Follow-up·April 28, 2026

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway arrived on April 28, 2026 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. The LPAs met with Administrator Denise Gilroy. On October 24, 2025, the Department concluded a complaint investigation regarding the allegation of Neglect/Lack of supervision: Facility employees failed to provide an appropriate level of supervision resulting in a resident (R1) falling multiple times and sustaining a fracture. The licensee was cited for California Code of Regulations (CCR) 87464(f)(1) Basic Services. At the time of the complaint visit on October 24, 2025, an immediate civil penalty of $500 was issued. Due to the fact that this was a repeated violation, an additional $500 was levied. 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 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 not providing care and supervision that resulted in R1’s multiple falls, sustaining a hip fracture, experiencing extreme physical pain, hospitalization, and operation. Report Continued on LIC 809-C Today, April 28, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on October 24, 2025, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Denise Gilroy and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.