Facility Evaluation Report

Licensing Program Analyst, Huma Rahimi arrived on 03/10/2026 for an unannounced inspection to follow up on a substantiated allegation of complaint investigation.

On March 14, 2022, the Department concluded a complaint investigation regarding the following allegation: “Resident #1 (R1) developed multiple pressure injuries while in the licensee’s care.”

The licensee was cited for California Code of Regulations (CCR) 87615(a)(1) Prohibited Health Condition, CCR 87616(a) Exception for Health Conditions, and CCR 87464(f)(1) Basic Services.

At the time of the complaint visit on March 14, 2022, 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 by the Licensee/administrator and staff failed to follow hospital/home health instructions to reposition R1 which resulted in the pressure injuries worsening.