Preview
1 KATHRYN A. STEBNER (SBN 121088)
KARMAN GUADAGNI (SBN 267631)
2 DEENA ZACHARIN (SBN 141249)
3 KELSEY CRAVEN (SBN 337179)
STEBNER GERTLER GUADAGNI & KAWAMOTO
4 A Professional Law Corporation
870 Market Street, Suite 1285
5 San Francisco, CA 94102
Tel: (415) 362-9800
6
Fax: (415) 362-9801
7
KIRSTEN FISH (SBN 217940)
8 NEEDHAM KEPNER & FISH LLP
1960 The Alameda, Suite 210
9 San Jose, CA 95126
Tel: (408) 244-2166
10
Fax: (408) 244-7815
11
Attorneys for Plaintiffs
12
13 SUPERIOR COURT OF THE STATE OF CALIFORNIA
14 IN AND FOR THE COUNTY OF KERN
15 BILLY CATES, Individually and as CASE NO. BCV-22-102864
Successor-In-Interest to the Estate of LOIS
16 CATES; BARBARA NEWTON, Individually; FIRST AMENDED COMPLAINT FOR
and PAUL CATES, Individually, DAMAGES
17
Plaintiffs, (1) Elder Abuse;
18 (2) Negligence;
vs. (3) Assault;
19 (4) Battery;
THE VILLAGE AT SEVEN OAKS AL MC,
LLC dba THE VILLAGE AT SEVEN OAKS (5) Wrongful Death; and
20 (6) Survivorship
ASSISTED LIVING AND MEMORY CARE;
21 SEVEN OAKS AL & MC; FRONTIER
MANAGEMENT LLC; FRONTIER SENIOR JURY TRIAL DEMANDED
22 LIVING, LLC; SAMANTHA DAVIDSON;
KELLAND LANCASTER and DOES 1-50,
23 Inclusive,
24 Defendants.
25 Plaintiffs BILLY CATES, Individually and as Successor-In-Interest to the Estate of LOIS
26 CATES; BARBARA NEWTON, Individually; and PAUL CATES, Individually (collectively
27 “Plaintiffs”), allege against Defendants THE VILLAGE AT SEVEN OAKS AL MC, LLC dba THE
-1 - FIRST AMENDED
COMPLAINT FOR DAMAGES
1 VILLAGE AT SEVEN OAKS ASSISTED LIVING AND MEMORY CARE; SEVEN OAKS AL
2 & MC, FRONTIER MANAGEMENT LLC; FRONTIER SENIOR LIVING, LLC; SAMANTHA
3 DAVIDSON, KELLAND LANCASTER and DOES 1-50 (collectively “Defendants”) as follows:
4 INTRODUCTION
5 1. LOIS CATES (hereinafter “Decedent”) was at all times herein mentioned a resident
6 of the County of Kern, State of California. Decedent was at all times herein mentioned an elder who
7 was substantially more vulnerable than other members of the public because of her age and
8 disability, and actually suffered substantial physical, emotional, or economic damage resulting from
9 the conduct described below.
10 2. Plaintiff BILLY CATES is the surviving husband of Decedent and the successor-in-
11 interest to the Estate of LOIS CATES. Plaintiffs BARBARA NEWTON and PAUL CATES are the
12 surviving children of Decedent. Plaintiffs are and were at all times herein mentioned residents of the
13 State of California.
14 3. At all times relevant, Defendants THE VILLAGE AT SEVEN OAKS AL MC, LLC
15 dba THE VILLAGE AT SEVEN OAKS ASSISTED LIVING AND MEMORY CARE; SEVEN
16 OAKS AL & MC; FRONTIER MANAGEMENT LLC; FRONTIER SENIOR LIVING, LLC;
17 SAMANTHA DAVIDSON and DOES 1-25 (collectively the “Frontier Defendants”) own and
18 operate and are the licensees of THE VILLAGE AT SEVEN OAKS ASSISTED LIVING AND
19 MEMORY CARE (referred to herein as “THE VILLAGE” or “Facility”), a licensed Residential
20 Care Facility for the Elderly (“RCFE”) as defined in Health and Safety Code Section 1564, et seq.,
21 located at 4301 Buena Vista Road, Bakersfield, CA 93311 in Kern County.
