Facility Evaluation Report

Licensing Program Analyst, Mary Flores arrived on December 5, 2025 for an unannounced inspection to follow up on a substantiated allegation of complaint investigation.

On October 12, 2023, the Department concluded a complaint investigation regarding the following allegations: Staff failed to provide appropriate care and supervision after falls, staff did not provide medical assistance to resident in a timely manner, and insufficient staff to meet the needs of the residents.

The licensee was cited for California Code of Regulations (CCR) § Section 87645(a)(1), Incidental Medical and Dental Care, CCR § 87411(a) Personnel Requirements – General, and CCR § 87466 Observation of the Resident.

At the time of the complaint visit on October 12, 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 of 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) after a fall where R1 was left on the floor in a prone position. This position has placed R1 at a risk for pressure injuries, increased chest and abdominal pressure, compressing organs, risk for respiratory complications and blood flow, which could lead to low oxygenation, vomiting, and hypotension. (CONTINUED ON LIC 809C)