Complaint Investigation Report

During visit conducted on April 22, 2025, LPA conducted a medication count for residents R1, R2, and R3, comparing the residents’ Centrally Stored Medication Forms (CSM) with medications centrally stored for the residents. LPA observed one (1) medication for R1 to be over the amount documented in R1's CSM. Facility was unable to provide any documentation to explain why R1's medication was over the amount documented. LPA observed Medication Administration Record (MAR) for R1, which indicated that medication was administered every day since start date documented and no tabs were missed. LPA observed one (1) medication for R3 to be over the amount documented in R3's CSM. Facility was unable to provide any documentation to explain why R3's medication was over the amount documented. LPA observed MAR for R3, which indicated that medication was administered every day since start date documented and no tabs were missed. LPA observed CSMs for R3's medication dating back to November 2024 and observed that R3's medication had gaps of several days between each refill. Facility was unable to provide documentation to explain the gaps of several days in which R3 was not provided medication between each refill.

Based on a medication count, observation, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. A civil penalty in the amount of $250 is assessed for April 23, 2025 for a repeat violation within 12 months of a prior violation of a statutory or regulatory provision designated by the same combination of letters or numerals per Health and Safety Code §1548.

Exit interview was conducted with ED. A copy of this report and appeal rights were provided. ED's signature on these forms acknowledges receipt of these documents.