Complaint Investigation Report

that R1's mother decided to remove R1 from this facility on 09/12/2025. It was learned that R1 was going to stay with R1's mother for a brief period, up to 3 weeks, and then return back to this facility at a later date. It was learned that R1 never returned back to this facility once R1 was taken out of this facility on 09/12/2025.

It was learned that R1 was then taken to a local hospital, San Joaquin General Hospital, on that same day where a request was made by the mother for a urine analysis to be performed to reveal if a particular medication was being dispensed and taken by R1.

It was learned that a urine toxicology found that R1 tested positive for fentanyl when this first test was administered in the evening hours, around 10 pm, of 09/12/2025. It was learned that a repeat test was administered for R1 in the early morning hours, around 2 am, on 09/13/2025 and was still shown to test positive for fentanyl.

However, a third urine analysis was conducted on 09/13/2025, around 10 am, in which R1 tested negative for fentanyl at that time. It was learned that R1 was admitted for experiencing a possible seizure which was later determined to be a muscle spasm. The health records noted that R1 was deemed to be stable and later discharged that same day around 12 pm.

It was learned that urine analysis were often times unreliable and prone to false positives and false negative results. It was learned that if R1 truly had fentanyl in R1's system then all (3) tests would have been positive for fentanyl for that span of time. It was learned that fentanyl remained in a person's system and drug screens could detect drug use for up to 3-5 days after they were initially taken.

It was learned that even though the resident tested positive initially for fentanyl but then tested negative several hours later might have indicated that likely the first results were false positives. It was learned that if the resident truly had fentanyl in R1's system then the third drug screen would still have tested positive at that time as well.

Based on a review of the forms and documents gathered during this investigation, it was learned that R1 took a total of (7) medications while residing at this facility. A review of the Medication Administration Record, dated 09/01/2025, displayed all (7) medications with a change in medication document, dated on 09/09/2025, by the attending licensed medical professional for R1 showing all (7) medications as being prescribed and authorized to be dispensed to R1 while a resident at this facility.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred.

There were no deficiencies observed or cited during today's complaint visit at this time.