Follow-up·October 23, 2025

Licensing Program Analyst, (LPA) T. Syess-Gibson, arrived on October 23, 2025, for an unannounced case management visit to follow up on a substantiated allegation complaint investigation. LPA met with Executive Director, Scott Shahade, and explained the purpose of the visit. On February 19, 2025, the Department concluded a complaint investigation regarding the following allegation “staff pushed resident resulting to resident sustaining injuries.” The Licensee was cited for California Code of Regulations (CCR), Title 22 § 87468.1(a)(3) Personal Rights of Residents in All Facilities. At the time of the complaint visit on February 19, 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(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 facility staff (S1) pushing a resident (R1) and causing R1 to fall. R1 suffered a closed compression fracture of the L-4 vertebrae and forehead contusion. Continue on LIC809C Continued from LIC809 Today, October 23, 2025, the Department will be issuing a civil penalty per Health and Safety Code §1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on February 19, 2025, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal Rights provided to Scott Shahade and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.