Complaint Investigation Report

The administrator stated that the medication administration record (MAR) log was marked as given, but the medication was still in the bubble pack. Staff interviewed stated that a staff on each shift will perform a 15-minute post-medication check after medications are administered to the clients. It was found that the staff did not administer the medication or conduct the medication review correctly, resulting in Client #1 missing a dose of Ferosul. The facility had submitted an incident report to Community Care Licensing regarding this error when it occurred. Staff stated that they receive medication training annually and as needed. LPA interviewed three (3) clients, and all three (3) stated they are given their medications daily and on time. During the visit on 3/3/26, LPA reviewed the medication and MAR logs. There were no additional errors found. Based on the interview and record review, the allegation is deemed substantiated.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 1), are being cited on the attached LIC 9099D.

An exit interview was conducted. A copy of this report and appeal rights were provided to the Administrator.