complaint·January 22, 2026

Continued form LIC9099) The facility initiated 24/7 one-on-one care using a third-party agency without prior family consent. ED Armour revealed that during the care conference, the family was not clearly informed that one-on-one care would be implemented. ED Armour also revealed a written notice was sent later via email after the service began. The department interviews with R1's Family members confirmed they were not informed prior to the initiation of one-on-one care and did not consent to its start. They later continued the service and paid for it but stated they never agreed to the initial implementation. The department's records review revealed the admission agreement authorizes the facility to require one-on-one care if the resident is a danger to self or others. However, the agreement and Health & Safety Code 1569.657 require written notice within two business days of initiating services at a new level of care, including a detailed explanation of additional services and charges. No documentation was provided showing timely written notice or a reassessment prior to initiating one-on-one care. LPA observations on October 27,2021 revealed R1 was receiving one-on-one care from a third-party agency during the visit. The facility failed to provide timely written notice within two business days of initiating one-on-one care and did not involve the R1's responsible person in care planning as required by the admission agreement and Health & Safety Code §1569.657. Regarding the allegation of an unlawful eviction, more specifically, the Reporting Party (RP) alleged that Resident #1(R1) eviction notice was invalid and retaliatory.  The department interviewed staff revealed that Executive Director David Armour confirmed R1's eviction notice was sent via email body only on 10/15/21, without attachments, and admitted it did not include Ombudsman contact or appeal rights. The department records review revealed that R1's  eviction notice lacked multiple required elements under HSC §§1569.682 and 1569.683, including specific facts supporting the eviction (dates, witnesses, circumstances): Relocation evaluation and resources for alternative housing; Ombudsman and CCL contact information; Complaint rights information; Mandatory unlawful detainer statement explaining court process; Formal written format (notice was sent via email body only). Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violations occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Wes Hebner to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.