Facility Evaluation Report

Licensing Program Analyst Angela Panushkina arrived on August 5 th , 2026, for an unannounced inspection to follow up on a substantiated allegation of complaint investigation.

On March 29, 2023, the Department concluded a complaint investigation regarding the following allegation:

Resident died due to staff administering the wrong medication.

The Licensee was cited for California Code of Regulations (CCR) 87466 Observation of the Resident, CCR 87465(g) Incidental Medical and Dental Care, CCR 87411(d)(4) Personnel Requirements - General, CCR 87405(b) Administrator - Qualifications and Duties, and CCR 87463(a) Reappraisals.

At the time of the complaint visit on March 29, 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(e).

The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that the Department determines resulted in the death of a resident. This is evidenced by the facility failing to provide proper care and supervision after R1 received another resident’s medications that resulted in R1’s death.