Complaint Investigation Report

LPA reviewed internal facility medication reports dated December 2023 through March 2024. LPA discovered medication errors involving GERD medication on the following dates 12/21/23 and 12/22/23. It should be noted that these medication errors were not reported to CCL.

LPA interviewed Operations Manager (OM) who stated that she recently "took over" for the previous OM. OM stated that she has discovered that the facility was not submitting incident reports to CCL as required. OM stated that as of now when a medication error occurs the staff are to inform "quality control" staff member of the error and also fill out an incident report which is then submitted to CCL. OM stated that she implemented a new "health and safety" binder which contains all of the medications errors by date. OM stated that all of the medication errors are also uploaded to the clients chart.

It was alleged that Licensee did not ensure that staff had a criminal record clearance. It was reported that a staff member was working at the facility without a finger print clearance. LPA reviewed the background clearance status for all of the staff members employed at the facility. The records indicated that all staff members had undergone the necessary criminal background checks and fingerprint clearance as required by licensing regulations, with the exception of two employees. The “start dates” of two employees were determined to be prior to their criminal record clearance. The Licensee could not provide documentation indicating that the staff members started after they received their criminal record clearance

It was alleged that staff did not treat clients with dignity. It was reported that the Operations Manager (OM) was rude and a bully towards clients in care. LPA interviewed Client 1 (C1) ( an LIC 811 Confidential Names List was provided to the facility representative to identify the client) who stated that they lived at the facility January 2024 through February 2024. C1 stated that OM was a difficult personality and OM would come off as very abrasive and condescending. OM was often rude and rejected all C1 requests for things that would have improved C1’s experience at the facility.

The current Operations Manager stated that she was asked to move over to the Rancho Santa Fe facility and although she did not have details as to what happened she was informed that their were some complaints regarding the previous Operations Manager specifically about her attitude towards other people.