“Reporting Requirements” – Complaint alleged that R1’s responsible party was not notified of a fall or bruising found on R1 in September 2025. Per complaint, R1 had two falls in September 2025. R1’s primary contact was unavailable in September 2025 and the facility was to call the secondary contact listed for R1. Complaint also stated that R1’s secondary contact was informed of R1’s falls in September 2025 by voicemail.

Review of facility documents showed that on 09/18/2025, R1 was found on the floor by facility staff. Per document, R1 denied hitting their head and denied any complaints of pain. Facility staff notified R1’s responsible party and Primary Care Physician. Review of Physician Communication dated 09/18/2025 showed that facility informed R1’s Primary Care Physician of the fall.

Review of facility documents showed that on 09/25/2025, R1 was observed to have bruising on their back while having their clothes changed. Per document, R1 informed facility staff that they had fallen earlier in the day but did not report it to facility staff. Review of facility’s internal incident report and physician communication dated 09/25/2025 showed that R1’s responsible party and Primary Care Physician were notified. Interview conducted with R1’s secondary contact revealed that they received a voicemail regarding R1’s falls in September 2025. This interview further revealed that they were not informed of any bruise on R1 and that they did not receive a written report from the facility regarding R1’s falls.

During the course of the investigation, it was revealed that R1 was served a meal containing their food allergen in May 2025. Interview conducted with facility staff confirmed that the incident occurred. It was observed that an incident report was not submitted to Community Care Licensing as required for this incident. It was also observed during a medication audit that multiple errors occurred in the administration of medication for R1. These medication errors were also not reported to Community Care Licensing as required.

Based on record review, observations made, and interviews conducted, this allegation is Substantiated.

“Medication Mismanagement” – Complaint alleged that R1 did not receive their “as needed” or PRN nystatin powder for groin rash as required, did not have a urinary analysis test completed timely, and did not receive their PRN epinephrine pen after having an allergic reaction. Complaint also stated that R1 did not receive their levothyroxine medication correctly.

Complaint stated that R1 did not receive their “as needed” or PRN nystatin powder for groin rash as required. Review of R1’s facility documents stated that R1 is able to communicate their PRN or “as needed” needs and can inform facility staff when they need or want a medication. 5 of 6 staff interviews reported that R1 has the ability to communicate if they need or

Continued on LIC9099C

Complaint stated that R1 did not have a urinary analysis test completed timely. Complaint stated that R1’s primary care physician faxed a urinary analysis test to the facility on 09/24/2025 but that the facility did not collect the sample until 09/28/2025. Review of R1’s facility file shows that facility sent a fax request to R1’s physician on 09/20/2025 for a urinary analysis test due to observing signs and symptoms of confusion, urine odor, and signs of anxiety. Review of R1’s progress note did not state when R1’s order was received or when the urine sample was collected by the facility. The urinary analysis order stated by the complainant to have been faxed to the facility on 09/24/2025 was unable to be found in R1’s file. Email correspondence provided to the Department showed that a copy of the urinary analysis order was provided to the facility on 09/27/2025 with the urine sample collected on 09/28/2025.

Complaint also alleged that facility did not administer R1’s epinephrine pen after R1 had an allergic reaction on 09/08/2025. Review of R1’s medication records showed that they were prescribed an epinephrine pen on 07/05/2023, which states “Inject 0.3 mL intramuscularly as needed for severe allergic reaction. Inject into thigh at the first sign of severe allergic reaction or as directed. Review of R1’s incident report received on 09/15/2025 stated that on 09/08/2025, R1 complained of feeling itchy and had visible signs of redness. Report stated that R1 was served a meal containing their food allergy. Report further stated that facility staff contacted R1’s responsible party who transported R1 to the hospital for further evaluation. Interviews conducted with facility staff members revealed conflicting information on who is allowed to administer epinephrine pens to residents if needed. 4 of 6 staff members stated that only nurses are allowed to administer epinephrine pens while 2 of 6 staff members stated that both medication technicians and nurses are allowed to administer an epinephrine pen. 1 of 6 staff members stated that medication technicians received training on how to administer an epinephrine pen. There was no documentation available to show that training for epinephrine pens was provided to medication technicians.

A medication audit was conducted where it was observed that R1 was administered their levothyroxine medication incorrectly. Per R1’s medication instructions, R1 is to receive their medication six times per week and skip Sundays. Per medication notes reviewed, it was stated that R1’s Levothyroxine was administered on Sunday, 09/29/2024, and therefore was not given the medication on Monday, 09/30/2024. It was also revealed that R1 did not receive their levothyroxine medication on 02/28/2025 as the medication was being refilled and was not available to be administered.

It was also observed that there were multiple instances of R1’s citalopram and losartan being unavailable at the facility to

Continued on LIC9099C

“Resident Care Plan not being followed” – Complaint alleged that facility staff were not providing incontinence care, were not providing showers, and were not doing skin checks for R1. Interviews conducted with facility staff stated that R1 receives their showers three times per week and is assisted with incontinence care at least every two hours. Interviews also revealed that R1 had been observed to try and do their own activities of daily living (ADLs) such as showers or toileting and would sometimes refuse care. Documentation to support this evidence was not found in facility progress notes.

Interviews conducted with facility staff stated that caregivers would verbally report any issues found with R1’s skin to the medication technicians or to the nurses on-site. These interviews revealed that skin checks were typically done during R1’s scheduled shower days. Facility staff interviews also revealed that any updates to a resident’s care plan would be verbally reported or written down on the communication board in the medication room.

Email correspondence dated August 5, 2024 revealed that the facility had a conference to discuss R1’s care. These emails stated that the facility was to implement weekly skin checks for R1 every Wednesday to ensure the integrity of their skin.

Review of R1’s progress notes revealed that another care conference was conducted on 06/27/2025 where it was stated that the facility would implement skin checks for R1 on their shower days. There was no indication that R1’s weekly skin checks were to stop since their implementation in August 2024. File review showed that R1 received skin checks on the following days, 11/15/2024, 11/16/2024, 11/17/2024, 11/18/2024, 11/20/2024, 11/21/2024, 11/22/2024, and 12/06/2024. There was no additional paperwork found to document proof of skin checks being done for R1 in 2024 or 2025.

Based on record review, interviews conducted, and observations made, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

**Executive Director/Administrator and LPA discussed PIN 19-21-ASC: Epinephrine Auto-Injectors (EpiPen).

Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights, discussed and provided to Executive Director. Signature on form confirms receipt of documents.

Review of facility documents showed that on 09/18/2025, R1 was found on the floor by facility staff. Per document, R1 denied hitting their head and denied any complaints of pain. Facility staff notified R1’s responsible party and Primary Care Physician. Review of Physician Communication dated 09/18/2025 showed that facility informed R1’s primary care physician of the fall.

Review of facility documents showed that on 09/25/2025, R1 was observed to have bruising on their back while having their clothes changed. Per document, R1 informed facility staff that they had fallen earlier in the day but did not report it to facility staff. Review of facility’s internal incident report dated 09/25/2025 and physician communication dated 09/25/2025 showed that R1’s responsible party and primary care physician were notified. Review of R1’s medication list dated 02/13/2025 indicated that R1 is not on any blood thinner medications. There is no additional documentation regarding R1’s skin or skin condition prior to the bruising being identified on 09/25/2025. Department is unable to determine how R1’s bruising occurred. Based on record review, this allegation is Unsubstantiated.

A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview conducted. Copy of report discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.