Complaint Investigation Report

The investigation revealed the following: regarding the allegation “ Staff did not administer medication to a resident in care .” It is alleged on 10/07/2025, C1 was not administered their medication. One (1) out of one (1) staff interviewed corroborated this allegation. Review of Eastern Los Angeles Regional Center Corrective Action Plan (CAP) dated 10/30/205 and Vendor Special Incident Report for C1 dated 10/08/2025 corroborated this allegation. Review of Vendor Special Incident Report for C1 dated 10/08/2025, revealed on 10/07/2025 during the PM medication pass, S2 did not administer C1’s scheduled PM medication of Benztropine MES 1mg tablet and Lisinopril 5mg. On 10/08/2025, Eastern Los Angeles Regional Center staff was conducting a Quality Assurance inspection and discovered these medications were still in C1’s medication bubble pack even though S1 indicated on the MAR that these medications were administered to C1 the night prior. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated .

“Staff did not properly manage residents P&I funds.” It is alleged staff did not properly manage Personal and Incidental (P&I) funds for C1, C3, C4 and C5. One (1) out of one (1) staff interviewed corroborated this allegation. Review of Eastern Los Angeles Regional Center Corrective Action Plan (CAP) dated 10/30/205 and Vendor Special Incident Report for C1 dated 10/08/2025 corroborated this allegation. Review of C1, C3, C4 and C5’s Record of Client’s/Resident’s Safeguarded Cash Resources corroborated this allegation. Interview with S1 revealed that in October and September of 2025, S2 took the clients out into the community to purchase items at local retail store. S2 did not ensure clients purchased their own items individually, obtain a receipt for each client’s purchase and commingled the clients’ monies to complete one group purchase. S1 revealed S2 did not follow facility staffing procedure on disbursement and safeguarding of clients P&I monies. On 10/08/2025, Eastern Los Angeles Regional Center staff were conducting a Quality Assurance inspection and discovered money shortages for C1, C3, C4 and C5’s Record of Client’s/Resident’s Safeguarded Cash Resources. C1 was owed $22.21 for a purchase made on 09/23/25, C3 was owed $32.91 for purchase made on 09/01/25 and $22.21 for a purchase made on 09/23/25, C4 was owed $22.21 for a purchase made on 09/23/25, C5 was owed $22.21 for a purchase made on 09/23/25 and C6 was owed $22.21 for a purchase made on 09/23/35. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated .

One (1) type A deficiency is being cited for this complaint investigation. A copy of this report, 9099-D and appeals rights was provided.