Complaint Investigation Report

331880967-8-11-2023-18-AS-MVAO-CVKQNX-20230911121947

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 1650 SPRUCE ST STE 200 MS29-27

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

08/07/2023 and conducted by Evaluator Janira Arreola

COMPLAINT CONTROL NUMBER: 18-AS-20230807084041

Licensee/ Administrator, Regina Holmes-Otto

Staff are mismanaging resident's medication(s).

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Licensee/ Administrator, Regina Holmes-Otto, who was informed of the purpose of the visit. During the visit, LPA conducted interviews, documented observations, and conducted records reviews.

It was alleged the facility was mismanaging the resident's medications. LPA interviewed the licensee who stated that they had provided another resident's medications to Resident #1 (R1) when they were discharged from the facility. Licensee stated they had R1's medication as well as Resident #2 (R2)'s medication on a table in the kitchen, and stated they had grabbed one of R2's medications and placed them with R1's medications by mistake. LPA observed R2's medication on the kitchen table during the time of the visit. LPA had licensee lock the medications immediately. Therefore, the allegation that the licensee mismanged the resident's medication is substantited.

Substantited findings were cited under California Code of Regulations Title 22. Plan of correction was created with licensee. An exit interview was conducted where this report was reviewed and provided to licensee Regina Holmes- Otto, along with deficency page, 811 and appeal rights.