Complaint Investigation Report

LPA Steve Chang interviewed Staff S1 and S2. Staff S1 stated R1 needs to use insulin and can administer it him/herself. S1 stated the facility he/she communicated with R1’s Family Member (FM) when he/she visited the facility.

S2 stated R1 is forgetful recently so it is difficult for R1 to do the insulin injection because he/she cannot adjust the volume of insulin. S2 stated home health also stated R1 might not be able to do insulin by him/herself. S2 stated he/she discussed with hospital social worker about R1's insulin injection problem. S2 stated the facility told R1's family that R1's family needed to come to the facility to help R1's insulin injection 3 times per day if R1 returns to the facility.

On December 22, 2025, LPA Manuel Monter interviewed R1’s Family Member (FM). FM stated R1 had gone to the hospital, and they were going discharge R1, But FM was informed that the facility was concerned about R1 taking his/her insulin. FM stated she was informed by the facility that there wasn’t a person who would be able to administer the insulin. FM stated he/she was informed by the facility that R1 wasn’t administering his/her medication consistently and was having trouble. FM stated that it wasn't true that R1 could not could administer his/her own medication and believed it wasn't an issue. FM stated he/she can’t say there wasn’t communication regarding R1's eviction. FM stated they were not actively communicating with him/her. FM stated the facility didn’t help him/her with R1’s new placement. FM stated he/she wasn’t provided with an eviction letter.

On December 22, 2025, LPA Manuel Monter interviewed ADM Davina Fernandez. ADM stated regarding R1; he/she was sent to the emergency room on July 28, 2025. ADM stated based on a conversation with the case manager of the hospital, R1 would require a higher level of care. ADM stated the issue at hand was R1’s ability to administer his/her insulin. ADM stated R1 needed to administer his/her own insulin 3 times a day. ADM stated R1 had days when he/she was not able to administer his/her own insulin. Furthermore, since R1’s hospitalization, R1 had become weaker and the issue of insulin administration would persist. ADM stated if R1 got sick or was unable to administer his/her own medication, the facility would not be able to administer his/her insulin.

ADM stated they don’t have a licensed professional to administer the insulin. ADM stated the facility was not able to meet the needs of the R1, since he/she was not able to administer his/her own medication. ADM stated R1 was not evicted, ADM stated R1 was just needed to be moved to a facility that was a higher level of care and FM agreed and choose to move R1 to another facility. Page 2 Out of 6.