Complaint Investigation Report

Allegation: Facility did not maintain accurate records. The complaint alleges that on June 10, 2026, resident Medication Administration Records (MARs) were reviewed by Regional Center Quality Assurance S pecialist, and a medication error was observed on resident (R1's) MAR. Medication Ergocalciferol Ergocalciferol 8,000 ML was not initialed by staff, but the medication was allegedly dispensed. In addition, during the Regional Center audit resident (R2's) Individual Health Care Plan (IHCP) was missing from the resident's file. The facility is an Adult Residential Facility for Persons with Special Health Care Needs (ARFPSHN) that serves medically fragile developmentally disabled residents that require 24/7 nursing support. A total of six (6) staff were interviewed. Resident (R1's) MAR medication error and R2's unavailable IHCP was confirmed by staff. 8:00 AM medications are typically given between 7:30 AM - 8:30 AM. Staff (S1) stated they administered the medication to R1, but forgot to initial the MAR and a 2nd staff forgot to check and initial the Medication Administration Verification form. The Medication Administration Verification form is to be signed by nursing staff and/or DSP staff. According to S1, they forgot to initial the MAR because they took 3 residents out for an outdoor walk after they got them ready following the 8 AM medication pass. During the visit, Medication Administration Records (MARs) were reviewed. No errors were observed. On June 12, 2026, the Regional Center issued a Corrective Action Plan (CAP). Therefore, based on document review and interviews there is sufficient evidence to corroborate the allegation.

Based on record review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Pursuant to Title 22, California Code of Regulations, a deficiency is cited.

An exit interview conducted, copy of the report and appeal rights was provided to LVN Andrea Lopez.