Complaint Investigation Report

Interview with S1 stated they were called by a police officer to make them aware there was no one available to administer medications. S1 stated they arrived at the facility at 8:45pm that day and finished passing medications at 9:30pm. One out of the remaining seven staff stated they have observed medications on the floor during their shifts. One out of the remaining six staff stated they have observed medications in residents' hands from a previous medication pass. One out of the remaining five staff stated there are no med techs that work on weekends. Two out of the remaining 4 staff stated they have not observed residents not given their medications. One out of the two remaining staff stated they assist residents with medications as prescribed. The remaining staff did not add anything relevant to the allegation. LPA attempted to interview R2 but was unable to qualify for the interview.

LPA reviewed a copy of the Costa Mesa PD log for the incident which stated "Per caregiver onsite the med tech did not respond like they were supposed to at 1400 hours no patients recieved memory care medications she tried calling the managers but no answer was able to reach employee (S1) who said would respond with 30 min eta and give medication per (S1) this was a scheduling error on managers behalf and has not happened in the past 5 years of his employment [12/07/25 18:28:49 Unit:322]". LPA conducted medication audit for R2 during the initial visit on December 16, 2025 which revealed seven medications that were marked as administered in the facility's electronic medication administration record (eMar) were physically still present in R2's medication bubble packs for multiple days. Staff could not account for discrepancies. LPA documented the seven medications and eMar via photographs.

Based on interviews conducted, observations, and record review, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.

California Code of Regulations, (Title 22, Division 6), is being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of the report was left with the facility representative along with appeal rights.