A review of R1’s facility records dated February 24, 2023, revealed R1’s Primary Care Physician (PCP) concurred that self-storage and administration is safe,” “and the “Resident agrees to keep medications in a locked cabinet or drawer and will lock apartment door when not in apartment.

Further review of R1’s resident records showed R1’s history of non-compliance regarding safeguarding their medication when R1 was still deemed able to self-medicate. Records include the following but are not limited to; facility records dated March 10, 2023, revealed facility Staff1 (S1) documented that R1 had medications out in their room and S1 and Staff 2 (S2) both told R1 they needed to purchase a lock box to store their medications however R1 got upset and refused. On April 4, 2023, the Executive Director (ED) observed R1 had opened bottles of medications out in their room, the ED emailed R1’s PCP regarding non-compliance with self-medicating. A review of R1’s facility records also revealed on April 27, 2023, R1 had misplaced their medication and subsequently a new prescription was ordered and staff delivered them to R1 by 9:00 am the following morning. Additionally, on June 7, 2023, R1 reported they never received that same prescription that had been ordered twice, and facility staff were able to locate the bottle under R1’s bed.

On March 25, 2025, the Department received a 3-Day eviction notice that disclosed R1 received a prescription of a 224 count of Narcotic Painkillers, on that same day, prior to access to their prescription had made suicidal threats to Staff 3 (S3) by means of taking their entire bottle of pain killers at once. Upon S3 notifying management safety measures were put in place, including a search of R1's room for the medication, that were not found and remain unaccounted for to date. The Resident Service Director (RSD) also revealed they found other medication bottles in R1’s room that contained medication that did not match the prescription label. An interview with the ED revealed they followed the facility protocol, removed all R1’s medications that were found from their room, placed R1 on 1:1 supervision, and contacted R1’s PCP for an updated Physician’s Report. However, the PCP only sent a letter that stated R1 can handle their own medication. A follow-up interview conducted with the ED, on July 12, 2025, revealed after multiple requests to the PCP, they have not sent an updated Physician’s Report to date.

[Continued on LIC 9099C]

This is an amended version of the original report delivered on July 15, 2025.

On June 23, 2025, the facility received a complaint that alleged a Personal Rights violation due to the facility staff taking R1’s medications, and after a thorough investigation by LPA Nguyen, that revealed R1 was not in-compliance with facility protocol regarding procedures of safeguarding Narcotic medication, and R1 was not taking their medication as prescribed, the complaint was determined unsubstantiated which allowed the facility to continue centrally storing R1’s medication and implement Medication Management, and had R1 re-assessed by a third party Physician’s Assistant (PA), that determined R1 was not able to manage their own medication.

In the event R1’s PCP conducts a reassessment of R1 and deems them able to self-medicate, California Code of Regulations (CCR) Section 87463(e) supports the right and responsibility of Licensees to conduct their own care assessments parallel to medical assessment(s). When health/safety concerns and/or unresolved questions are identified, regulation requires Licensees to further communicate with the physician to obtain recommendations on these issues. However, Licensees retain some independence in forming the written record of care that the resident shall receive while living at the facility, particularly when provisions reasonably uphold resident health/safety in balance with resident rights.”

The interview conducted with ED on July 12, 2025, as previously mentioned, revealed R1 remained non-compliant even after being placed on Medication Management. The ED revealed R1 continued to have their Prescriptions refilled and have picked them up from Pharmacies on their own. In addition, R1 has prohibited staff from removing them from their possession. R1 also continues to have their medication unsecured and sprawled around their room. Due to R1’s continued noncompliance with medication management R1 was given a 30-day eviction notice on June 4, 2025, and an amended version on June 13, 2025, which resulted in the current complaint regarding and unlawful eviction that was under investigation.

Based on staff interviews and record reviews revealed a preponderance of evidence that R1 has displayed disregard to the facility’s policy regarding safeguarding their medication, therefore the complaint regarding an unlawful eviction was determined to be unsubstantiated. An UNSUBSTANTIATED finding means that there was not a preponderance of evidence to prove the violation occurred.

An exit interview was conducted with Irma Miranda,, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) will be provided after the conclusion of the visit.