Complaint Investigation Report

The investigation revealed the following:

Allegation: “Staff mismanaged resident medication.” I t is alleged that during an unannounced visit by the Regional Center multiple discrepancies in medication administration were observed, including missing medications from the blister packs and medication being dropped and replaced with doses from the following day's blister pack without proper documentation. Administrator was interviewed and corroborated the allegation. During Regional Center's initial unannounced visit to the facility on June 25, 2025, Administrator stated that Regional Center discovered discrepancies in medication administration for R1-R2 , including missed medications in the blister packs and medications that were dropped and replaced with doses from the following day's blister pack without proper documentation. Following the instructions of the Regional Center, the Administrator stated that they filed an incident report with CCL and the Regional Center on the same day. The Regional Center conducted an unannounced follow-up visit to the facility in July 2025 after reviewing discrepancies in the reports submitted for R1–R2. The Administrator explained to them the reasons behind the identified medication issues via email correspondence. The administrator has agreed with the Regional Center’s findings, as stated in the Corrective Action Plan (CAP) dated 08/07/2025, and has signed and stated they would comply with it, supporting the allegation.

Allegation: “Staff did not follow reporting requirements.” It is alleged that the facility failed to report incidents concerning multiple medication administration discrepancies for R1-R2. Administrator was interviewed and corroborated the allegation. Administrator stated that they submitted the incident report to CCLD and the Regional Center following the Regional Center’s instructions during their visit to the facility in June 25, 2025. Administrator indicated that the incident report should have been submitted right after the staff noticed the errors/discrepancies, but they had failed to do so. Based on the interview and the Corrective Action Plan (CAP) dated 08/07/2025 (agreed & signed by the Administrator), the allegation has been substantiated.