Complaint Investigation Report

Allegation: Staff did not administer medication to residents according to physician's instructions. It is alleged that a medication error occurred for Client #1 (C-1) on 11/25/2025. Per issued Corrective Action Plan (CAP), for C-1, BD medication Risperidone 2mg was administered in the morning instead of the prescribed evening (PM) dose. LPA confirmed above information with Administrator Robert Talens. Per Administrator, he agrees with the CAP findings and will be complying with the CAP. Per CAP report and Administrator Robert Talons agreement, this corroborates this allegation.

Based on interviews conducted and document review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiency is being cited according to California Code of Regulations, Title 22. Refer to LIC 9099D.

Exit interview conducted, appeal rights and this report was provided to Administrator.