Complaint Investigation Report

Per Client #1 (C1)'s MAR for April 2025, Quetiapine is intended to be given by mouth every 6-8 hours as needed and should not exceed 4 tablets within 24 hours. Based on the review, it appears that C1 was given at most three times day, in the morning, noon, and bedtime. The second dose if needed was intended to be administered at least six hours after the first dose in the morning, however the dosing interval was inadequately spaced. Other medications that were not administered the entire month of April 2025 includes, Mucus Relief ER 600 mg tablet and on May 1st, Multivitamin tablet, Certrizine HCL 10 mg tablet also in May 1st, Eye Itch Relief 0.025% drops, Fluticasone Drop 50 MCG Spray was only applied for two days out of the month, and FT Allergy Relief 3-24 hour tablet. For the month of May 2025, Polyethylene Glycol, and Vyvance 20 MG Capsule were also not administered. Three out of the three staff interviewed acknowledged the errors after the audit and one out of three clients did not corroborate the allegation. Interviews with the remaining two clients were unsuccessful.

Therefore, based on observation, interviews, and record review, the preponderance of evidence standard has been met, therefore the following allegation, Facility did not administer medication as prescribed is deemed SUBSTANTIATED as per the Title 22 California Code of Regulations. Refer to the attached LIC9099D.

An exit interview was conducted with Administrator Laura Palomino, and a copy of this report including the LIC811, and the appeal rights were provided at exit.