Facility Evaluation Report

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway arrived on October 24, 2025 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. The LPA met with facility designees Agnes Gazaryan and Ashley Kumar.

On November 25, 2024, the Department concluded a complaint investigation regarding the following allegations: Neglect/lack of supervision leading to questionable death; neglect/lack of supervision: facility employees failed to properly supervise resident resulting in an unwitnessed fall and injuries to the resident; licensee did not meet resident’s ADL needs; licensee did not provide resident’s responsible party an updated care plan; and licensee did not comply with reporting requirements.

The licensee was cited for California Code of Regulations (CCR) 87464(f)(4) Basic Services; CCR 87411(a) Personnel Requirements – General; CCR 87705(c)(6) Care of Persons with Dementia; and CCR 87211(a)(1)(B) Reporting Requirements.

At the time of the complaint visit on November 25, 2024, an immediate civil penalty of $500 was issued. Due to the fact that this was a repeated violation, an additional $500 was levied. 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 is evidenced by the facility not providing proper care and supervision which led to a resident (R1) falling, sustaining fractures and brain