Complaint Investigation Report
Allegation: “Staff do not insure an appropriate skilled professional is administering insulin to residents.”
Interviews conducted revealed the following:
On 08/22/2025, W1 indicated that there was no Licensed Vocational Nurse (LVN) in the morning shifts, and a Medical Technician (MedTech) was providing insulin and providing blood sugar checks to residents.
On 08/22/2025, S1 indicated that they are the only LVN in the facility and they work Monday to Friday from 7 AM to 4 PM. Moreover, S1 indicated that recently they started to work weekend shifts. Furthermore, S1 indicated that they “usually make it” to provide residents with their injections and blood sugar checks. S1 was asked what happens when they do not make it and S1 did not answer the question.
On 08/22/2025, S2 indicated that S1 does not come in during the weekends and residents do not receive their injections nor blood sugar checks on the weekends.
On 08/22/2025, S3 indicated that S1 sometimes comes in during the weekends and sometimes agency LVNs (the facility contracts agency staff when they are short staffed) come in during the weekends but sometimes no LVNs come during the weekends; S3 is not sure what happens when no LVNs come in.
On 08/22/2025, S7 indicated that before there were no LVNs in the facility during the weekends and a MedTech had to come in the facility and provide injections and blood sugar checks to residents.
On 08/25/2025, S8 indicated that they have witnessed MedTech’s provide injections and blood sugar checks to residents. Furthermore, S8 explains that the facility has requested for them to provide injections and blood sugar checks to residents because the LVN was not in the facility, S8 declined and indicated, that day, residents did not receive their injections nor blood sugar checks.
On 12/11/2025, S9 indicated that they have heard of a MedTech providing injections and blood sugar checks to residents.
On 12/12/2025, S10 indicated that on 12/10/2025 an agency LVN did not provide injections nor blood sugar checks to residents.
On 12/12/2025, W3 confirmed that an agency LVN did not provide injections nor blood sugar check to residents. W3 explained that on 12/11/2025 residents informed them that they were upset that they did not receive their insulin injections nor blood sugar checks.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction