Follow-up·October 21, 2025

Licensing Program Analyst, Esther Cortez a rrived on October 21, 2025 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. The LPA met with Executive Director Christian Castillo. On February 1, 2024, the Department concluded a complaint investigation regarding the following allegation: Neglect/Lack of Care and Supervision – Resident (R1) choked to death without any medical intervention while under the care and supervision of the facility. The licensee was cited for California Code of Regulations (CCR) 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. At the time of the complaint visit on February 1, 2024, 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(e). The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that the Department determines resulted in the death of a resident. This is evidenced by the licensee and administrator not ensuring that a sufficient number of competent personnel were present and available to meet R1’s needs when R1 was observed choking on food, which resulted in death. Report will continue on LIC809-C, 2nd page. Today, October 21, 2025, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(e) for a violation that the Department determines resulted in the death of a resident in the amount of $15,000. However, since an immediate civil penalty of $500 was previously issued on February 1, 2024, the amount of the civil penalty issued today will be $14,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Executive Director Christian Castillo and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.