306005934-10-23-2025-22-AS-APAO-DMRVHN-20251024162726

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005934
Report Date: 10/23/2025
Date Signed: 10/23/2025 03:12:49 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/01/2025 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250801083105

FACILITY NAME:	ADULT CARE OC SATURNA		FACILITY NUMBER:	306005934
ADMINISTRATOR:	SCHOTT, BRIAN		FACILITY TYPE:	740
ADDRESS:	24591 SATURNA DRIVE		TELEPHONE:	(949) 593-9290
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	10/23/2025
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Rosmie Morota- Lead Caregiver		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility is not administering medications as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit for the purpose of delivering the investigation findings into the above allegation. LPA met with Supervisor John Bardon and explained the reason for the visit.

On August 1, 2025, the Department received a complaint, and the investigation was initiated by LPA on August 11, 2025. During the course of the investigation, LPA observed the medication closet, inspected residents’ medications, interviewed four residents/staff, and obtained the following documentation: Resident/Staff Rosters, Face Sheets, Physician’s Reports, Medication Administration Records (MARs) for all residents in addition to the Admission Agreement and medical records for Resident #1 (R1).

Regarding the allegation, Facility is not administering medications as prescribed, the investigation is as follows: It is alleged that the facility staff laced R1’s food and water with Coumadin also referred to as warfarin.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20250801083105

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ADULT CARE OC SATURNA	FACILITY NUMBER: 306005934
	VISIT DATE: 10/23/2025

NARRATIVE

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Per the incident report dated August 4, 2025, R1 was admitted to the hospital per the nurse’s advice on July 28, 2025. The American Heart Association indicates that warfarin is a prescription medication used to prevent blood clots. Warfarin is adjusted based on the results of the blood test, International Normalized Ratio (INR). A normal INR range is between 2 and 3.5 when taking blood thinners. However, R1’s INR levels was an 8 and increased to 12 upon hospital admission which is considered high.

Based on the interviews, four out of four staff denied the allegation indicating that R1’s medications were administered appropriately. For R1’s warfarin, the Veterans Affair (VA) Inquiry Sheet dated November 5, 2024, indicates that one tablet is given every evening. In review of the Medication Administration Records (MARs) for June and July 2025, R1 did not receive warfarin on June 16, 19, 21, and 23. One out of the four staff indicated that medication was not given due to R1’s refusal. R1 did not recall why the warfarin was refused at the time of the interview. Three out of the four staff denied tampering R1’s food and water with warfarin and had only administered the medication at the request of R1 which was instructed and relayed by R1’s nurse. The remaining one staff was not assigned to administer medication at this facility and could not provide further information. During the initial visit conducted on August 4, 2025, LPA observed all medications were secured in the medication closet. There were no medication errors observed in review of four out of four residents. Two out of the four residents reported having no issues with their medications. LPA was unable to qualify the remaining two residents due to their medical diagnosis.

The investigation revealed that there was insufficient corroborating evidence to prove staff were tampering with R1’s food and water. The Physician’s Report dated January 22, 2025, indicated that R1 did not have a food allergy or a special diet prescribed by the doctor. There was no order suggesting removing garlic from R1’s diet.

Therefore, based on the observations made, interviews which were conducted, and the records that were reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Facility is not administering medication as prescribed is deemed UNSUBSTANTIATED.

An exit interview was conducted with Lead Caregiver Rosmie Morata, and a copy of this report was provided at exit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

LIC9099 (FAS) - (06/04)

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