Facility Evaluation Report

Licensing Program Analyst (LPA) Javina George arrived on 02/25/25 for an unannounced case management visit to follow up on a substantiated allegation on a complaint investigation. LPA George met with Janette Vega Racelis, Administrator and reviewed the report.

On December 28, 2023, the Department concluded a complaint investigation regarding the following allegation: staff neglect contributed to a resident’s death.

The licensee was cited for California Code of Regulations § 87469(c)(3) – Advanced Directives and Requests Regarding Resuscitative Measures which states in part, “If a resident who has an advance directive and/or request regarding resuscitative measures form on file experiences a medical emergency, facility staff shall do one of the following: specifically for a terminally ill resident that is receiving hospice services and has completed an advance directive and/or request regarding resuscitative measures form pursuant to Health and Safety Code section 1569.73(c), and is experiencing a life-threatening emergency as displayed by symptoms of impending death that is… not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).”

At the time of the complaint visit on December 28, 2023, an immediate civil penalty of $500 was assessed and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for the death in accordance with Health and Safety Code Section § 1569.49. This is evidenced by the licensee’s failure to contact 911 or obtain emergency medical services when they observed an imminent threat to the health of the resident; and for failure to follow hospice nurse’s recommendation for medical intervention.