Follow-up·October 23, 2025

Licensing Program Analyst (LPA) Charlie Yang arrived on 10/23/2025 for an unannounced inspection to follow up on a case management visit in which deficiencies were cited related to injuries sustained by a resident in care. LPA Charlie Yang met with the facility designated Administrator Andrea Armstrong and explained the reason for the visit. On May 18, 2023, the Department conducted a case management visit and issued citations due to the facility not ensuring sufficient provisions were in place to aid in fall prevention of a resident (R1) after R1 sustained multiple falls over a four month period. The licensee was cited for violating California Code of Regulations (CCR) section 87405(h)(5) Administrator Qualifications and Duties and CCR section 87211(a)(D) Reporting Requirements. Today, the Department also issued a citation for CCR section 87464(d) Basic Services for not meeting R1’s needs after R1 was accepted for care. At the time of the visit on May 18, 2023, the issuance of a civil penalty was still being determined, and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code section 1569.49. 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 information gathered through file review and documentation, the licensee did not appropriately address multiple fall episodes of R1 which led to R1 sustaining a right forehead contusion with findings of a subdural hemorrhage, after a fall episode on September 28, 2022, and R1 seeking medical intervention related to a hip contusion on September 13, 2022. Today, 10/23/2025, the Department will be issuing a Civil Penalty per Health and Safety Code section 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of ten thousand dollars ($10,000). An exit interview was conducted, and a copy of this report was given to the facility designated Administrator Andrea Armstrong . Appeal Rights provided. The facility designated Administrator, Andrea Armstrong's , signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.