Complaint Investigation Report

247209026-5-15-2026-24-AS-SMOA-DU8LLQ-20260519085130

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

This is an official report of an unannounced visit/investigation of a complaint received in our office on

05/01/2026 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 24-AS-20260501091427

Staff mismanaged residents medication records

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on the allegations lsited above. LPA met with Licensee, Lindsey Lamerson and explained the purpose of today's visit.

Regarding the allegation that staff mismanaged resident’s medication records, Licensing Program Analyst (LPA) Sarah Hurt conducted interviews and reviewed facility records including physician orders, over the counter PRN medication administration records, medication logs, and additional documentation maintained by facility staff regarding physician notification for over the counter PRN medication administration. LPA reviewed multiple over the counter PRN medication administration records maintained by the facility for the resident. Records reviewed documented over the counter PRN medications administered for symptoms including pain, anxiety, and other symptoms. LPA reviewed handwritten documentation maintained by the facility reflecting staff communication with the house manager and/or physician regarding over the counter PRN medication administration. Documentation reviewed reflected the facility maintained an internal process in which staff notified the house manager and/or physician when over the counter PRN medications were needed for the resident.. LPA identified documentation deficiencies within the PRN medication records. LPA observed several entries on the over the counter PRN medication administration records which contained incomplete documentation including missing times, incomplete results documentation, missing follow-up entries regarding effectiveness of medication administration, and inconsistent documentation regarding symptom resolution following administration of over the counter PRN medications. LPA did not observe evidence indicating the resident suffered harm related to the medication administration practices reviewed. However, the facility failed to ensure over the counter PRN medication records were consistently and accurately completed as required. . Based on interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The following deficincies are being cited Per title 22 regulations.

Exit interview conducted with Licensee, Lindsey Lamerson and copy of report provided along with appeals rights provided.