Complaint Investigation Report

547209023-4-17-2026-24-AS-AWAN-DUFTGW-20260526144349

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

11/04/2025 and conducted by Evaluator Les Xiong

COMPLAINT CONTROL NUMBER: 24-AS-20251104154137

Staff did not distribute resident's medication as prescribed

On 04/16/26, Licensing Program Analyst (LPA) L. Xiong arrived unannounced to deliver findings on the above allegations.

During the course of this investigation, LPA conducted interviews and reviewed records.

Upon review of facility records, it was found that on 10/09/2025, facility staff administered 0.5mg lorazepam to R1 at 8:36AM and again at 12:04(PM). Additionally, on 10/10/2025, facility staff administered the same medication to R1 at 7:20AM and 12:28PM. Records revealed that the medication should be administered every 6 hours as needed.

Based on record review, the preponderance of evidence standard has been met, therefore the allegations: Staff did not distribute resident's medication as prescribed is found to be SUBSTANTIATED.

A deficiency is being issued in accordance with California Code of Regulations, Title 22, Division 6 on the attached 9099D.

An exit interview was conducted and a plan of correction was reviewed and developed with Brianna Esquivel. A copy of this report and appeal rights were provided to Brianna Esquivel.