Complaint Investigation Report

C1 is non-verbal and was not able to provide information. Regional Center Service Coordinator was unaware of the 07/21/2024 missing pill and they received an incident report on 07/16/2024 providing information about medication documentation errors for C1 that occurred on the months of April and May 2024. At this point it is unknown what happened to C1's 07/21/2024 5pm Midodrine 5mg pill.

Regarding the allegation "staff did not report medication error to Community Care Licensing", it is alleged that this medication error was not reported to the Community Care Licensing Department (CCLD) because the previous administrator has instructed staff to not report to avoid citations. Per interviews this medication error was not reported to CCLD. LPA Mora did not see an incident report submitted to CCLD.

Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 1 are being cited on the attached LIC 9099-D.

Exit interview held and a copy of the report and appeal rights was provided.