Inspector’s narrative
What the inspector wrote
Interviews with staff member (S1) and House Manager, Stephanie Harmon-Christensen, indicated that Licensee would work NOC shift and sleep through their shift. House Manager stated that staff member (S3) would also sleep through their shift. Physician’s Report (LIC 602A) for resident (R3) states R3 needs “total dependent assistance” for all activities of daily living (ADLs). Resident Appraisal for R3 on file states that R3 needs special observation/night supervision (due to confusion, forgetfulness, wandering) as they are “unable to get out of bed/supervision.” Appraisal/Needs and Services Plan for R3 dated December 18, 2025 states R3 “needs assistance with all activities and all ADL’S.”
S1 stated that R3 has cut their arm from falling out of bed. S1 stated that R3 has fallen out of bed twice during Licensee's shift. S1 stated that S3 has left R3 on the floor because they couldn't get R3 up on their own. S1 stated that S3 gave R3 a blanket and pillow while they laid on the floor. S1 stated that the floors are hard. S1 stated that they did not know when R3 fell. S1 stated that resident (R2) has fallen and resident (R4) has fallen out of bed (LPA verified Incident Reports submitted regarding falls for both residents). S1 stated that all falls have been during Licensee's shift. S1 stated that R2's most recent fall was at approximately 7:15 AM ending in Licensee's shift. S1 stated that they lifted R2 into bed and called the paramedics. S1 stated that R2 bumped their head. S1 stated that House Manager told S1 to call paramedics.
The Department received information from R3’s Home Health (HH) regarding R3’s fall. HH reported that R3 is mostly bedbound and is unable to turn or transfer self. HH reported to have visited R3 on January 3, 2026. HH reported that staff member (S2) stated that R3 had an unwitnessed fall and night shift caregiver (S3) left R3 on the floor for possibly one (1) to two (2) hours. HH reported that S2 had stated that S3 did not call supervisor until the end of their shift. HH reported that supervisor found R3 soaked in urine and blood to their right arm while face down on the floor next to their bed. HH reported that supervisor contacted paramedics and R3 was returned to bed and provided basic wound care. HH reported assessing R3’s arm and found no signs of infection. HH reported providing R3 wound care and instructing care staff regarding wound care as ordered by physician. HH reported providing extensive fall prevention education to care staff. HH recommended bed alarms and 24 hour closer supervision.
** Report continued on 9099-C **
HH reported a new rash that is possibly incontinence related with no open areas. HH reported both injuries to be deemed not serious injuries. PIN 25-06-ASC stat
es the following: “to ensure resident safety, licensees as a best practice should immediately call 9-1-1 if a resident is experiencing any of the following symptoms/conditions listed below: (…)
Falls with complaints of pain or loss of range of motion
.” Based on the information above, the allegation is determined to be substantiated.
Allegation: Facility is not financially solvent
Upon opening the complaint on November 24, 2025, Licensee had yet to pay license fees for approximately two (2) years. By the conclusion of this investigation, all license fees have been paid. Upon opening the complaint on November 24, 2025, Licensee had yet to update liability insurance for the care home. By the conclusion of this investigation, liability insurance has been updated as of February 12, 2026. The Department referred allegation regarding financial solvency to Audit Section. On February 24, 2026, April 1, 2026, April 8, 2026, and April 14, 2026, auditor requested Licensee to provide requested documentation. As of the conclusion of this investigation, Licensee did not provide any requested documentation. Due to lack of documentation, auditor was unable to proceed with solvency audit.
During visit conducted on April 14, 2026, LPA discovered that Licensee was issued a Notice of Filing Unlawful Detainer Complaint on April 8, 2026, which states "You are hereby notified that an Unlawful Detainer complaint (eviction action) has been filed against you." Interview conducted with Licensee on April 14, 2026 indicated that Licensee only paid partial rent for March, 2026 and had yet to pay rent for April, 2026. As a result of the visit conducted on April 14, 2026, a deficiency was cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87213 Finances - "The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents" (...). This requirement was not met based on interview conducted and records reviewed, which identified that Licensee did not ensure to secure funds to meet operating costs for care of residents.
** Report continued on 9099-C **
Based on the information above, the allegation is determined to be substantiated. Due to care home receiving a citation for Section 87213 Finances during visit conducted on April 14, 2026, no additional citations will be issued. There will be no additional plan of corrections as the care home is now closed.
Allegation: Staff mismanaged residents’ medications
During visit conducted on January 14, 2026, LPA arrived at the facility and conducted a medication count for residents R2 and R3, comparing residents' Centrally Stored Medication Forms (CSMFs) and Medication Administration Records (MARs) with medications centrally stored for the residents. LPA observed five (5) of six (6) medications counted for R2 to be over the amount documented. Interview with Licensee indicated that R2 has refused medications but refusals were not documented. LPA observed two (2) of four (4) medications counted for R3 to be under the amount documented. There was no documentation provided to account for why medications were off count by the conclusion of LPA's visit conducted on January 14, 2026. Based on the information above, the allegation is determined to be substantiated.
Allegation: There is no qualified administrator at the facility
During visit conducted on February 12, 2026, LPA discovered facility had yet to employ a certified administrator. As a result of the visit conducted on February 12, 2026, a deficiency was cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87405 Administrator - Qualifications and Duties (a) "All facilities shall have a qualified and currently certified administrator." This requirement was not met based on interviews conducted and observations, which determined that the facility did not ensure to employ a certified administrator. The facility was to hire a certified administrator and send proof of employment to LPA by plan of correction (POC) due date of February 24, 2026. Licensee did not provide proof of employment of an administrator to LPA by POC due date and a civil penalty in the amount of $100 a day was issued until the closure of the care home.
