Complaint Investigation Report

486803614-6-6-2023-21-AS-CMAZ-CSMVX6-20230609164902

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 1450 NEOTOMAS AVENUE, STE. 100

This is an official report of an unannounced visit/investigation of a complaint received in our office on

05/10/2023 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20230510081951

Medications - medication is not dispensed per physicians orders

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with TJ Ilagan and discussed the allegation and findings. During the course of this investigation, this Department has interviewed witnesses and obtained and reviewed documents, as well as made site visits to the facility. The following determinations are made: R1 was placed at the facility on 3/23/23 from a medical facility; 4 new medications were sent with R1 to the placement; medications previously ordered for R1 were not sent to facility; Facility staff state that both the medical facility and the Responsible Person for R1 were contacted more than once in attempts to obtain the medications for R1; R1 was not administered the previously ordered medication; A Home Health Nurse was ordered to obtain and manage the medications for R1; The order for the Home Health Nurse expired due to a mis-communication by the medical facility and the issue of the prior medication was not addressed. Although the allegation may be true, based on statements and documents, there is not a preponderance of evidence to prove the allegation true or, not true. Therefore, the allegation is UNSUBSTANTIATED.