Complaint Investigation Report

Allegation: Staff did not properly care for client resulting in illness.

The details of the complaint alleged that facility failed to care for (C#1)’s medical needs resulting in illness.

On 11/25/2025, the Department found, in its investigation, that the facility failed to provide the required services for (C#1) and did not properly respond to their change in condition, which may have prolonged their suffering. There was no Licensed Vocational Nurse (LVN) at the facility on 6/28/2025 as needed to provide three hours of daily care. The overnight staff on 6/28/2025 into 6/29/2025 did not inform (C#1)’s clinical team about their chest congestion during the 3-6 hours before their breathing problems were noticed. Also, staff did not provide the necessary medication, Geri-Tussin, to ease (C#1)’s chest congestion, partly because they were not certified to administer medication as required. The facility Quality Improvement Specialist said, “There is a preponderance of evidence to support (C#1) had a change of condition during the Noc shift on 6/29/25; no medications were administered during this time.”

During this investigation, LPA found sufficient evidence to support the above-mentioned allegation.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D).

An exit interview was conducted, and a copy of the Complaint Report was given to Maria Cristina Serafico/Program Director.