Facility Evaluation Report

On May 11, 2023, Licensing Program Analyst (LPA) V Gorban met with administrator, Mark Castillo for a case management visit to follow up on a substantiated complaint allegation of failure to seek timely medical attention resulting in the death of a resident (R1).

On December 12, 2019, the Department concluded a complaint investigation which alleged that the facility staff did not seek timely medical service for a resident (R1) who passed away in the facility after complaining of pain for at least 7 hours.

The allegation regarding failure to seek timely medical service for R1 was substantiated and the licensee was cited for violating the California Code of Regulations (CCR) Title 22, § 80075 (a) Health Related Services states, “the licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services” for staff not properly assessing resident’s symptoms, and not seeking further medical attention for R1, who had been complaining of pain for more than seven hours.

The investigation revealed that on the night of January 8, 2019, R1 was yelling and crying for help. Staff responded to R1’s room and provided medication for nausea. R1 continued to complain through the morning of January 9, 2019, of stomach pain, difficulty breathing and nausea.