Complaint Investigation Report

547200844-3-6-2026-24-AS-SMOA-DSWU26-20260407151121

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

03/03/2026 and conducted by Evaluator Kamaldeep Kaur

COMPLAINT CONTROL NUMBER: 24-AS-20260303131432

Staff did not administer residents medication in a timely manner.

Staff do not keep an accurate medication log.

Licensing Program Analyst (LPA) K. Kaur arrived at the facility for initial 10-day complaint inspection. Administrator was unavailable to meet. LPA met with Resident Care Director Brittney Polman and explained the purpose of the visit and reviewed the elements of the allegations. LPA delivered the following complaint investigation findings.

The Department investigated the allegations listed above. Based on observations, interviews conducted and records reviewed, the facility med-cart keys were locked in the cart on 03/2/2026 in error. Staff did not administer residents’ medication in a timely manner. The facility was unable to open the med-cart until 3/3/2026 6 AM. Residents R1 – R6 did not get 3/2/26 night medications. During Medication review facility discovered Staff were not keeping a log of medications in the Centrally Stored Medication and Destruction Record.

The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. See citations on the attached LIC9099D. Repeat Civil penalties assessed. Exit interview was conducted with Resident Care Director and appeal rights were provided.