Complaint Investigation Report

R1's LIC 9172 Functional Capability Assessment (dated 08/27/2025), R1's Concise Care Group (dated 08/06/2025), R1's Patient Chart (not dated), Besht Wellness (dated 03/05/2026), R1's Appraisal/Need & Service Plan (dated 12/19/2025), R1's Invoice for Monthly Room Charge (September 2025 -April 2026) R2's Internal Resident Incident Report (dated 09/26/2025) and R1's & R2's ALl Order Administered/ Medication List (January 2026- June 2026) .

The investigation revealed the following:

Allegation: Facility staff mismanage residents’ medications.

It was alleged that residents’ medications were not administered as prescribed and that documentation was incomplete.

On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated med-techs assist with self-administered medications when LVNs are unavailable. A1 reported not being aware of any missed doses or medication errors.

On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Four (4) out of five (5) staff denied the allegation. One (1) staff was unaware. Staff reported they were not aware of missed doses and stated they notify the med-tech or charge nurse if unable to administer medications.

On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegatio n. One (1) of ten (10) residents confirmed the allegation. One (1) out ten (1) resident was unsure of the allegation. Eight (8) out of ten (10) denied the allegation. One resident reported missed doses; another resident was unsure of their medication management.

On 05/13/2026 between the hours of 10:10am – 11:00am, the Department conducted a records review of the April and May 2026 Medication Administration Records (MARs) and observed multiple missing staff initials indicating undocumented medication administration for several residents. The Department also observed medications remaining inside bubble packs despite being initialed as administered. Missing initials were noted for daily medications which include, diabetic medications, antihypertensives, anticoagulants, and ophthalmic treatments. These discrepancies were observed for multiple residents on multiple dates, and no documentation was found to explain the missing initials or unadministered medications.

Based on the Department's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was provided with appeal rights.