Complaint Investigation Report

The investigation revealed the following in regards to the allegation: “Staff did not administer residents medication as directed.” It is alleged that the staff did not dispense medications for C1’s medication Topiramate Tab 50MG tablet in the morning of 08/29/2025. LPA interviewed C1 that denied the allegation stating that there was no issues regarding receiving medications. LPA interviewed four (4) out of five (5) staff that corroborated with the allegation stating that a medication error did occur on 08/29/2025. One (1) out of five (5) staff interviewed could not confirm nor deny the allegation stating not being able to recall an medication error incident occurred on 08/29/20025. Four (4) out of five (5) staff interviewed stated the reason why the medication Topiramate Tab 50MG was not administered because it did not scan onto the Quick MAR prior to handing that medication to C1 and C1 left the facility at 7:15am, so there was not enough time for the medication to be given. However, four (4) out of five (5) staff stated that there is an alternate way of processing the medications on the Quick MAR by manually entering the medication using the mouse if the scanning did not work. Per Administrator, S1 did not do the alternate way of processing the medication on 08/29/2025. LPA reviewed the Special Incident Report dated 08/31/2025 which confirms that the staff did not administer Topiramate Tab 50mg at the scheduled time to C1 on the morning of 08/29/2025. In addition, SGPRC (San Gabriel Pomona Regional Center) conducted an investigation regarding this allegation which was substantiated. LPA reviewed the facility’s Registered Nurse re-trained medication pass training for S1 on 09/11/2025. Per Administrator, S1 was placed on a 30-day administrative oversite. Five (5) out of five (5) staff interviewed also stated that the facility now conducts a 15-minute post check every time medications are passed to all clients. Per Administrator, the facility has two (2) staff that are involved in medication administration to the clients. LPA reviewed four (4) clients’ medications that are centrally stored and bubble packed. Based on observations, record review, and interviews conducted with facility staff, and facility residents, there was sufficient supportive evidence to concur with the reported allegation.

A civil penalty in the amount of $ 250.00 is being issued during today's visit as a result of a repeat citation within the past 12 months.

Based on LPA interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. An exit interview was conducted with the Administrator, Ronnie Chua. A copy of the report and appeal rights were provided.