Complaint Investigation Report

Interview with Administrator revealed that on June 29, 2025, C1 was hospitalized for stroke-like symptoms. Administrator also stated that on July 1, 2025, facility recording from June 29, 2025, revealed that S1 was observed issuing C1 multiple medications and a few hours later, C1 was heard slurring speech and could not hold body upright. Statement from C1 established that C1 recalls being issued incorrect amount of medication by S1. Medical records established that C1 was diagnosed with lethargy and slurred speech could be a result of medication error as other tests were negative. S1 records reviewed revealed S1 was up to date with medication management training. After the incident, Administrator reported the incident to primary care provider, CCL and terminated S1.

Based on interviews conducted and records reviewed a preponderance of evidence exists to support the allegation. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted and a copy of this report, LLIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Administrator and signature on this form confirms receipt of documents.