Facility Evaluation Report

Licensing Program Analyst (LPA) Nicholas Reed arrived on 08/07/26 for an unannounced inspection to follow up on a substantiated complaint investigation.

On 07/15/2025, the Department concluded a complaint investigation regarding the following allegation: Resident sustained multiple unstageable pressure injuries due to staff neglect.

The licensee was cited for California Code of Regulations (CCR) 87615(a)(1) Prohibited Health Conditions.

During the non-compliance conference on 02/20/26, the licensee was informed that the complaint was referred to the Department’s legal branch for possible legal action including additional civil penalties, administrative decertification, and a non-immediate exclusion of the licensee.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not providing appropriate care and supervision related to the development, prevention and management of a Stage 3 sacral pressure injury and wounds to both knees and feet, all of which required wound care and treatment.

Today, 08/07/26 , the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes a serious bodily injury in the amount of $10,000.

Exit interview conducted. A copy of the report issued. Appeal rights provided. Iulia Laktinova 's signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.