By the River Assisted Living

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Type of visit: Case Management - Other

Licensing Program Analyst, Rebecca Knight arrived on September 01, 2026 for an unannounced inspection to follow up on a substantiated allegation of neglect resulting from an incident investigation. The licensee was unavailable for the visit and gave permission for administrator Lindsey Lang to meet with LPA. On July 1, 2025, the Department concluded an incident report investigation which alleged the following: Lack of supervision resulted in resident heat exposure and death. The Licensee was cited for California Code of Regulations (CCR), Title 22, §87411(a)- Personnel Requirements – General. At the time of the case management visit conducted on July 1, 2025, 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’s failure to protect a resident (R1) from exiting the premise and remaining unsupervised amid hazardous heat conditions for a prolonged period, resulting in the death of R1. Continued on LIC809-C Today, September 01, 2026, 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 July 1, 2025, the civil penalty issued today will be $14,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Administrator Lindsey Lang's name and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Sep 1, 2026

Type of visit: Required - 1 Year

11/13/2025 11:48 AM Licensing Program Analysts (LPAs) Rebecca Knight and Marisa Chiarelli arrived at the facility unannounced to conduct a Required-1 Year inspection. LPAs met with house manager Lindsey Lang and explained the purpose of the visit. Licensee/administrator Linda O'Sullivan ( 7008272740 exp. 06/22/2025) arrived shortly after. LPAs and staff toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to six (6) resident rooms, common areas, four (4) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. All employees requiring background checks are cleared. Administrator certificate has expired and a citation is being issued this date. There is a schedule of recreational activities planned for the residents. Bedding, linens, and towels for clients were observed and found to be clean and in good repair. Medication is locked in a locked room. Medications were reviewed. The facility was observed to be at a comfortable temperature. Hot water measured between 105 – 120 degrees F. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors are all operational. No pools/bodies of water are on premises. The facility has been conducting fire drills every 3 months. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, Nov 13, 2025

Type of visit: Case Management - Deficiencies

07/01/2025 11:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with licensees Mark & Linda O’Sullivan, and care staff Lindsey Lang. Today’s visit is regarding an incident that occurred on 06/29/2025 and was reported to licensing on 06/30/2025. It was reported that on 06/29/2025 at 3:30 PM Staff 1 (S1) saw Resident 1 (R1) heading to their room. At 04:50 PM S1 went to get R1 from their room for dinner, R1 was not in their room. S1 found R1 in the facility backyard almost laying down against the chicken coop. S1 checked R1 for breathing, heartbeat, and awareness. S1 carried R1 inside and placed R1 on a recliner. S1 placed ice packs wrapped in towels and wet wash cloth on R1's forehead, then called 911. R1 stopped breathing, S1 started CPR. EMS arrived and took over. R1 passed away in the facility. According to The City of Red Bluff past weather report the temperature was 106 degrees at 3:53 PM on 06/29/2025 as a high for that day. LPA requested the following documents during the visit: Admission agreement, Physicians Report, MAR for one resident, staffing schedule for the date of June 29 2025, meal schedule. Continued on LIC809-C Based on evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to licensee Linda O’Sullivan. At the time of the case management visit, an immediate civil penalty of $500 shall be assessed for a violation of California Code of Regulations § 87411(a) and is documented on the attached LIC421. The licensee has been informed that a civil penalty is under review and may be assessed at a future date according to Health and Safety Code §1569.49.the state’s words, verbatim · CDSS document, Jul 1, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 15, 2025

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on records review it was determined that the licensee failed to provide adequate care and supervision to R1 which resulted in R1 going out to the back yard of the facility on a hot day unknown to staff. This resulted in the death of the resident which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: A civil penalty in the amount of $500.00 was assessed today. The licensee agrees to provide a detailed plan explaining how they will ensure facility staff are competent and aware of how to properly provide care and supervision to residents during hot weather. Licensee to provide a plan to Licensing as to how they will ensure that the staff are alerted every time the exit doors open or close. This plan shall be completed and submitted within one week. In addition, the Licensee agrees to conduct a training for all staff on the requirement to ensure that all residents are accounted for at all times. Licensee will schedule the training and provide LPA signed staff attendance sheet as the POC. The proof of correction is to be received by LPA Knight by 07/15/2025.

Type of visit: Required - 1 Year

09/25/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with licensee/administrator Linda O'Sullivan ( 6027018740 06/22/2025 ) and explained the purpose of the visit. LPA Knight and the administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to six (6) resident rooms, common areas, four (4) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. All employees requiring background checks are cleared. Administrator certificate is current. There is a schedule of recreational activities planned for the residents. Bedding, linens, and towels for clients were observed and found to be clean and in good repair. Medication is locked in a locked room. The facility was observed to be at a comfortable temperature. Hot water measured between 105 – 120 degrees F. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors are all operational. No pools/bodies of water are on premises. Last disaster drill was conducted in July 2024 which was a fire drill, the facility has been conducting fire drills every 3 months. In the areas toured no immediate health, safety, or personal rights violations were observed. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report was provided to administrator Linda O'Sullivan.the state’s words, verbatim · CDSS document, Sep 17, 2024