Complaint Investigation Report

Allegation: Staff did not notify all authorized representatives of a medication error.

It is alleged that facility staff failed to notify all required parties following a medication error involving C1's prescribed Magnesium Glycinate. During staff interviews, S1 and S2 reported a Special Incident Report (SIR) documenting the medication error was submitted to the Regional Center and Community Care Licensing on 03/30/2026 in accordance with reporting requirements. During record review, LPA obtained a copy of the Special Incident Report (SIR) dated 03/30/2026, along with a fax confirmation verifying that the report had been submitted to the appropriate parties.

Based on the investigation conducted, which included interviews with staff and a review of relevant records, there was insufficient evidence to support the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was held, and a copy of this report was provided.