Complaint Investigation Report

306006472-4-9-2026-22-AS-APAO-DT44LE-20260412191147

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 770 THE CITY DR., SUITE 7100

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

09/23/2024 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20240923110559

Facility gave resident another resident's psychotropic meds which resulted in hospitalization

Licensing Program Analyst (LPA) Kimberly Lyman conducte an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.

During the course of the investigation, the department reviewed and obtained pertinent documentation such as facility notes. Regarding the allegation that facility gave resident another resident's psychotropic meds which resulted in hospitalization, the investigation revealed the following: Facility self reported an incident on 09/04/2024 where Resident 1 (R1) was incorrectly given another resident's Seroquel, Risperidone, and Lorazapam. R1 was transferred to Mission Hospital for observation and remained admitted until 09/08/2024. Facility notes indicate Mission Hospital stated there were no adverse effects from the medication error. Staff 1 (S1) was provided a written warning from the facility. Review of records showed the staff had received medication training from the facility. Based on record review, the preponderance standard has been met. Therefore the allegation is deemed substantiated. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of the report provided as well as appeal rights.