Complaint Investigation Report

Brief discussion with C1 while LPA and QAS were sitting at the dining table on 8/13/25, LPA noted that C1 was slurred in their words and could be unclear. C1 was able to carry on a conversation and even told a couple of jokes during this discussion, showing that while their speech may have been slurred, they were aware, awake, and able to communicate.

In reviewing the allegations, a prior Incident on 7/9/25 was noted by LPA where facility gave C1 their bedtime medication at 4:40 pm, one medication was Trazadone, one was Melatonin. Facility then took C1 to a community club meeting and left C1 without facility staff supervision. Before and during the meeting, per an interview with Witness 1 (W1), C1 was lethargic, unable to carry on conversations, and could not stay awake. W1 stated this was not normal behavior for C1 who usually participates in the meetings.

An incident report was submitted by the facility for this event, facility substantiated the medication was given early and provided the 4:40 pm notation on their report but claims that C1 asked for the medication early. Interview with administrator on 7/10/25, administrator stated the facility did not know that C1 had a meeting planned and that C1 asked for their bedtime medication early. LPA reminded administrator during initial conversation that C1’s Physician Report states that C1 is “unable to manage medications” therefore it is the responsibility of the facility staff.

During visit on 9/25/25 LPA confirmed that Trazadone order states “Take one tablet by mouth at bedtime.” The melatonin bottle which is a non-prescription medication states “Sleep Support” on the bottle. Despite the request of C1, staff cannot dispense medication against the doctor’s order and should not have left C1 unattended in the community knowing that C1 had medication intended to help C1 sleep.

Based on interviews and record reviews, the incident on 7/9/25 showed the facility did miss handle medication in giving a bedtime medication at 4:40 pm in the afternoon, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED .

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D).