Complaint Investigation Report

LPA found bubble pack with some medication left in it and licensee confirmed the resident R1 received some of their medication, but does not understand what happened or why medication mentioned above was not provided to R1.

It was also alleged staff are not maintaining resident's medical records as required. LPA requested to view 5 resident files on 9/14/2021, and licensee, Evelyn Serrano informed LPA, she did not have the medical records, Physicians reports for 2 residents, R2 and R3.

Based on LPA’s observations, review of medications and record review of 9/14/21 and today 9/22/21, the preponderance of evidence standard has been met, therefore the allegations for staff are not administering medication(s) to resident as prescribed by their physician and staff are not maintaining resident's medical records as required are both found to be SUBSTANTIATED.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights and this report will be emailed to facility due to printer problems.