Complaint Investigation Report

The schedule shows the Matilija building was normally scheduled with 1 Guide and 1 Lead Guide on the AM, PM and NOC shifts from 08/29/2021 till 09/27/2021. The Lead Guide is the medication-technician (MT) that does the medications for all 3 buildings on each shift. The records show on 08/29/2021 there was no Lead Guide on the PM and NOC shift so the Wellness Care Manager came in to work a shift of 2:00 PM – 7:00 PM for coverage leaving no one at the facility to do medications after 7 PM, on 09/05/2021 the AM shift did not have a Lead Guide scheduled but their was a manger on duty to distribute medications, on 09/06/2021 no Lead Guide was scheduled on the PM shift, on 09/11/2021 no Lead Guide on NOC shift scheduled, on 09/15/2021 no Lead Guide scheduled for the NOC shift, on 09/17/2021 no Lead Guide scheduled, on 09/25/2021 no Lead Guide scheduled for the NOC shift, on 09/26/2021 no Lead Guide scheduled on NOC, on 09/27/2021 no Guide scheduled on the PM shift. On 09/28/2021 the normal staffing schedule now showed 2 Guides on AM/PM and 1 Guide on NOC with 1 Lead Guide for all 3 facilities each shift. The Matilija schedule showed on 10/02/2021 only 1 AM Guide scheduled, on 10/03/2021 only 1 AM Guide and no Lead Guide scheduled on the NOC shift, on 10/04/2021 only 1 AM & PM Guide scheduled, on 10/07/2021 on 1 AM Guide scheduled, on 10/09/2021 only 1 AM & PM Guide was scheduled and No Lead Guides scheduled on the NOC shift, on 10/10/2021 only 1 AM Guide scheduled and no Lead Guide scheduled on the PM shift, on 10/11/2021 only 1 AM Guide scheduled, on 10/14/2021 only 1 AM Guide scheduled, on 10/16/2021 only 1 AM Guide scheduled, on 10/17/2021 only 1 AM/PM Guide scheduled and no Lead Guide scheduled for the PM/NOC with a Manager only working 8AM-5PM, on 10/18/2021 only 1 PM Guide scheduled, on 10/19/2021 only 1 PM Guide scheduled, on 10/21/2021 only 1 AM Guide scheduled, on 10/22/2021 only 1 PM Guide scheduled and no Guide scheduled on NOC, on 10/23/2021 only 1 AM/PM Guide scheduled, on 10/24/2021 only 1 AM/PM Guide scheduled and PM Lead Guide only worked 8PM-10PM, on 10/28/2021 only 1 AM Guide scheduled, on 10/29/2021 only 1 PM Guide scheduled, on 10/30/2021 only 1 AM Guide scheduled, on 11/01/2021 only 1 AM Guide scheduled, on 11/02/2021 only 1 AM Guide scheduled, on 11/03/2021 only 1 PM Guide scheduled, on 11/04/2021 only 1 AM Guide scheduled, on 11/05/2021 only 1 PM Guide scheduled, on 11/06/2021 no NOC Guide scheduled. The Topa Topa Building had a complaint with the same allegation and was substantiated in Complaint #29-AS-20210927103652.

LPA De Leon reviewed Facility staff notes on R1 it was reported on 09/28/2021 R1’s family suspected UTI and asked for a urine sample and push fluids, another note on 09/30/201 staff reported R1 frequency and odor in urine, 09/30 staff note later that day R1’s family worried about R1’s UTI, on 10/01/2021 a note by staff 6 (S6) indicating R1 has UTI and antibiotics are starting tonight.