Facility Evaluation Report

Licensing Program Analyst, Zabel Chochian arrived on 06/13/2025 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. The LPA met with Madison Lewis .

On February 21, 2024, the Department concluded a complaint investigation regarding the following allegations: Questionable Death – The death of the resident was due to neglect and lack of supervision; and Neglect/Lack of Care and Supervision – The facility failed to respond to the resident in a timely manner.

The licensee was cited for California Code of Regulations (CCR) 87464(f)(1)(5) Basic Services and CCR 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities.

At the time of the complaint visit on February 21, 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(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 resulted in death due to intracranial hemorrhage from a fall.

Today, 06/13/2025 , the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(e) for a violation that the Department determines resulted in the death of a resident in the amount of $15,000. However, since an immediate civil penalty of $500 was previously issued on February 21, 2024, the amount of the civil penalty issued today will be $14,500.

Exit interview conducted. A copy of the report issued. Appeal rights provided. Signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.