Complaint Investigation Report
The investigation revealed the following:
Allegation: Facility failed to ensure a supply of resident's medication.
The detail of complaint alleges that there was a pharmacy change at the facility, and the pharmacy had trouble filling R1’s medication resulting in R1 only receiving 2 out of 9 of R1’ medications.
On October 1, 2025, the Department obtained, reviewed and evaluated R1 Medication Administration Record (MAR) for March 2022, April 2022 and May 2022. Records revealed that all R1's medications, including PRNs were given and properly initialed by staff; no discrepancies found. Additionally, the records reveal there weren’t any lapses in medication administration during the specified time frame as indicated in the complaint.
On October 1, 2025 at 9:35am, The Department interviewed Administrator (A1), who denied the allegation stating there were no reports of R1 missing medication as mentioned in the complaint. A1 went on to state that in the event a resident medication has not arrived due to any issue, the facility's pharmacy will provide them an emergency supply of medication until issue is resolved so that resident is not missing the medication.
On October 1, 2025, between 10:00am and 11:00am, The Department interviewed 4 staff regarding the allegation and of those interviewed, 4 out 4 stated that at no time has R1 missed any of her medication. Additionally, 4 out of 4 stated that medications for all residents are dispensed as prescribed and are on time.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction