Facility Evaluation Report

On 08/04/2026, at 12:30pm, Licensing Program Analyst, LPA Zina Brown conducted a Case Management for complaint Control Number 11-AS-20251201153121. LPA met with Esperanza Naaktgeboren, Administrator as the purpose of the visit was explained.

** Please be advised: when the Department initiated this investigation for complaint Control Number 11-AS-20251201153121. , Joel Niblett was serving as the facility’s Administrator

The department conducted interviews on 12/03/2025 with Administrator (A1) at 10:57am, on 12/05/2026, with Staff (S1-S7) between the hours of 9:21am - 3:00pm, and on 08/04/2026 between the hours of 8:31am - 940am with Residents (R2- R11).

LPA conducted an initial unannounced complaint investigation on 12/05/2026 in regards to a resident sustained an unstageable pressure injury due to staff neglect/lack of supervision.

Based on records review the facility retained Resident 1 (R1), who had a unstageable pressure injury which is prohibited by title 22 regulations. The facility failed to submit an exception request from the department to retain R1.

Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D with civil penalty assessed.

Exit interview conducted with Esperanza Naaktgeboren (Administrator ), and copy of this report was provided with appeal rights.