Facility Evaluation Report

Licensing Program Analyst (LPA) Cassie Yang arrived on August 19, 2025, to follow up on substantiated allegations resulting from a complaint investigation. Licensing staff met with Facility Representative, Liz Cruz, to discuss the Department’s findings.

On December 23, 2024, the Department concluded a complaint investigation substantiating the following allegations: Due to facility staff's lack of care and supervision, resident sustained serious bodily injury, and facility staff's lack of care and supervision resulted in resident's death.

The Licensee was cited for California Code of Regulations (CCR) Title 22, § 87468.2(a)(4) Personal Rights of Residents in All Facilities.

At the time of the complaint investigation on December 23, 2024, 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.

The Department has concluded an analysis of the following incident 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 facility staff’s inadequate supervision of residents in care, resulting in a fatal altercation between residents.