Facility Evaluation Report

On 9/26/25 at 12:30 pm Licensing Program Analyst (LPA) J. Leffall conducted a case management regarding report and findings from CCLD’s Investigative Bureau. LPA met with Administrator House Manager (HM) Jethro Pandy and stated purpose of visit.

The department conducted interviews and reviewed records. Based on information obtained staff admitted, failed to conduct hourly safety check during night shift on 1/17/25, 2 residents reported that staff falls asleep. Staff admitted to falling asleep during shift, staff failed to generate a Special Incident Report for one or more falls suffered by R1 from 1/9/25-1/12/25 where R1 hit head and sustained multiple bruises, and staff failed to seek timely medical attention for R1. Staff statements and facility records indicated that R1 suffered rapid weight loss, refused to eat, was weak, shaky, had diarrhea, vomiting and stopped being able to walk on her own since December of 2024.

The following deficiencies is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

Exit interview conducted. A copy of this report along with appeal rights was provided to House Manager whose signature confirms receipt of this report.