22 4. Defendant SAMANTHA DAVIDSON is and was the Executive Director of THE
23 VILLAGE at all relevant times listed herein. Plaintiffs are informed and believe, and accordingly
24 allege, that Defendant SAMANTHA DAVIDSON is and was at all times relevant to this complaint
25 a resident of the State of California. Plaintiffs are informed and believe, and accordingly allege, that
26 at all times relevant to this action, in her capacity as Executive Director, Defendant SAMANTHA
27 DAVIDSON is and was responsible for all operational activities of the Facility and for the day-to-
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COMPLAINT FOR DAMAGES
1 day functions of the Facility, including the duty to ensure the Facility is adequately staffed to meet
2 the needs of the residents and the duty to make sure the persons working in the Facility were
3 adequately trained to meet the needs of the residents. Plaintiffs are informed and believe, and
4 accordingly allege, that at all times relevant to this action, in her capacity as Executive Director,
5 Defendant SAMANTHA DAVIDSON exercised substantial discretionary authority over decisions
6 that ultimately determined the Frontier Defendants’ policies and procedures without getting
7 approval for those decisions from anyone else. For example, as the Executive Director of the
8 Facility, SAMANTHA DAVIDSON was more than a mere supervisory employee of the Frontier
9 Defendants, but rather had responsibility and authority over their corporate policies and procedures
10 at the Facility. For example, Plaintiffs are informed and believe, and accordingly allege, that the
11 Frontier Defendants held SAMANTHA DAVIDSON out to the California Department of Social
12 Services, Community Care Licensing Division (“DSS/CCL”) and everyone at the Facility as
13 belonging to the Frontier Defendants’ leadership group of officers, directors and managing agents
14 by giving her the responsibility and authority to sign Statements of Deficiencies on the Frontier
15 Defendants’ behalf and to approve the Frontier Defendants’ Plans of Correction as submitted to
16 DSS/CCL on their behalf.
17 5. Plaintiffs allege, upon information and belief, that the Frontier Defendants owned,
18 leased, licensed, operated, administered, managed, directed, and/or controlled and are “managing
19 agents” of THE VILLAGE and actively participated in and controlled the business of the Facility
20 during Decedent’s admission. Defendant FRONTIER SENIOR LIVING, LLC and Defendant
21 FRONTIER MANAGEMENT LLC both have their principal place of business at 7420 Bridgeport
22 Rd. #105 in Portland, Oregon. FRONTIER SENIOR LIVING, LLC is registered with the California
23 Secretary of State as a “Senior housing management company,” and FRONTIER MANAGEMENT
24 LLC is registered with the California Secretary or State as a business that exists for “senior
25 community living.” Plaintiffs are informed and believe, and accordingly allege, that FRONTIER
26 SENIOR LIVING, LLC and/or FRONTIER MANAGEMENT LLC must approve budgets,
27 marketing costs and other expenditures for all of the Frontier Defendants’ facilities, including THE
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COMPLAINT FOR DAMAGES
1 VILLAGE. Defendant SEVEN OAKS AL & MC is registered with the California Department of
2 Health, Community Care Licensing as the licensees of THE VILLAGE. Plaintiff is informed and
3 believes that FRONTIER SENIOR LIVING, LLC created FRONTIER MANAGEMENT LLC to
4 oversee operations at their RCFE facilities, including THE VILLAGE. Plaintiffs are informed and
5 believe that the Frontier Defendants acted jointly to make decisions regarding their facilities,
6 including THE VILLAGE. Plaintiffs are informed and believe that there was a Management
7 Agreement between THE VILLAGE and FRONTIER MANAGEMENT LLC, stating that
8 FRONTIER MANAGEMENT LLC will manage THE VILLAGE. Plaintiffs are informed and
9 believe that the Frontier Defendants drove the operations at THE VILLAGE, and that the Frontier
10 Defendants, and each of them, were aware of the laws, regulations and best practices related to
11 resident safety, and staffing procedures, yet failed to implement them despite knowing this would
12 put residents at the Facility at great risk. Plaintiffs are informed and believe that at all relevant times
13 the Frontier Defendants were participating in a joint venture, acting under an express or implied
14 agreement for a common purpose with a community of pecuniary purpose wherein each of the
15 Frontier Defendant has an equal right to a voice in the direction of the joint venture. Plaintiffs
16 allege that each of these Frontier Defendants was responsible in some capacity for the events alleged
17 herein or is a necessary party for obtaining relief.
