Complaint Investigation Report
The investigation revealed: allegation: Facility did not administer medication as prescribed. It is alleged that facility is not administering medication/liquids as prescribed and that is leading to client being frequently hospitalized. LPA interviewed a family member and a witness after initial visit. Client was admitted to facility on 11/14/2025. Since then, client has been hospitalized on 12/11/2025, 12/18/2025, 12/28/2025, 01/05/2026, 01/06/2026, 02/02/2026, 02/03/2026, 02/07/2026, 02/22/2026. Not once has any health professional at hospital raised concern or reported possible neglect on facilities part. LPA reviewed medications for all three clients residing at facility, and the medications are being administered as ordered. There was a self reported medication error on 02/02/2026 where Desmopressin was signed off as given and was still in the bubble pack. There is not enough evidence that the medication error caused client’s hospitalization. Before being admitted to Tern Bay, client was living with mother and during this time hospital records show that client was hospitalized on the following dates: 05/08/2025, 05/13/2025, 05/22/2025, 06/24/2025, 09/19/2025, 09/23/2025, 10/10/2025, and 10/29/2025. The client's hospitalization before and after client was admitted to facility show a consistent pattern and there is no evidence that facility was neglectful.
Based on documents reviewed and interviews, there is not enough evidence to substantiate the allegation that the facility did not administer medication/liquids as prescribed that led to multiple hospitalization of client. It appears more likely based on interviews, records of hospitalization months before admitted to facility and during client’s stay at facility that client may require a higher level of care.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
Exit interview was held and a copy of the report was provided
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction