Complaint Investigation Report

The investigation revealed the following: In regards to the allegation that there was a "Medication Error," it is alleged that on 2/22/2024 the medications for C1 were reviewed, and it was discovered that their medications were still in the bubble pack for the date of 2/21/2024, and the MARs was incorrectly marked indicating that the medication was provided to C1. During interviews with the clients, zero (0) out of four (4) corroborated the allegations that they have experienced any medications errors while living at the facility. LPA attempted to interview C1 regarding the allegation, however they are currently hospitalized. During interviews with the staff, two (2) out of four (4) corroborated that there was a medication error that occurred on this date. One staff interviewed stated that it was discovered on this date the evening medications were mistakenly not provided to C1, and that training was subsequently conducted in order to ensure that staff understand how to properly distribute medications to the clients. Another staff interviewed confirmed that training was conducted in response to the incident to ensure that it does not occur again. During record review of the CAP from ELARC, it explains how medications signed off on the MARs as if it were distributed however was still found in the bubble pack, and details the retraining that will be conducted amongst the staff in response to the incident.

Based on LPA interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED . California Code of Regulations Title 22, Division 6, Chapter 1 is being cited on the attached LIC9099D.

Exit interview held administrator Brenda Venegas. Exit interview was held and a copy of the report along with the appeal rights were provided.