18 6. The Frontier Defendants, by and through their corporate officers and directors, and
19 others presently unknown to Plaintiffs, acted recklessly and egregiously and later ratified the
20 conduct of their co-defendants in that they were aware that there was both an insufficient number of
21 staff and that the staff present at THE VILLAGE was not adequately trained, and were aware of the
22 relationship between understaffing and sub-standard provision of care to residents of the Facility,
23 including Decedent, which resulted in numerous poor outcomes, and numerous statements of
24 deficiencies being issued to the Facility by the California Department of Social Services. This
25 knowing flouting of regulations was part of the Frontier Defendants’ pattern and practice to cut
26 costs, thereby endangering the Facility’s elderly and dependent residents, including, but not limited
27 to, Decedent. Plaintiffs allege, upon information and belief, that the misconduct of the Frontier
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COMPLAINT FOR DAMAGES
1 Defendants which led to the injury to Decedent and Plaintiffs as alleged herein, was the direct result
2 and product of the financial and control policies and practices forced upon THE VILLAGE by the
3 financial limitations imposed upon the Facility by and through the Frontier Defendants’ corporate
4 officers, directors and managing agents.
5 7. KELLAND LANCASTER was a resident at THE VILLAGE who assaulted
6 Decedent on or about November 15, 2022 at the Facility. Plaintiffs are informed and believe that
7 KELLAND LANCASTER is and was at all times herein mentioned a resident of the County of
8 Kern, State of California.
9 8. Plaintiffs are ignorant of the true names and capacities, whether individual, corporate,
10 associate or otherwise and the true involvement of those defendants named and sued herein as
11 DOES 1-50, and for that reason has sued said defendants by such fictitious names. Plaintiffs will
12 seek leave to amend this complaint to reflect their true names when ascertained. Plaintiffs are
13 informed and believe, and accordingly allege, that each of the defendants sued herein as DOES 1-50
14 is responsible in some manner for the occurrences alleged in this action and that these defendants
15 proximately caused the harms suffered by Decedent and Plaintiffs.
16 9. Plaintiffs are further informed and believe, and accordingly allege, that at all relevant
17 times each of the Frontier Defendants was the employer, employee, agent, servant, alter ego,
18 principal, or subsidiary of the other Frontier Defendants and at all times acted within the course and
19 scope of such employment or agency and with the knowledge and approval of said co-defendants.
20 In particular, at all times material hereto, the Frontier Defendants individually and through their
21 officers, directors, and/or managing agents, (i) had advance knowledge of the unfitness of their
22 employees and employed said employees with a conscious disregard of the rights and safety of
23 others, (ii) authorized the wrongful conduct alleged in this complaint, and/or (iii) were personally
24 guilty of oppression, fraud, malice and/or recklessness.
25 10. Plaintiffs are further informed and believe, and accordingly allege, that at all relevant
26 times the Frontier Defendants, and each of them, were participating in a joint venture, acting under
27 an express or implied agreement for a common purpose with a community of pecuniary purpose
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COMPLAINT FOR DAMAGES
1 wherein each defendant has an equal right to a voice in the direction of the joint venture.
