Complaint Investigation Report

Continued from LIC9099...but no vendor actions noted with follow up date of 8/4/26. The facility provided LPA with pharmacy order for medication Levothyroxine Sodium 175mg one tablet in the morning on empty stomach and no food for 30 minutes after, the last filled prescription was on 9/24/25, but centrally stored medication and destruction report dated 9/24/25 through 10/16/25 includes date filled only and there is no record of when the medication was started or expiration date of prescription. The facility was unable to provide proof that they have been assisting R1 with prescribed medication and Licensee stated that they will assist C1 with medication, but there was no indication that Licensee will give Levothyroxine according to prescriptions instructions. According to C1’s physician report (LIC602) dated 4/7/26 indicates C1 is non-ambulatory with a diagnosis of dementia with higher risk of falls, hypothyroidism and needs assistance with medication management. LPA obtained C1’s individual program plan (IPP) dated 4/15/2026 confirms that C1 has a diagnosis of hypothyroidism with endocrinologist follow ups needed every six months to perform labs. Based on records review, C1 needed consistent medical care to support their medical needs including thyroid prescribed medication according to their physician’s direction due to C1 do not have a thyroid, which there was no indication that the facility assisted C1 with medication management as directed by their physician. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

Regarding the allegation of Personal Rights. The Reporting party alleges that after the facility has knowledge of client’s (C1) diagnosis of dementia, the facility is engaging in conduct that escalates C1’s emotional distress by making them subject of verbal interactions that upset C1 to the point where C1 developed self-harm behaviors. These documented self-harm behavioral incidents have resulted in a 30-day eviction notice issued to C1. Per reporting party, the placement agency was made aware of photographs of C1’s bruises as a result of a fall, but they have not provided guidance regarding safe placement alternatives. On 5/14/26, LPA conducted 10-day visit to the facility, made observations, reviewed records and conducted interviews with staff and clients in care. Based on interviews with the Licensee confirmed that they have made comments to C1 about whether their loved ones won’t have a desire to be around them due to their behavior but deny that their comments have triggered C1’s emotional distress. On May 15, 2026, the department received a revised written lawful 30-day eviction notice issued to C1 due to failure to comply with the general facility policies with effective date of June 14, 2026. However, on May 20, 2026, LPA learned that C1 was residing with them after another incident of fall occurred resulting in C1’s hospitalization, where C1 will be residing until their relocation process is safely completed. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations is cited on the attached LIC 9099D. Appeal Rights Given.