Facility Evaluation Report

Licensing Program Analyst (LPA) Komal Curley arrived on April 17, 2026 for an unannounced inspection to follow up on a substantiated complaint allegation.

On November 6, 2024, the Department concluded a complaint investigation which alleged, due to lack of supervision, resident (R1) had an unwitnessed fall resulting in a hip fracture and staff did not seek timely medical care for resident.

The allegation was substantiated, and the Licensee was cited for violating California Code of Regulation (CCR) Title 22 87464(f)(1) Basic Services and CCR 87465(a) Incidental Medical and Dental Care.

At the time of the complaint visit on November 6, 2024, two immediate civil penalties of $500.00 were issued and the licensee was informed that an additional civil penalty was being determined and might be assessed based on Health and Safety Code § 1569.49(f).

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Welfare and Institutions Code § 15610.67, defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not providing proper care and supervision or seeking timely medical attention for R1. R1 suffered an unwitnessed fall, complained of pain, and was not transported to the hospital for over 24 hours. R1 was diagnosed with a hip fracture and was discharged to a skilled nursing facility. (Continue to 809C)