2 JURISDICTION AND VENUE
3 11. This Court has jurisdiction under Code of Civil Procedure §410.10. Plaintiff’s
4 damages exceed the jurisdictional minimum of this Court.
5 12. Venue is proper in Kern County under Code of Civil Procedure §395(a) because the
6 Frontier Defendants are doing business in this County, THE VILLAGE is situated in Bakersfield,
7 California, in Kern County, the incident described herein occurred in Kern County, and defendant
8 KELLAND LANCASTER is and at all times was a resident of Kern County.
9 FIRST CAUSE OF ACTION
10 (By BILLY CATES, as Successor-In-Interest to the Estate of LOIS CATES, for Elder Abuse
11 against the Frontier Defendants)
12 13. Plaintiffs refer to, and incorporate herein by this reference, all preceding paragraphs
13 and incorporates them into this First Cause of Action as though fully set forth herein.
14 14. THE VILLAGE is licensed as a residential care facility for the elderly (“RCFE”) as
15 defined in Health and Safety Code §1564, et seq. Pursuant to Section 1569.2(1) of the California
16 Health and Safety Code, “‘[r]esidential care facility for the elderly’ means a housing arrangement
17 chosen voluntarily by persons 60 years of age or over, or their authorized representative, where
18 varying levels and intensities of care and supervision, protective supervision, personal care, or
19 health-related services are provided, based upon their varying needs, as determined in order to be
20 admitted and to remain in the facility.” The law governing RCFEs is in large part set forth in
21 sections 1569 through 1569.87 of the California Health and Safety Code, and sections 87100
22 through 87730 of Title 22 of the California Code of Regulations.
23 15. Each adult resident of THE VILLAGE is a dependent adult and/or an elder as defined
24 by Welfare and Institutions Code §§15610.27 and 15610.23, respectively. The Frontier Defendants
25 knew or should have known that their conduct, as described below, was directed to one or more
26 senior citizens or dependent adults.
27 16. At all times mentioned, Decedent was an elder within the meaning of Welfare &
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COMPLAINT FOR DAMAGES
1 Institutions Code §15610, et seq.
2 17. Decedent, who was 89-years-old at the time of her injury at THE VILLAGE and who
3 suffered from dementia, was an elder who was substantially more vulnerable than other members of
4 the public to the conduct of Defendants because of her age, medical condition and cognitive
5 impairment, and Decedent actually suffered substantial physical, emotional, and economic damage
6 resulting from the conduct of Defendants, as described below.
7 18. At all times herein mentioned, the Frontier Defendants were providing for the care
8 and custody of Decedent and were “care custodians” under Welfare & Institutions Code §15610.17.
9 19. Decedent was admitted to THE VILLAGE on approximately May 12, 2019. During
10 Decedent’s admission to THE VILLAGE, she had multiple medical diagnoses, including, but not
11 limited to, chronic kidney disease, hypertension, hypothyroidism, ventricular tachycardia, and
12 vascular dementia. The Frontier Defendants knew at the time of Decedent’s admission to THE
13 VILLAGE that Plaintiff, due to her diagnoses, her age and her need for assistance with activities of
14 daily living, supervision and protection, was at risk for assault and required assistance and/or
15 supervision with her activity of daily living. However, Plaintiffs are informed and believe, and on
16 that basis allege, that no procedures were put in place by the Frontier Defendants to ensure Decedent
17 was not assaulted while a resident at THE VILLAGE and that the custodial care promised and
18 required to meet Decedent’s basic needs, including but not limited to care and supervision to protect
19 her from health and safety hazards, was not provided to her at THE VILLAGE.
