Complaint Investigation Report

therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Complaint alleges staff does not ensure resident's showering needs are being met. During investigation, LPA reviewed R1’s physician report in which it states that R1 is at risk if allowed direct access to personal grooming and hygiene items as well as having a lack of capacity to bathe or dress/groom themselves. Additionally, R1 is non-verbal and cannot refuse showers. During investigation, Admin indicated to LPA that R1 gets bed baths every day and that R1 gets showered two [2] times per week, but that showers occur on random days of the week. During investigation, LPA reviewed facility shower logs from 4/1/25-4/30/25. LPA review of shower log indicates that R1 was only showered three [3] times in the month of April on 4/12, 4/19, and 4/27. Based on LPA’s interview and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Complaint alleges staff mismanages resident's medication log. Complainant states that resident's medications are not being documented in the medication log each time the resident is being administered a medication. During investigation, LPA reviewed R1’s physician report in which it states that R1 is not able to administer their own medications or communicate their needs. During investigation, LPA reviewed Medication Administration record (MAR) for R1 and current physician’s medication orders for R1. LPA observed incomplete MAR records for both R1’s prescription and PRN medications. Admin acknowledged incomplete MAR records. Additionally, facility did not list the time at which any PRN medications were administered, as required per regulation 87465(d)(3), So, based on LPA’s interview and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given .