Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff are not adequately trained

It is alleged that it is alleged that the staff at the facility who hold a CPI training are not given the required yearly refresher training's. Per interview with S1 it was revealed that 30-minute monthly CPI training's are conducted for staff, however, during a visit from Regional Center it was observed that some staff did not sign the sign in sheet for the training and this implied that the staff did not complete their training. LPA reviewed the in-service sign in sheets for CPI Refreshers and observed that the following proof of completion was missing: Sign in Sheet dated 7/29/25, S3 and S4 missing their training; Sign in Sheet dated 8/27/25, S4-S8 missing their training; Sign in sheet dated 9/24/25, S4 missing their training; Sign in Sheet dated 10/16/25, S1,S3,S4,S7,S9 & S10 missing their training; Sign in Sheet dated 11/26/25, S10-S12 missing their training; Sign in sheet dated 12/30/25, S13 missing their training; Training's for January-April 2026 all staff have completed their required training. S1 confirmed that they are now offering 3 different classes each month to allow for all staff to attended and ensure they are maintaining the required training.

Allegation: Staff did not dispense medication to residents as prescribed

It is alleged that C1 ran out of medication and missed their routine evening medication on 2/26/26 and 2/27/26. LPA reviewed the Medication Administration Record (MAR) for C1 and observed that the medication in question was signed for by staff, after reviewing the internal notes it was documented that C1 was not administered their routine medication as medication was not at facility and C1 refused to wait for emergency medication to be prescribed to them at urgent care. LPA interviewed 3 staff and 2 of the 3 confirmed the allegation, S1 stated that the medication was not refilled in error, it was observed to be out on a Friday and due to the weekend and pharmacy being closed they were not able to get the medication refilled until the following Monday. S1 stated they attempted to take C1 to urgent care in effort to get an emergency replacement medication refilled, however, C1 was non-compliant and refused to wait to be seen for the medication.

Based on LPAs observations, interviews which were conducted, and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 6 are being cited on the attached LIC 9099D. Exit interview held, and a copy of this report and appeal rights were provided.