Facility Evaluation Report

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

On July 17, 2025, the Department concluded a complaint investigation which alleged staff did not provide adequate supervision resulting in resident (R1) sustaining multiple fractures and staff did not seek medical attention to resident in a timely manner.

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

At the time of the complaint visit on July 17, 2025, two immediate civil penalties were issued to the licensee totaling $1,000. Due to the fact that one of these citations was a repeat violation, an additional $500 was levied. Licensee was informed that an additional civil penalty 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. The welfare and Institutions Code section § 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 fell, was in pain, and yelled for help for two days before R1 was sent to the hospital. R1 was diagnosed with a rotation to the left leg, deformity to the left hip, and mildly displaced fracture. (continue to 809C)