Complaint Investigation Report

Per review of LIC 624 Unusual Incident/Injury Report received on May 01st, 2026 for an incident that occurred on April 26th 2026 it was reported that staff was passed incorrect medication during evening med pass at 9:03pm. Client 2 was supposed to receive half tablet of Remeron/Mirazapine (7.5mg) and instead received half tablet (1mg) of Rexult/Brexpiprazole. Per report nursing team was made aware of the issues and staff has been provided re-training for medication administration.

Therefore based on the preponderance of evidence through records reviewed the allegation that Staff are not providing clients with their medications as prescribed is determined to be SUBSTANTIATED, meaning the complaint allegations are valid and that a violation has occurred.

Based on above findings deficiencies are being cited per California Code of Regulations Title 22 Division 6 chapter 8.

An exit interview was conducted and a copy of this report was provided.