Facility Evaluation Report

Licensing Program Analyst, Angela Hood arrived on October 1, 2025 for an unannounced inspection to follow up on substantiated allegations of neglect resulting from a complaint investigation.

On September 13, 2023, the Department concluded a complaint investigation, alleging the following: Facility staff did not adhere to resident’s special diet, and facility staff did not provide care and supervision during meals, resulting in the death of resident (R1).

The licensee was cited for California Code of Regulations (CCR), Title 22, § 87555(b)(7) General Food Service Requirements, and CCR, Title 22, § 87464(f)(4) Basic Services.

At the time of the complaint visit on September 13, 2023, 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(e).

The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that the Department determines resulted in the death of a resident. This is evidenced by the facility not providing adequate care and supervision to R1. The facility did not adhere to R1’s physician’s diet order resulting in R1 choking, sustaining aspiration, cardiac arrest, hospitalization, anoxic cerebral injury, which resulted in R1’s death.

Today, October 1, 2025, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(e) for a violation that the Department determines resulted in the death of a resident in the amount of $15,000. However, since an immediate civil penalty of $500 was previously issued on September 13, 2023, the amount of the civil penalty issued today will be $14,500.

Exit interview conducted. A copy of the report issued. Appeal rights provided. Chantel Krahn name and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC421D.