Complaint Investigation Report

374604261-5-26-2023-08-AS-DPOL-CV5TQD-20230828145545

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 7575 METROPOLITAN DR. #109

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

06/12/2020 and conducted by Evaluator Tiffany Holmes

COMPLAINT CONTROL NUMBER: 08-AS-20200612121300

Staff mishandled resident's medication while in care

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to close out a complaint. LPA identified herself, was granted entry, and stated the purpose of the visit to Lynn Torino, Assistant Administrator . During the investigation, LPA toured the facility, conducted interviews and conducted a records review.

It was alleged staff mishandled resident's medication while in care. Interviews revealed that staff assist the residents with their medications. Interviews revealed Resident 1 (R1) recieves a medication that is based on their bloodwork. This means that either the medication will increase/decrease or stay the same amount after the bloodwork is reviewed. A review of the Medication and Administration Record (MAR) revealed an inconsistency in the resident recieiving their medication for the day of June. 30, 2020. Records show an empty space where staff initials should be once a medication is given to the resident. Interviews with staff did not reveal a reason on why the resident was not given their prescribed medication for that day. Interviews with staff revealed that if the resident refuses their medicaton it is marked with an R for refused. There is evidence that staff mishandled resident's medication while in care.

Based on the evidence obtained from the investigation, the above-mentioned allegation is substantiated. An exit interview was conducted with Lynn Torino, Assistant Administrator and a copy of this report and Licensee Rights (LIC 9058 03/22) was provided at the end of the visit.