Complaint Investigation Report

LPA observed that in September 2024 C1 had not received any doses of their eardrops. In April 2025 C1 was given 1 dose of their ear drops for the entire month in the evening on April 1, 2025. LPA observed the MAR which reflected that the ear drops had not been given in May 2025. LPA observed the dosage change for Risperdal from 3mg to 2mg per physician’s orders starting April 1, 2025. LPA observed in May 2025 C1 was receiving both 3mg and 2mg of Risperdal.

During interviews 1 of 2 staff stated that C1 could not get their eye drops due to not all staff being able to sign off on the MAR. Staff #1(S1) informed LPA that according to the MAR it looks as if the medication was not given properly and that they are trying to catch up on the medication. S1 informed LPA that they are not sure what happened and why the medication was missed.

Based on observation, interviews, information gathered during the investigation, and review of all documents obtained, the preponderance of evidence standard has been met. Therefore, the above allegation is deemed SUBSTANTIATED. A deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with AD Leona Smtih and a copy of this report along with 9099-D, LIC811 and appeal rights were left at the facility.