Facility Evaluation Report

Licensing Program Analyst, Magdaleno arrived on 7/9/2026 for an unannounced inspection to follow up on substantiated complaint findings, Complaint # 21-AS-20250929084229

On February 04, 2026, the Department concluded a complaint investigation regarding the following allegations: Facility did not seek timely medical and staff did not respond to call button timely.

The licensee was cited for California Code of Regulations (CCR) 87411(a) Personnel Requirements and CCR 87466 Observation of the Resident.

On February 03, 2026, the Licensee was assessed a $500 Civil Penalty and was informed that an additional civil penalty might be assessed. Assessment of Civil Penalty is allowable 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 seeking timely medical attention that resulted in Serious Bodily Injury. Interviews and documentation provided during investigation showed that facility did not respond to resident’s call bell for at least an hour. Resident was found unresponsive with significant blood loss, per Death Report. Additionally, four of seven staff interviewed were not aware that resident required increased monitoring following discharge from the hospital the day prior to death.