Complaint Investigation Report

During interviews with the clients, three (3) out of seven (7) clients interviewed corroborated the allegation that they have had issues with getting their medications dispensed to them. One client interviewed stated that they requested their medications be provided to them in their room due to back pain, however they were told by staff that they needed to come to the medication room otherwise they would be marked as refusing their medications. During interviews with staff, three ) out of five (5) interviewed corroborated that there have been some issues with distributing medications to the residents. One staff interviewed stated that they have observed S2 failing to follow-up with clients in their rooms if they do not come to obtain their medications after initially being called to do so. Another staff member who was interviewed stated that they have noticed if clients do not obtain their medications in the morning, S2 advises staff to distribute their morning medications in the afternoon instead, which is against physician's orders. During review of the medications, LPA observed that three (3) out of five (5) clients had medications that were empty and in need of a refill, which staff stated they were working on obtaining from the pharmacy.

In regards to the allegation that "Staff speaks to residents in an inappropriate manner", it is alleged that S2 has called clients rude names in the past including "stupid" or "idiot" if they do not come to obtain their medications. During interviews with the clients, four (4) out of seven (7) clients state that they have been spoken to in a rude manner at some point by staff in the facility. One client interviewed stated that they have been yelled at by S2 to get out of bed to get their medications. Another client interviewed stated that they have observed S2 speaking to other clients in a rude manner in the past. During interviews with the staff, two (2) out of five (5) interviewed corroborated that they have seen staff speak to clients in an inappropriate manner. One staff interviewed stated that they witnessed S2 yelling at C5 and C6 in the past. Another staff interviewed stated that they also observed S2 shouting at clients previously.

Based on LPAs interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegation, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 1 are being cited on the attached LIC9099D.

Exit interview held and a copy of the report and appeal rights was provided to the Case Manager Doris Elicanal.