20 20. Despite the Frontier Defendants’ knowledge of Decedent’s care needs, vulnerability,
21 risk for injury, and need for care and supervision due to her dementia, they did not take adequate
22 steps to prevent assaults at THE VILLAGE, to provide requisite supervision, monitoring, assistance
23 or protections, to properly assess or adequately care for Decedent, or to keep her safe and free from
24 health and safety hazards and injury at THE VILLAGE. Plaintiffs are informed and believe that the
25 Frontier Defendants’ Residence and Services Agreement for their Memory Care Unit states that
26 Defendants will provide for close monitoring of physical whereabouts and condition, as well as
27 behavior modification intervention and additional levels of programming support, staffing and staff
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COMPLAINT FOR DAMAGES
1 training.
2 21. On or about November 15, 2021, Defendants’ Facility staff called Decedent’s
3 daughter, BARBARA NEWTON, and told her that a “verbal altercation” had taken place involving
4 her mother and Facility resident KELLAND LANCASTER and that Decedent was going to be
5 moved to the Hoffman Hospice facility located at 4401 Buena Vista Road, a building directly south
6 of the main Facility building. BARBARA NEWTON came to visit her mother on or about November
7 20, 2022 and found that Decedent was suffering from several serious bruises on her face, breasts, and
8 chest and had multiple open wounds on both of her forearms, as shown below:
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22 22. Due to Decedent’s dementia, she was only able to tell BARBARA NEWTON that
23 “the bad man hurt me.” BARBARA NEWTON transported Decedent to the hospital on or about
24 November 20, 2022 in order to screen for any internal injuries, which the Frontier Defendants had
25 not done in violation of 22 C.C.R. § 87465(g). BARBARA NEWTON also called the Bakersfield
26 Police Department, something else the Frontier Defendants had not done in violation of 22 C.C.R. §
27 87465(g). The Bakersfield Police Department spoke to SAMANTHA DAVIDSON, the Executive
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COMPLAINT FOR DAMAGES
1 Director of the Facility, who stated that both Decedent and KELLAND LANCASTER were housed
2 in the Memory Care Unit at the Facility which is specifically designated for subjects who suffer
3 from dementia and Alzheimer’s. SAMANTHA DAVIDSON stated that she was informed of an
4 incident that occurred on November 15, 2021 at approximately 8:30 p.m. SAMANTHA
5 DAVIDSON stated that she was informed that an on duty caregiver identified as Heidi Shaefer
6 heard a loud verbal altercation down one of the hallways to the Memory Care Unit. SAMANTHA
7 DAVIDSON stated that when Shaefer went to investigate, she found KELLAND LANCASTER on
8 top of Decedent inside Decedent’s room as she was laying on her back in her bed. Shaefer told the
9 police department that KELLAND LANCASTER “was hitting on [Decedent]” and that “it was just
10 a crazy night [at the Facility].”
11 23. The California Department of Social Services, Community Care Licensing Division
12 (“DSS/CCL”) also investigated the attack on Decedent at the Frontier Defendants’ Facility.
13 DSS/CCL found that, on the night of the attack on Decedent – November 15, 2021, only 4 staff
14 members were on duty to supervise 36 residents in the Memory Care unit. Moreover, one staff
15 member was on break during the attack, “which only left Staff S1 and Staff S2 on duty the evening
16 of the incident.” According to the DSS/CCL investigation, Staff S1 “was able to pry Resident R2’s
17 hands off of [Decedent] to break up the altercation.” DSS/CCL found that the Frontier Defendants
18 sought emergency respite care for Decedent two days after the incident and that Decedent was taken
19 to the hospital five days after the incident occurred, but “[Decedent] had not yet been evaluated by
20 medical staff.” Based on its investigation, DSS/CCL found that “the facility did not provide care and
21 supervision which resulted in injury to [Decedent]” and that the “Facility did not call 9-1-1 after the
22 resident’s assault which poses an immediate Health, Safety and/or Personal Rights risk to residents
23 in care.” As a result, the Frontier Defendants were issued a statement of deficiency by DSS/CCL for
24 violating 22 C.C.R. § 87468.1(a)(3) by failing to ensure that Decedent was free from abuse, which
25 “pose[d] an immediate risk to residents in care.” The Frontier Defendants were also issued a
26 statement of deficiency by CCL for violating 22 C.C.R. § 87465(g) when “911 was not called and
27 medical attention was not received for [Decedent] until 5 days after the incident” and “[m]edical
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COMPLAINT FOR DAMAGES
1 treatment and police reporting was initiated by family of the resident,” which “pose[d] an immediate
2 risk to residents in care.” CCL also issued an immediate civil penalty to the Frontier Defendants
3 pursuant to Health & Safety Code § 1569.49(c)(1).
