Complaint Investigation Report

496802052-10-3-2024-21-AS-VBEI-D9UT7R-20241008142908

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SANTA ROSA RO , 1450 NEOTOMAS AVENUE, STE. 100

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

08/01/2024 and conducted by Evaluator Christi Coppo

COMPLAINT CONTROL NUMBER: 21-AS-20240801170623

Facility not administering medication per physician orders, neglect resulting in resident death

At approximately 9:00AM, Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings regarding the above allegation.

Facility not administering medication per physician orders, Neglect resulting in resident death – Complaint alleges that resident, R1 was given an incorrect medication causing R1 to require emergency intervention and eventually passing away at the hospital. Statement from Licensee indicated that they misspoke when reporting to emergency personnel and the resident was not given an incorrect medication. Review of medical records do not show that an overdose was a reason for or contributed to R1’s death.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.