Complaint Investigation Report

On 06/11/2025, medical records from Adventists Health – Simi Valley were reviewed. Between 07/07/25 and 09/15/25, The Department interviewed current and former facility staff, R1’s Responsible Party (RP) and other relevant parties. R1’s charting notes covering periods from 01/28/25 through 07/06/25 were also reviewed. On 11/26/2025 between 09:30 a.m. to 12:30 p.m., LPA Balisi conducted a subsequent complaint visit. At approx. 09:45 a.m. LPA conducted physical plant tour, interviewed staff and reviewed and obtained additional copies of pertinent documentation relevant to the investigation.

It was reported that due to neglect/ lack of care and supervision R1 had toxic levels of a prescribed medication identified by medical providers. Interviews conducted and records review revealed that R1 was transported to the hospital on 04/21/2025 for evaluation of a skin rash and blistering. During that hospitalization, medical staff identified toxic levels of the prescribed medication Depakote in R1’s system. Hospital discharge instructions directed that Depakote be held, pending follow-up with R1’s primary care provider. Upon R1’s return to the facility, the discharge instructions were provided to facility staff by R1’s family and private caregiver, and staff were verbally informed of the medication hold. On 05/14/2025, R1 was again transported to the hospital, at which time laboratory results showed Depakote levels that were higher than those recorded on 04/21/2025. A review of facility medication records indicated that on 04/28/2025, staff began administering a newly prescribed medication, Keppra, but did not discontinue Depakote as directed in the hospital discharge instructions. As a result, from 04/28/2025 through 05/14/2025, R1 received both Depakote and Keppra. Based on the information obtained during the investigation, the allegation of neglect / lack of care and supervision, related to the continued administration of a medication that had been ordered to be held, has been deemed substantiated at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Executive Director was informed that failure to correct the deficiency may result in civil penalties.

Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided.