Facility Evaluation Report

Licensing Program Analyst, [LPA] Huma Rahimi arrived on 12/30/2025 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. Upon arrival LPA observed that the facility is locked and not occupied with any residents. LPA contacted the Licensee Starr Carver via telephone and explained the reason for the visit, which is to deliver enhanced civil penalties (ECP). The Licensee arrived at 2:20 PM to the facility to grant access to the facility.

On November 22, 2024, the Department concluded a complaint investigation regarding the following allegation staff neglect led to resident sustaining pressure injuries.

The allegation was substantiated, and the licensee was cited for violating California Code of Regulations, (CCR) Title 22, Section 87465(a)(1) Incidental Medical and Dental Care, CCR Title 22, Section 87411(a) Personnel Requirements General, CCR Title 22, Section 87615(a)(1) Prohibited Health Conditions, CCR Title 22, Section 87463(a) Reappraisals, and CCR Title 22, Section 87405(d)(1,2) Administrator Qualifications.

At the time of the complaint visit on November 22, 2024, 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