complaint·August 21, 2025

Investigation revealed the following: Allegation: Unlawful eviction. Record review of the eviction noticed (04/14/25) indicated that R1’s final residency would be 05/14/25. The notice did not include the following requirements: resources available to assist in identifying alternative housing and care options, a statement informing residents of their right to file a complaint with the licensing agency including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office, and the following exact statement as specified in Health and Safety Code Section 1569.683(a)(4): "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing." Regarding the allegation, “ Unlawful eviction ,” based on record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Allegation: Staff abandoned resident. Regarding the allegation, “Staff abandoned resident,” it is being alleged that Resident #1 (R1) was ready for discharge, but the Administrator (S1) refused to accept R1. Record review of Incident Report (07/21/25) revealed R1 complained about mid-section pain. Staff #2 (S2) recommended calling 911 but Witness #1 (W1) stated W1 would take R1. W1 texted S2 on 07/22/25 explaining that R1 would be in the hospital for 10 days to 2 weeks due to UTI. Review of text messages initiated by S1 with W1 revealed that S1 inquired about R1’s location so that S1 could speak with case management about appropriate placement (07/22/25), S1 requested to speak with case manager prior to R1’s return to determine higher level of care (07/28/25), and S1 acknowledged S1 was able to speak with someone from the hospital (07/29/25). Record review of Social Worker notes revealed that the hospital called S1 on 07/29/25, 07/31/25, and 08/06/25 and S1 refused to accept R1 due to R1’s need for a higher level of care. Continue to LIC9099-C. Discharge summary (07/28/25) revealed R1’s diagnosed conditions that were consistent with R1’s Pre-placement Appraisal (09/06/24), Physician's Report (09/09/24) and Reappraisal (04/07/25). The facility’s Plan of Operation for Dementia Care revealed the facility has special techniques for managing behavioral expressions such as avoiding aggressive behaviors, sundowning, and threatening (verbal and nonverbal). Interview with S1 indicated that R1’s behaviors got worse and R1 was throwing things at the dining table, hitting, and scratching. S1 indicated special techniques would have probably worked with W1 and skilled professional support. Regarding the allegation, “Staff abandoned resident,” based on record reviews and interviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D An exit interview was conducted, plans of correction developed, and a copy of this report with appeal rights were provided to Area Manager Irene Formentera.