Facility Evaluation Report

Licensing Program Analyst (LPA) Nune Margaryan arrived on 04/16/26 , for an unannounced inspection to follow up on a substantiated complaint allegation.

On October 16, 2023, the Department concluded a complaint investigation regarding the following allegations: Resident sustained a fracture due to staff neglect and staff did not seek medical attention for the resident in a timely manner.

The licensee was cited for California Code of Regulations (CCR) § 87411(a) Personal Requirement and 87468.1(a)(2) Personal Rights of Residents in All Facilities. At the time of the complaint visit on October 16, 2023, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49(f).

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 proper care and supervision to a resident R1 resulting in a fall and fracture. The facility also did not provide care and supervision to R1 in a timely manner after a fall and identified fracture. R1 was diagnosed with a Left Tibia Fracture, Left Fibula Fracture and Left Calcaneus Body Fracture that required medication for extreme physical pain.