Exit interview conducted with Executive Director. A copy of this report and appeal rights provided for facility records.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction