Facility Evaluation Report

On August 30, 2021, Licensing Program Analyst (LPA) Chris Arnhold conducted an unannounced case management visit to follow up on a substantiated allegation pertaining to a client (C1) failure to receive medication.

On June 29, 2018, the Department concluded a complaint investigation which alleged that the licensee allowed client’s medication to run out which resulted in C1’s hospitalization from April 9, 2018 to April 25, 2018.

The allegation was substantiated, and the licensee was cited for violating the California Code of Regulations (CCR) Title 22, § 80075(b) for Health Related Services, which requires that “ Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.” C1 did not receive C1’s medication.

The investigation revealed that C1 had an admission agreement with the facility date January 17, 2018. The Admission Agreement notes under section 2(d) indicate “Assistance as needed with taking prescribed medications in accordance with physician’s instructions unless prohibited by law or regulations”. C1’s Physician’s Report dated January 16, 2018, lists the above three medications among other medications. The Medication Administration Record (MAR) for March was also reviewed and showed one medication (Metoprol) with the last dose given on March 1, 2018, with the notation “DC (discontinued)”. Two other medications (Glipizide and Lovastatin) last doses were March 2, 2018. Glipizide with the notation “prescription was not renewed on March 1, 2018” and Lovastatin with the notation “DC (discontinued).” Multiple staff and witness interviews were conducted, and pharmacy records were reviewed. The investigation revealed that C1’s medications were arriving on a weekly basis until staff noted that the pharmacy did not refill the medications in March 2018. Facility staff (S1) informed LPA during an interview on April 17, 2018 that S1 attempted to contact C1’s responsible party (RP) and a message was left on RP’s cell phone and work phone. S1 never heard back from responsible party so it was assumed the medication was discontinued. C1’s responsible party stated that they did not receive a call or message from S1. Continued on LIC89-C...