Facility Evaluation Report

Licensing Program Analyst, Tena Herrera arrived on 7/30/2026 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation.

On September 03, 2025, the Department concluded a complaint investigation regarding the following allegation: Facility staff caused injuries to resident during a transfer.

The licensee was cited for California Code of Regulations (CCR) § 87468.1(a)(2) Personal Rights of Residents in All Facilities.

At the time of the complaint visit on September 03, 2025, 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 as facility staff were not properly trained to use a Hoyer lift and that failure to train staff resulted in resident sustaining a head laceration with 15 J-staples and a large scalp hematoma during a transfer.

Today, 7/30/2026 , the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department determines constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on September 03, 2025, the amount of the civil penalty issued today will be $9,500.

Exit interview conducted. A copy of the report issued. Appeal rights provided. Administrator Blasia Lee-Lole and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.