Complaint Investigation Report
The investigation consisted of the following:
On 07/24/2025, facility records were gathered. On 08/22/2025, a tour of the facility was conducted, interviews were conducted, and facility records were gathered. A tour of the facility consisted of the medication room and kitchen. Interviews consisted of Witness 1 (W1), Resident 1 (R1) to Resident (6), and Staff 1 (S1) to Staff (7). On 08/25/2025, Staff 8 (S8) was interviewed. On 12/11/2025, interviews were conducted, records were gathered and reviewed. Interviews consisted of Witness 2 (W2), Resident 7 (R7) to Resident 11 (R11), and Staff 9 (S9). On 12/12/2025, a tour of the Medication Room was conducted, interviews were conducted, records were gathered and reviewed. Interviews consisted of R5, R7, R10, Resident 12 (R12) to Resident 14 (R14), Staff 10 (S10), and Witness 3 (W3). R1’s to R15’s records were reviewed which consisted of Medication Administration Records (MARs), Physicians Reports, and Residents that Receives Daily Insulin/Boold Sugar Checks. Facility records reviewed consisted of Personnel Reports, Resident Rosters, Schedule Reports, Staff Training's. Other pertinent records were also reviewed during this investigation.
Allegation: “Staff do not ensure 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.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction