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32 | ****This report supersedes the original complaint investigation report dated 12/19/2025 to update important information. Investigation findings remain the same. ****
This investigation was completed by Investigator Bendana with the Investigations Branch and revealed the following:
Allegation: Staff did not seek medical attention to resident in a timely manner. It is alleged that staff failed to seek medical attention in a timely manner for R1 when they had elevated blood sugar. Interviews conducted and records showed R1 had elevated blood sugar throughout various days. Administrator and staff stated that they notified P1's office whenever R1's blood sugar was high. Per P1, most of the communication was done through fax. The facility failed to seek medical attention when R1’s blood sugar was 480, 531, 467, 393, 424, or 328. R1 was described to be difficult who did not follow their diet. The facility did not seek medical attention when R1’s blood sugar was high; the facility would fax P1 with R1 blood sugar reading. When R1 was discovered, the facility contacted P2, who instructed them to call 911. The investigation provided sufficient evidence to substantiate neglect/lack of care against Administrator. Based on the totality of circumstances the facility did not seek medical attention in a timely manner when R1’s blood sugar was elevated; therefore, the allegation is substantiated.
Allegation: Staff mismanaged resident's medication. It is alleged that staff mismanaged medications for R1 by not providing R1 prescribed medication and by providing R1 with unprescribed supplements. Interviews conducted and records showed R1did not receive prescribed medication from 11/16/2024 to 11/19/2024. The MARS provided in the service request with date of 11/2024 showed R1 did not receive medication from 11/16/2024 to 11/19/2024. Administrator provided a computerized Medication Administration Records (MARs) which may have been altered to include medication disbursement from 11/16/2024 to 11/19/2024. P1 reported R1 family did not pay for their medication and owed the pharmacy. Also, P1 disclosed R1 family wanted R1 off their medication at one point. Medication reports indicated R1 received their medication when it was filled. P2 reported there was an issue with R1’s prescription due to an outstanding balance. And with regards to providing R1 with unprescribed supplements, records showed R1 was provided B-complex without it being prescribed by P1. Staff reported they initialed the medication report, for when B-complex was disbursed, because B-complex was on the list. Staff claimed they did not provide R1 with B-complex because it was not on the medication cart. Nevertheless, Administrator nor staff were able to explain why they would initial a medication/supplement that was not disbursed. The investigation did provide sufficient evidence to substantiate neglect/lack of care against Administrator. Based on the totality of circumstances, the facility did not provide R1 with their prescribed medication and provided R1 with an unprescribed supplement; therefore, the allegation is substantiated.
Based on statements and interviews conducted by the Investigations Branch as well as reviewed files and documentation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.
Due to the closure of the facility on 12/01/2025 initiated by the Licensee, a copy of this report along with the Appeals Rights will be emailed to the former Licensee's information on file. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
01/12/2026
Section Cited
CCR
87468.2(a)(4) | 1
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7 | 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities ..(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidenced by:
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7 | Licensee/Administrator to ensure that care, supervision, and services are delivered by staff that are sufficient in numbers, qualifications, and competency to meet the needs of the residents. Licensee/Administrator shall develop a written Plan of Correction to ensure compliance with |
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14 | Based on interviews, records review conducted by Investigator Bendana, the Administrator/Licensee did not comply with the section cited above in which staff failed to seek medical attention when R1’s blood sugar was high (480, 531, 467, 393, 424, or 328) which poses an immediate health, safety or personal rights risk to residents in care.
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14 | California Code of Regulations Title 22, Section 87468.2(a)(4). Written POC must be submitted to CCL/LPA by POC due date.
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Type A
01/12/2026
Section Cited
CCR
87465(b) | 1
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7 | 87465 Incidental Medical and Dental Care...(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.
This requirement is not met as evidenced by:
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7 | Licensee/Administrator to ensure that facility staff shall be able to assist the resident with self-administration of his/her prescription medication. Licensee/Administrator to re-train staff regarding Title 22 regs. 87465(b) / medication administration and send a copy of the staff in service log to CCL/LPA by POC due date. |
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14 | Based on interviews, records review conducted by Investigator Bendana, the Administrator/Licensee did not comply with the section cited above in that R1 did not receive prescribed medication from 11/16/2024 to 11/19/2024. which poses an immediate health, safety or personal rights risk to residents in care.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
01/12/2026
Section Cited
CCR
87465(e) | 1
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7 | 87465 Incidental Medical and Dental Care..(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.
This requirement is not met as evidenced by:
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7 | Licensee/Administrator shall ensure that all residents have current medication list from their physicians. Licensee/Administrator will re-train staff regading Title 22 regs 87465/medication administration and submit the staff in service log to LPA/CCL by POC due date. |
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14 | Based on interviews, records review conducted by Investigator Bendana, the Licensee/Administrator did not comply with the section cited above in that staff mismanaged medications for R1 by providing R1 with unprescribed supplements which poses an immediate health, safety or personal rights risk to residents in care. | 8
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