Complaint Investigation Report

306006204-3-30-2026-22-AS-AORZ-DSWNVZ-20260407104843

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

03/24/2026 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20260324083753

WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVING

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into 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, LPA interviewed staff and resident as well as reviewed and obtained pertinent documentation such as medication orders. Regarding the allegation that staff mismanaged resident's medication, the investigation revealed the following: Resident 1 (R1) admitted into the facility late on March 19, 2026. R1 came from a hospitalization at Chapman Global Medical Center and arrived without clothing or medications. Medication orders were sent out and medications were received from the pharmacy at 6:30 PM on evening of March 20, 2026. Resident was sent out via 911 at 6 AM on March 21, 2026. Review of medication administration record shows resident is prescribed seven medications to be administered at 8:00 PM and did not receive those medications on the 20th. 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.