Incident investigation·December 2, 2025

Licensing Program Analyst (LPA) Evelin Rios conducted a Case Management - Incident visit. LPA met with the Administrator, Edina Lemus and Assistant Administrator, Wendi Doyon. LPA informed them of the purpose of the visit. On 11/17/25, the Department received a self-reported Unusual Incident Report (UIR) indicating that on 11/14/25, the California Highway Patrol (CHP) visited the facility to investigate an allegation involving Staff #1 (S1). The allegation reported that S1 engaged in neglect, yelling, and intimidation towards Resident #1 (R1), and failed to provide basic services to Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4). Additionally, S1 was alleged to have intimidated Resident #5 (R5). During today’s visit, LPA interviewed staff and residents, and reviewed a copy of the letter provided to CHP as well as the UIR. According to the Administrator, on 11/21/25, CHP conducted resident interviews and informed the Administrator that the investigation would be closed. LPA interviewed five (5) out of five (5) residents named in the report, as well as a randomly selected Resident #6 (R6). All six residents denied experiencing any form of mistreatment from staff and stated they were satisfied with the care provided. R2 stated they prefer to do their own laundry and do not require staff assistance for most basic needs. S1 denied the allegations. LPA’s review of records confirmed that once the facility was informed of the allegation by CHP, they notified Community Care Licensing and the Long-Term Care Ombudsman as required. Based on the information reviewed, no further action will be taken at this time. LPA did not identify any witnesses to the alleged incidents, and interviews conducted did not corroborate the allegations. No health or safety hazards were observed during the visit. An exit interview was conducted, and a copy of this report was provided.