4 24. As a result of the November 15, 2021 assault and battery of Decedent at THE
5 VILLAGE, Decedent suffered numerous serious bruises and lacerations on her face, breasts, chest
6 and arms and was unable to ambulate afterwards. Decedent was also extremely upset, fearful and
7 disturbed by the traumatic experience of being attacked and beaten in her bed by a male resident at
8 the Facility. Decedent’s condition went dramatically downhill following the November 15, 2021
9 physical attack at THE VILLAGE and as a result, she died on July 20, 2022.
10 25. Prior to the November 15, 2021 physical attack on Decedent at the Facility, the
11 Frontier Defendants knew that Decedent was not able to care for or defend herself from attacks and
12 needed increased care and supervision due to her dementia. Plaintiffs are also informed and believe
13 that KELLAND LANCASTER had a history of violent behavior prior to the attack on Decedent that
14 was well known to the Frontier Defendants. Specifically, Plaintiffs are informed and believe that
15 KELLAND LANCASTER had been violent with his wife at home, which is why he was placed in
16 the Facility. In addition, Plaintiffs are informed and believe that prior to the attack on Decedent,
17 KELLAND LANCASTER had injured two other staff members at the Facility and that the Frontier
18 Defendants were therefore aware of his violent outbursts. However, despite this knowledge, the
19 Frontier Defendants consciously and recklessly failed to take any actions necessary to ensure
20 Decedent’s safety at THE VILLAGE, failed to protect her from health and safety hazards, and
21 subjected her to abuse, which caused her injury and death. While Decedent was a resident at THE
22 VILLAGE, Decedent was egregiously neglected, abused, and mistreated as set forth herein. The
23 Frontier Defendants failed to provide Decedent with a safe environment at the Facility, failed to
24 prevent health and safety hazards at the Facility and did not put safety interventions in place at the
25 Facility to keep her free from injury and assault. The Frontier Defendants failed to properly assess
26 Decedent and failed to provide her with the necessary care and assistance that she required to keep
27 her safe.
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COMPLAINT FOR DAMAGES
1 26. Pursuant to California law, the Frontier Defendants are required to provide an elder,
2 such as Decedent, “basic services” including, at a minimum, safe and healthful living
3 accommodations and services, regular observation of the resident, arrangements to meet the health
4 needs of a resident, adequately trained and sufficiently staffed employee levels necessary to provide
5 minimum services and oversight of residents, policies and procedures to ensure that basic services
6 and oversight are implemented to assure health and safety of residents, employment and training of
7 staff such that staff is experienced and competent to perform the job duties necessary to assure
8 safety and oversight of residents, accepting, training and employing staff in a manner that avoids “a
9 revolving door” of crucial managerial employees such that there is little or no continuity and/or an
10 absence of crucial managerial employees at critical times.
11 27. The Frontier Defendants failed to ensure that Decedent was provided with continuing
12 supervision and assessment of her care needs while at THE VILLAGE and failed to protect
13 Decedent from known health and safety hazards. This failure by the Frontier Defendants had a
14 direct relationship to the health and safety of Decedent and proximately caused her injuries and
15 death, as described herein.
16 28. At the time that Decedent was admitted to THE VILLAGE, the Frontier Defendants
17 knew that according to their plan to increase profits at the expense of residents such as Decedent, the
18 operation of THE VILLAGE was neither designed, administered, nor funded in a manner
19 reasonably necessary to provide adequate care, oversight and integration Decedent into the Facility.