** Report continued on 9099-C **
Based on the information above, the allegation is determined to be substantiated. Due to care home receiving a citation for Section 87405 Administrator – Qualifications and Duties during visit conducted on February 12, 2026, no additional citations will be issued. There will be no additional plan of corrections as the care home is now closed.
Allegation: Facility is insufficiently staffed
During visit conducted on November 24, 2025, LPA observed S2 working at the facility by themselves. LPA observed that S2 did not have a criminal background clearance on file. During visit conducted on November 25, 2025, LPAs Michael Hood and Marisa Chiarelli observed S1 working at the facility without a criminal background clearance. As a result of the visit conducted on November 25, 2026, a deficiency was cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87355 Criminal Record Clearance (d) "All individuals subject to criminal record review shall be fingerprinted" (...) (3) "The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility." This requirement was not met based on LPA's observations, which determined facility did not ensure that a criminal record clearance was obtained for two (2) staff members.
During office meeting conducted on January 16, 2026, staffing concerns were discussed, including the need for hiring an interim Administrator. Licensee agreed to provide to LPA staff schedule bi-weekly as a result of the office meeting. During visit conducted on February 12, 2026, LPA observed that facility had yet to create a staff schedule to provide to LPA bi-weekly. Per interviews, LPA was informed that Licensee will have worked three (3) shifts in a row, including night shift for February 11, day shift for February 12, and night shift for February 12. As a result of visit conducted on February 12, 2026, a deficiency was cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87411 Personnel Requirements - General (a) "Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs." This requirement was not met based on interviews conducted and observations, which determined that the facility did not ensure to have sufficient staff to meet the residents’ needs.
** Report continued on 9099-C **
During visit conducted on February 18, 2026, LPA and Licensing Program Manager (LPM) Lauren Crocker toured the premises and conducted interviews, including resident (R1), Licensee, and House Manager. LPA and LPM also reviewed records for the residents. As a result of the visit conducted on February 18, 2026, a deficiency was cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87411 Personnel Requirements – General. This requirement was not met based on interviews conducted, observations, and records reviewed, which determined that the facility did not ensure to schedule staff to meet the needs of R1. Facility was required to schedule at minimum two (2) caregivers per shift to meet the level of care needs of the current residents and required to submit an updated staff schedule for the next six (6) weeks to LPA by POC due date of February 19, 2026.
Based on the information above, the allegation is determined to be substantiated. Due to care home receiving a citation for Section 87411 Personnel Requirements – General during visits conducted on February 12, 2026 and February 18, 2026, no additional citations will be issued. There will be no additional plan of corrections as the care home is now closed.
Allegation: Staff are not providing adequate food service to residents in care
During visit conducted on November 24, 2026, LPA observed approximately 18 expired food items in the pantry and refrigerator of the care home. All expired food items were pulled and disposed of during visit. Based on LPA’s observations, the allegation is determined to be substantiated.
Allegation: Staff did not ensure that complete resident records were maintained at the facility
During visit conducted on January 14, 2026, LPA reviewed records for all residents residing at the care home. LPA observed Personal Rights records missing for two (2) residents, Safeguard of Property/Valuables records missing for two (2) residents, and identification and emergency information missing for one (1) resident. During visit conducted in February 18, 2026, LPA and LPM observed care home to be missing pre-admission appraisal for R1. As a result of visit on February 18, 2026, deficiencies were cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87457 Pre-Admission Appraisal due to care home not completing a pre-admission appraisal for R1 prior to admission.
** Report continued on 9099-C **
During visit conducted on April 16, 2026, LPA requested medication documentation pertaining to R3 from January 14, 2026 to February 10, 2026. Facility could not provide requested documentation to LPA by the conclusion of the inspection. As a result of the visit conducted on April 16, 2026, a deficiency was issued pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87465 Incidental Medical and Dental Care (h) "The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year" (...). The requirement was not met based on LPA's observations and records reviewed, which determined that the facility did not ensure to maintain records of R3's centrally stored medications for at least one year. Based on the information above, the allegation is determined to be substantiated.
Allegation: Staff did not follow proper reporting requirements
On December 19, 2025, LPA received an Unusual Incident/Injury Report (LIC 624) from House Manager for resident (R4) with a date occurred listed as December 11, 2025. LPA did not received LIC 624 within seven (7) days of the incident occurrence per Title 22 regulations. Interviews conducted with S1 and House Manager indicated that R2 reported that they received R4’s medications. House Manager stated that they did not submit an incident report to the Department regarding incident. Based on interviews conducted, the allegation is determined to be substantiated.
Based on interviews conducted, observations, medication count, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D pages.
Facility is closed. A copy of this report and appeal rights were provided to the Licensee via certified mail.
During investigation, LPAs Michael Hood and Marisa Chiarelli observed cameras in the common areas of the care home. LPA Michael Hood did not observe cameras placed in any resident bedrooms or bathrooms. Interviews conducted with staff indicated that cameras were not operable and no one could identify who had access to footage from the cameras. Cameras were removed from the common areas during the investigation.
Based on interviews conducted and observations, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
Facility is closed. A copy of this report was provided to the Licensee via certified mail.
