Facility Evaluation Report

At approximately 10:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to several incident reports submitted by the facility. LPA met with Executive Director Zenia Shah and reviewed records.

On 07/02/2026, the Department received four unusual incident reports regarding a staff (S1) being rude, pushy and impatient with residents in care. The facility conducted an investigation and found the allegations to be true and terminated S1. LPA received copies of the investigation, staff statements and personnel file. The report showed that S1 threw a shoe at a resident, threw a bundled up blanket at a resident and pulled strongly on the shorts of a resident, causing the resident pain.

On 05/26/2026, the Department received a report of a medication error. Staff, S2, was assisting resident with medication and did not realize one of the medications had a hold order. The error was reported immediately to the physician and resident was monitored for adverse reactions. S2 was removed from medication duties and conducted retraining. S2 no longer works as a medication technician. This is a repeat violation in a 12 month period. An Immediate civil penalty is being issued in the amount of $250.

On 0601/2026, the Department received a report of unexplained bruising on a residents, R1, arms. R1 stated that a staff hurt him because they were impatient and grabbed their arm and twisted. Law Enforcement was contacted and an internal investigation was conducted. Due to R1 not providing the same information during the course of the investigation it is believed the bruises were caused from R1 hitting their arms on the bed rail and not from staff. There was no supporting evidence to show a staff caused the bruising. LPA reviewed R1's history and observed there were several falls in the time period that could cause bruising to the arms.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Zenia Shah and Appeal rights were given.