Follow-up·March 24, 2025

Licensing Program Analyst Kelly Dulek arrived on 03/24/2025 at 03:40PM for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. The LPA intially met with front desk staff, then Director of Nursing and explained the reason for today's visit. LPA met with Executive Director Christian Castillo at 05:08PM. On October 26, 2022, the Department concluded a complaint investigation regarding the following allegations: Staff did not report a change in condition to resident's authorized representative; staff did not seek medical attention for resident in a timely manner; staff mismanaged resident's medication; staff did not ensure that resident's needs were met; and resident fell multiple times while in care. The licensee was cited for California Code of Regulations (CCR) 87466 Observation of the Resident, 87463(b) Reappraisals, 87464(f)(1) Basic Services, 87465(a)(4) Incidental Medical and Dental Care, and 87555(b)(5) General Food Service Requirements. At the time of the complaint visit on October 26, 2022, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). 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 Report Continued on LIC 809-C 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 the facility did not seek guidance for the resident’s changes of condition, including weight loss of 36 pounds, multiple hypoglycemic episodes, and fall events, which resulted in dehydration, acute kidney injury and hospitalization. Today, 03/24/2025, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department determines constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on October 26, 2022, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Executive Director Christian Castillo’s signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.