Complaint Investigation Report

During an audit of the clients medication inventory on 04/25/2025: LPA verified that Medications were on-hand for all clients. Client 1 (C1) had an evening medication that had not been given correctly.

A review of records and interviews of staff showed that the medication was an active prescription for C1. Licensee’s staff last gave C1 their medication dose the evening on 04/20/2025. LPAs observation showed that C1 missed their medication from 4/21/2025 through 04/24/2025. (A total of 4 days) until LPA’s involvement on that day.

Per interviews with staff, they did not know why C1 had not been receiving their evening medication which was also initialized in the MARs as given. LPA observed that the medication was designed to treat Cholesterol. Interviews with outside source revealed that when C1 visits home they are given their medications that they get from the facility when C1 leaves. Interviews with C1 revealed they get their medications and when they make home visits they are given their medications from the staff and their family assists them at home with the medications.

Based on LPA observation, records, and interviews, a preponderance of evidence exists to show that staff are not distributing residents' medications as prescribed. The allegation is therefore Substantiated. A deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page).

An exit interview was conducted with Ayad George, Operator, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.