20 The Frontier Defendants and their managing agents had knowledge of, ratified and/or otherwise
21 authorized all of the acts or omissions, which caused the injuries to Decedent. The Frontier
22 Defendants and their managing agents knew that their operation was designed in a manner so as to
23 maximize profitability by circumventing the legal duty to assure the health, safety and oversight of
24 residents such as Decedent, and, in particular, the duty to provide oversight and management of
25 Decedent during her residency at THE VILLAGE. The Frontier Defendants, and each of them,
26 knew or should have known that THE VILLAGE’s operations were designed and operated by the
27 Frontier Defendants in a manner to circumvent their legal duty to comply with applicable statutes
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COMPLAINT FOR DAMAGES
1 and regulations so as to maximize profitability. That knowledge was exclusively in the possession
2 of the Frontier Defendants and their managing agents. Neither Decedent nor Plaintiffs had any such
3 knowledge, or the opportunity to obtain such knowledge and information. Decedent and her family
4 believed that the Frontier Defendants’ business operations were, as represented by the Frontier
5 Defendants, properly run in compliance with the law and that the care afforded to its residents was
6 within all State guidelines. In particular, they understood that the management and staff of THE
7 VILLAGE were “experts” and were readily familiar, capable, able and committed to the care and
8 oversight of residents with dementia such as Decedent.
9 29. The Frontier Defendants, and each of them, had responsibility for meeting the basic
10 needs of Decedent, including her health and safety. Although the Frontier Defendants knew of
11 conditions that made Decedent unable to provide for her own basic needs and safety as described
12 herein, the Frontier Defendants denied and withheld goods or services necessary to meet Decedent’s
13 basic needs as described herein. The Frontier Defendants denied and withheld this basic care to
14 Decedent despite the knowledge that by doing so, injury was substantially certain to befall Decedent
15 or with conscious disregard of the high probability of such injury. The Frontier Defendants’
16 reckless and egregious denial and withholding of basic care to Decedent caused her injuries and
17 death as described herein.
18 30. Specifically, the Frontier Defendants, and each of them, recklessly and egregiously
19 failed to take necessary precautions to protect Decedent from assaults and serious injury, and these
20 failures caused her injury and death. The Frontier Defendants failed to provide Decedent with
21 supervision and assistance that she required, failed to provide her with comprehensive assessments,
22 failed to provide her with assistance for activities of daily living, and failed to protect her from
23 health and safety hazards, which caused her injury and death. The Frontier Defendants failed to
24 implement timely and adequate interventions, which caused her injury and death.
25 31. At all times relevant, the Frontier Defendants, and each of them, knew of Decedent’s
26 condition and the critical need to monitor and treat her condition properly and to provide adequate
27 custodial care and supervision to her at all times. However, the Frontier Defendants recklessly and
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COMPLAINT FOR DAMAGES
1 egregiously failed to provide custodial care to Decedent despite her condition, including her known
2 history of dementia. The Frontier Defendants’ conduct, as detailed herein, was reckless, egregious
3 and in conscious disregard of Decedent’s rights and safety.
4 32. As a result of the acts and omissions of Defendants, and each of them, Decedent was
5 violently attacked and suffered trauma which required hospitalization and hospice care and which
6 caused her severe pain and a significant decline in condition and caused her untimely death.
