Complaint Investigation Report

Regarding the allegation: Dispensed Medication not properly documented. LPA alongside with Administrator and S1 reviewed records for September 2023 medication records (MARS) for C1 medication Lorazepham 1mg, as needed (PRN) was documented in the back of the MARS that C1 was given medication on Sept 10th 2023 at 7am, it was observed that facility did not properly document date given for Lorazepham PRN that was given at 2pm. Interview with S1 and Administrator informed LPA for C1 the way MARS documentation for 2pm medication for C1 PRN administration date was not clearly written using date format in the nurses notes. LPA reviewed SIR dated 9/25/23, stating medication error for C1 was observed and facility was notified by Quality Assurance Specialist from East Los Angeles Regional Center upon medication review of error. Medication review on MARS for C2 was observed to have documentation written once for date 5/09/23 for medication Acetaminophen 500mg and per interview S1 and Administrator informed LPA C2 was observed to have medication error. Administrator stated on 5/09/23, for C1 staff administered medication twice and staff documented once on MARS and not twice. Administrator informed LPA that medication training was provided to staff who administer medication.

Regarding the allegation: Facility Staff mishandled P&I ledger. LPA reviewed P&I's ledger and monies that were present at the facility for C1-C4 for the month of December 2023 and looked at past ledgers for ledger errors for clients who had ledger errors based on interviews with staff who informed LPA on the client's that were affected. Based on interview with S1 and Administrator there were documentation errors on ledgers for clients. Upon review for C1 and C2 past ledger LPA observed miscalculation for C1 for month of September 2023 and miscalculation for C2 for the month of August 2023. LPA observed Administrator documenting properly and adjusting C1 and C2 ledger and providing monies to client to make adjustment for error conducted.

Based on interviews, observation, and document review conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Tittle 22, are being cited, see 9099-D.

A copy of report, and appeal rights were provided to Mylene Bumanlag/ Administrator