Complaint Investigation Report

Interview with C1 reported that they never returned to the facility on the night of 7/4/2025. C1 reported returning the morning of 7/5/2025. When C1 returned, C1 walked to the dining room and observed their medication dispensed into a clear cup and administered their medication believing it to be C1’s morning dose of medication. C1 reported that shortly after taking the medication on the dining table, S1 dispensed the morning medication. C1 alleges that they advised S1 of already taking their medication and S1 ignored C1 account and insisted on C1 taking the medication. Interviews with S1 reported that S1 was not made aware of the medication error until C1 advised S1 of what occurred approximately 1 hour after taking the second dosage of medication. Interviews with S1 reported that they immediately informed C1’s responsible person, poison control, and C1’s psychiatrist. S1 and C1 corroborated that staff monitored C1 for 24 hours and were not given their prescribed medication on 7/6/2025 as requested by C1’s psychiatrist. The facility does not maintain documents or written order advising facility staff to withhold the medication temporarily. A records review conducted of C1’s medication administered on 7/5/2025 revealed that C1 was administered the evening medication despite there being an error with the morning medication. Interview with S1 reported that the medication was administered as prescribed on 7/5/2025 as the facility staff did not receive a response with instructions from C1’s psychiatrist and S1 was advised by poison control that the dosage did not merit the situation to be an emergency as it was not a high enough dosage to be considered an overdose. A records review conducted of the facility’s incident reports confirmed S1 and C1’s account of their being a medication error. Although the timeline of when C1 advised S1 of the medication error did not corroborate, there is substantial amount of evidence that confirms C1 was given double dose of their prescription medication due to lack of care and supervision. Through observations, LPA observed sticky note paper on a center piece located on the dining room table. Each sticky note had the clients name along with a small clear container. Interview with C1 verified that medications are dispensed into the clear cup and are left on the table for clients to administer. Therefore, the allegation of staff did not provide an accurate dosage of medication to resident is deemed substantiated.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. California Code of Regulations Title 22 is being cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of the LIC9099, LIC9099C, LIC 9099D, and appeal rights were reviewed and provided to Administrator Makiz Asmatyar.