Incident investigation·December 29, 2025

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident inspection. At 10:30 a.m., the LPA met with Executive Director (ED) Francesca West and Wellness Director (WD) Jovany Guerra and explained the reason for the visit. The reason for today's inspection is to follow up on a self-reported incident report and Report of Suspected Dependent Adult/ Elder Abuse (SOC 341) received on 12/19/2025, regarding three (3) staff members consuming alcohol and sleeping while working at the facility. On 12/17/2025, LPAs Peraldi and Huynh conducted a subsequent complaint visit for Complaint 29-AS-20251119143627 and LPA Peraldi Substantiated the allegation, “Staff sleep at the facility while on shift.” During the visit, LPA Peraldi Unsubstantiated the allegation “Staff members consumed alcohol during work hours, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care”, due to inconsistent statements provided by staff interviewed and insufficient evidence to corroborate the allegation. Per incident report and SOC 341, on 12/18/2025, the ED received pictures of three (3) staff members consuming alcohol and sleeping while working at the facility. On 12/19/2025, the ED began an internal investigation and contacted the Department regarding the pictures and information obtained from the day prior. On 12/19/2025, the three (3) staff members were terminated. The ED also provided copies of staff schedules and explained that residents’ care would not be interrupted by the terminations, as the ED and WD are providing assistance with residents’ care and supervision as needed. The ED explained that they are also in the process of hiring additional care staff. No immediate health and safety concerns were observed during today's inspection. Continued on LIC 809-C. Due to new information and evidence being presented, LPA Peraldi conducted today’s visit and cited the following: Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 809-D). Exit interview conducted. A copy of the report and appeal rights were provided.