Complaint Investigation Report

One of the clients' probiotic blend medication that needed to be refrigerated was not kept locked in the small refrigerator. The medication was placed outside of the locked box in the refrigerator. Staff stated that they recently added a lock to the small refrigerator. LPA observed that the medications are centrally stored and locked in the medication cart. The facility uses a small refrigerator to store any medications that need to be refrigerated. The refrigerator door has a lock and was locked at the time of visit.

Allegation - Staff did not accurately maintain client's medication records. It is alleged that the staff did not initial the Medication Administration Record (MAR) when the morning medication (Levothyroxine) was given on 4/1/26. Staff acknowledged the error and stated that staff forgot to initial the MAR when the medication was administered to the client. Staff were provided an in-service training after the error. LPA checked the medication with the MAR logs today. There were no discrepancies found.

Allegation - Staff did not properly dispose of expired medications. It is alleged that the expired medications were found in the overflow basket. Staff acknowledged that one of the clients’ medications (Enema) had expired during an audit review. Staff stored the expired medication within the overflow basket in the locked cabinet and had not disposed of the expired medication. Per staff, the Department of Developmental Services and Regional Center reports noted that the Enema medication expired on 10/19/24 per the affixed pharmacy label. LPA observed the overflow medications and expired medications stored separately in a locked cabinet.

Based on interviews 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 1), are being cited on the attached LIC 9099D.

An exit interview was conducted. The Plan of Corrections were reviewed and developed with Administrator Hazel Gatan. A copy of this report and appeal rights were provided.