Complaint Investigation Report

LPA interviewed four (4) staff regarding this allegation. Staff acknowledged that the medication error occurred in house #1 (#10746) for Client #1 (C1). Staff stated that when they administer medication, they call the client one at a time. Staff stated they do not dispense medication into a pill box. Instead, staff dispense the medication into a small cup and hand it to the client to take. After the medication is completed, staff will initial the Medication Administration Record (MAR). Staff indicated that they submitted a special incident report to Licensing and Regional Center regarding this medication error. LPA reviewed the incident report provided, and the report stated that on 6/25/26, at approximately 8pm, staff accidentally administered another dose of C1’s bedtime cycle medications after it was already given. Staff immediately realized the mistake and transported C1 to the hospital for evaluation. C1 remained stable and was discharged back to the facility the next day.

LPA observed that medications are centrally stored and locked in a white cabinet in the dining area. LPA reviewed six (6) clients’ medications and did not find any discrepancies. Five (5) clients interviewed stated they receive their medication daily from staff. Based on information gathered, staff keep the medications locked at all times and do not pre-dispense medication into a pill box ahead of scheduled times. Clients do not have access to the medications for overdosing.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Staff N. Centeno. A copy of this report, along with the appeal rights, was provided.