1
2
3
4
5
6
7
8
9
10
11
12
13 | Licensing Program Analyst (LPA) Sarah Hurt to deliver findings on the allegations listed above. LPA met with Administrator, Rocio Granda (by phone), and Business Manager, Monica Garcia.
Regarding the allegation delayed medical care resulting in serious harm, it was alleged that the facility failed to ensure timely medical care for Resident 1, resulting in serious harm. During the investigation, it was determined that Resident 1, who had a known diagnosis of Type II Diabetes, hypothyroidism, and dementia, was not provided with proper medical oversight after exhibiting symptoms of decline. On 01/14/2025, Resident 1 was sent to Scripps Hospital and treated for hyperglycemia, dehydration, and diabetic ketoacidosis (DKA). Hospital records confirmed the resident’s blood sugar was critically elevated, and she presented with altered mental status and dehydration. Facility records and staff interviews revealed that Resident 1 had been eating minimally, was lethargic, and her blood sugar had been checked two days prior with elevated results; however, no immediate medical intervention or 911 activation occurred. Staff confirmed that the Wellness Director and Administrator were aware of the resident’s condition and ongoing lack of medication but failed to ensure prompt medical attention or reassessment of her care needs. Based on record review and interviews with staff, this allegation is substantiated.
Continued...
|
| Substantiated | Estimated Days of Completion: |
|
NARRATIVE |
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 | Regarding the allegation medications not given as prescribed, it was alleged that the facility failed to administer medications as prescribed to Resident 1. During the investigation, it was discovered that Resident 1, who was dependent on insulin to manage Type II Diabetes, did not receive her prescribed insulin for approximately one month while residing at the facility. Staff interviews revealed that facility management was aware of the lapse in medication but failed to take action to ensure medication orders were refilled or that appropriate care arrangements were made. The facility Wellness Director stated the resident’s insulin was not being administered due to insurance issues and admitted the facility did not have documentation of a physician’s order for insulin administration. Caregivers confirmed Resident 1’s condition declined over several days, and she became lethargic and weak before being hospitalized. The facility’s failure to maintain accurate medication records, provide the required insulin, and reassess the resident’s medical needs resulted in a severe health decline requiring hospitalization for diabetic ketoacidosis (DKA) and dehydration. Based on record review and interviews with staff, this allegation is substantiated.
The following deficiencies are being cited (see LIC 9099D) from the California Code of Regulations, Title 22, and the California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on H&S Code section 1569.49(f). Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted with Administrator, Rocio Granda (by phone), and Business Manager, Monica Garcia, and appeal rights provided. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
02/22/2026
Section Cited
CCR
87465(a)(1) | 1
2
3
4
5
6
7 | 87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.The following requirement has not beem met as evidenced by:
| 1
2
3
4
5
6
7 | The licensee will retrain staff on • Retrain all staff, including management, on, recognizing signs and symptoms of diabetic complications (hyperglycemia, DKA, lethargy, altered mental status), hen to contact a physician, when to contact 911 for emergency medical care, provide a written plan requiring immediate physician notification and emergency response when a resident misses critical medications such as insulin and submit to LPA by POC date of 02/22/2026.
|
 | 8
9
10
11
12
13
14 | Resident 1 was not provided timely medical care resulting in serious harm, which poses an immediate health, safety, or personal rights risk to residents in care. | 8
9
10
11
12
13
14 | |
Type A
02/22/2026
Section Cited
CCR
87465(a)(4) | 1
2
3
4
5
6
7 | 87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4)The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by:
| 1
2
3
4
5
6
7 | The licensee will ensure all staff responsible for medication assistance will receive retraining on medication administration procedures, including:
Administering medications strictly according to physician orders
Accurate documentation on the MAR
Identifying and reporting missed or refused doses immediately, and submi proof to LPA by POC date of 02/22/2026. |
| 8
9
10
11
12
13
14 | Resident 1's medications were not given as prescribed, which poses an immediate health, safety, or personal rights risk to residents in care. | 8
9
10
11
12
13
14 | |