Facility Evaluation Report

Licensing Program Analyst (LPA) Kelly Dulek arrived on July 29, 2026 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation.

On March 25, 2025, the Department concluded a complaint investigation regarding the following allegations: Neglect/lack of care & supervision – Resident 1 (R1) caused severe injuries to Resident 2 (R2) that led to the death of R2; Facility did not provide basic services to resident(s) in care; Facility did not reappraise resident(s) in care; Facility retained a resident that required a higher level of care; Facility staffing is inadequate.

The licensee was cited for California Code of Regulations (CCR) 87464(f)(2) Basic Services, CCR 87463(a) Reappraisals, and CCR 87411(a) Personnel Requirements - General.

At the time of the complaint visit on March 25, 2025, 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 led to a resident #1 (R1) physically attacking resident #2 (R2) while in their shared room, which ultimately led to the death of R2.

Today July 29, 2026 , the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(e)