CDPH Issues Lowest Level Citations for Evictions It Forced Laguna Honda to Make

San Francisco – On December 20, 2022, the California Department of Public Health (CDPH) issued a dozen Class B citations to San Francisco’s Laguna Honda Nursing Home for the evictions of residents that led to at least eleven deaths.  Class B citations are the lowest class of fine issued by CDPH to skilled nursing facilities and come with a $3,000 fine, a mere slap on the wrist for repeated and lethal acts of elder abuse.

Laguna Honda’s residents have been living in crisis since the facility was decertified on April 14, 2022.  The federal Centers for Medicare and Medicaid Services (CMS) agreed to continue to fund Laguna Honda but required it to establish a closure plan.  CMS and CDPH then pressured Laguna Honda to immediately begin evicting some of its nearly 700 residents to any place that would take them, until two eviction “pauses” and the settlement of a City lawsuit postponed the evictions to February 2023.

Prior to the pauses and settlement, Laguna Honda evicted 57 residents, mostly to nursing homes outside of San Francisco that had poor track records.  Some were discharged to homeless shelters.

The CDPH citations are the first official confirmation that the evicted residents were subjected to nightmarish failures and cruelty:

• Laguna Honda selected extremely disabled, sick, and dependent residents for eviction, who were known to be at high risk for transfer trauma.  Many of the evicted residents had lived at Laguna Honda for years, and had become reliant on the facility environment and its routines.  These should have been the last residents to be evicted but instead they went first.
• The evicted residents received generic, non-individualized care plans that failed to provide for their well-being once they were evicted.  Laguna Honda’s doctors and nurses failed to provide the kind of follow-up care that may have minimized transfer trauma.  Once the residents were out of sight, they were out of mind.
• The evicted residents experienced severe transfer trauma, characterized primarily by diminished nutritional intake, weight loss, and death.  Of the twelve residents whose evictions were cited, eleven died within weeks of their eviction.
• Almost all of the residents had been assessed as “not discharge ready” due to their fragile health, yet they were discharged anyway.
• A 68 year-old resident with advanced dementia was knowingly evicted to a facility in the midst of a COVID-19 outbreak, where she became infected and died three days later.
• A 100 year-old resident, described in an assessment as a “frail tiny thin elderly woman, curled up in bed” died about three weeks after being evicted.

Meanwhile, instead of protecting residents’ rights and enforcing relocation protections for nursing home residents, CMS and CDPH pressured Laguna Honda to evict residents quickly, knowing it had no safe places to send them, and muting the residents’ right to appeal the evictions.  They also allowed operators with poor track records to roam Laguna Honda looking for residents to fill their beds.  Without question, CMS and CDPH played a lead role in endangering the residents who were evicted and died.  So it’s no surprise that CDPH issued only tiny fines and quietly posted the citations to its Cal Health Find website without taking any other actions to alert the public.

“CDPH must not be allowed to whitewash the deaths of these vulnerable residents and its own role in them,” said Patricia McGinnis, CANHR’s Executive Director. “We call on CMS to stop the Laguna Honda closure before more residents are killed, and the Legislature to investigate CDPH and hold its leaders accountable.”

Laguna Honda is the nation’s largest publicly run nursing home, housing more than a third of San Francisco’s nursing home residents.  As an irreplaceable resource for hundreds of the most vulnerable San Franciscans, it must be improved, preserved and protected.

The relevant citations can be read and downloaded in full length HERE (pdf files).