Facility Evaluation Report

Licensing Program Analyst, Arvin Villanueva (LPA), arrived on January 13, 2026 for an unannounced inspection to follow up on a substantiated allegation from complaint investigation 27-AS-20241007094603.

On January 16, 2025, the Department concluded a complaint investigation which alleged the following: Lack of care and supervision resulted in resident death.

The licensee was cited for Health and Safety Code § 1569.312(e)Basic services requirements.

A Complaint visit was conducted on January 16, 2025, where an immediate civil penalty of $500.00 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 was evidenced by interviews and record reviews indicating that the licensee/administrator did not ensure staff provided adequate care and supervision to the resident, who was left unattended outdoors in direct sunlight and heat, resulting in heat-related injuries, heat stroke, and ultimately, death.

Today, January 13, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(e) for a violation that the Department constitutes as death in the amount of $15,000. However, since an immediate civil penalty of $500 was previously issued on January 16, 2025, the amount of the civil penalty issued today will be $14,500.

Exit interview conducted. A copy of the report issued. Appeal rights provided to Elena Cuevas and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.