Murrieta Gardens

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff mismanaged Resident 1's medication

On 04/28/2026, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility to investigate the allegation listed above. LPA met with Administrator Kylee Carter who was informed of the purpose of the visit. LPA toured the facility with Administrator Carter, conducted interviews, and obtained copies of pertinent documentation. Regarding the allegation, “Facility staff mismanaged Resident 1's medication” it was reported that on 01/16/2026, Resident 1 (R1) received a 30-day refill supply of Medication 1 (M1) to be dispensed every night at bedtime which required to be refilled again on or before 02/16/2026. It was alleged that the facility staff did not notify R1’s responsible person that M1 had depleted which resulted in R1 not receiving M1 until mid March of 2026. It was further alleged that on 01/20/2026, R1 received a 90-day supply of Medication 2 (M2) to be administered every evening, which required to be refilled on or by 04/20/2026. However, it was rethe state’s words, verbatim · CDSS document, Apr 28, 2026 · control 18-AS-20260420151242

Allegation investigated: Staff did not prevent a resident from sustaining a fracture while in care

On 3/30/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering the investigative findings into the allegation listed above. LPA Flores met with Administrator Kylee Carter and explained the purpose of the visit. The investigation was conducted by the Investigation Branch and is summarized as follows: Information received alleged staff did not prevent Resident #1 (R1) from sustaining a fracture while in care. Staff interviews revealed that R1 is known to be a fall risk but primarily uses a wheelchair. Administrator reports R1 exhibited signs of pneumonia and R1’s responsible person requested R1 to be transferred to the doctors for evaluation. During that hospital visit, a chest x-ray was taken of R1. Administrator reported that the X-Ray revealed multiple rib fractures. (Continue to LIC9099C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 30, 2026 · control 18-AS-20250721211454

Allegation investigated: Staff did not prevent one resident from hitting another resident

On 3/3/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of launching the complaint investigation into the allegation listed above. LPA met with Administrator Kylee Carter and explained the purpose of the visit. Information received alleged staff did not prevent Resident #2 (R2) from hitting Resident #1 (R1). Interview with Staff #1 (S1) reported that R1 and R2 were sitting on the couch in the main room. S1 was standing in close proximity to the resident when S1 overheard noises. S1 glanced up and observed R1 and R2 grabbed onto each other’s forearms and were tugging back and forth. As S1 approached the residents, S1 observed R2 release their right hand from R1’s left forearm and began striking R1 on the left side of R1’s head with an open hand. S1 reported that they placed their body in between both residents to separate the residents. S1 further reported that Staff #2 (S2) overheard the commotion and redirected R1 to athe state’s words, verbatim · CDSS document, Mar 3, 2026 · control 18-AS-20260225084111

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.