7 33. As described in detail herein, the Frontier Defendants recklessly failed to use
8 ordinary care, and such other care as is prescribed by law, regarding the care and protection of
9 Decedent while a resident of THE VILLAGE. In particular, and without limiting the generality of
10 the foregoing, Plaintiffs are informed and believes that the Frontier Defendants:
11 a. Failed to provide comprehensive care and supervision to its residents at THE
12 VILLAGE, including Decedent, as defined in 22 C.C.R. § 87101(c)(3) and Health
13 and Safety Code § 1569.2(c) and as required by 22 C.C.R. § 87464(f)(1);
14 b. Failed to maintain RCFE personnel in sufficient numbers at all times at THE
15 VILLAGE, and competent to provide the services necessary to meet resident needs,
16 including Decedent’s, as required by 22 C.C.R. § 87411;
17 c. Failed to provide safe accommodations to Decedent at THE VILLAGE in violation
18 of 22 C.C.R. § 87468.1(a)(2);
19 d. Failed to maintain dignity and prevent mental and physical abuse of Decedent at
20 THE VILLAGE as required by 22 C.C.R. § 87468.1(a)(3);
21 e. Failed to immediately telephone 911 if an injury or other circumstance has resulted in
22 an imminent threat to a resident’s health including, but not limited to, an apparent
23 life-threatening medical crisis as required by 22 C.C.R. § 87465(g) and 22 C.C.R. §
24 87211;
25 f. Failed to adhere to 22 C.C.R. 87455 with respect to KELLAND LANCASTER,
26 which states “No resident shall be accepted or retained if any of the following apply:
27 (3) The resident's primary need for care and supervision results from either: (A) An
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COMPLAINT FOR DAMAGES
1 ongoing behavior, caused by a mental disorder, that would upset the general resident
2 group;
3 g. Failed to adhere to 22 C.C.R. § 87461 with respect to KELLAND LANCASTER,
4 which states that “The facility shall determine the amount of supervision necessary by
5 assessing the mental status of the prospective resident to determine if the individual:
6 (5) has a documented history of behaviors which may result in harm to self or
7 others”; and
8 h. Made false and/or misleading statements regarding the services and staffing the
9 Frontier Defendants would provide in violation of 22 C.C.R. § 87207.
10 The foregoing regulations define the duties of care owed to the residents of RCFEs such as
11 Decedent. The Frontier Defendants’ violations of these regulations constitute a negligent failure to
12 exercise the care that a similarly situated reasonable person would exercise and/or a failure to protect
13 Decedent from health and safety hazards. Further, the Frontier Defendants promoted, advertised,
14 and held their Memory Care unit at THE VILLAGE out in their marketing materials as specifically
15 being a safe and secure environment for residents such as Decedent.
16 34. During Decedent’s admission to THE VILLAGE, the Frontier Defendants recklessly
17 and egregiously created a dangerous situation at the Facility that exposed all residents, including
18 Decedent, to harm. Plaintiffs are informed and believe that all of the residents at the Facility suffer
19 from memory impairment or other cognitive issues. Plaintiffs are informed and believe that many of
20 the residents lack the ability to control their behavior and can, and have, lashed out at other
21 residents, resulting in a dangerous environment for the Facility’s residents, including Decedent. Yet
22 despite the Frontier Defendants’ knowledge that residents need to be observed, monitored, and kept
23 engaged to prevent physical harm to the residents, the Frontier Defendants failed to adequately staff
24 the Facility, failed to adequately train staff and gave residents unfettered access to each other by
25 allowing residents to roam the Facility unattended to, unsupervised, and unengaged. As a result, a
26 dangerous situation was created that resulted in direct harm to Decedent. Plaintiffs are informed and
27 believe that the Frontier Defendants were aware of the high needs of their residents, including
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COMPLAINT FOR DAMAGES
1 Decedent, yet failed to provide a sufficient number of trained staff to provide care for their residents.
2 As a result of this failure, the Frontier Defendants exposed all of their residents to the ongoing risk
3 of serious harm and death. As a result of this failure by the Frontier Defendants and their managing
4 agents, Decedent was harmed and died.
5 35. The acts and omissions by the Frontier Defendants, as described herein, were not
6 only to Decedent, but, instead, were part of a continual pattern at THE VILLAGE in failing to
7 provide adequate care and supervision, failing to provide a safe and secure environment, and other
8 inadequacies that resulted in residents assaulting people at THE VILLAGE even prior to the
9 November 15, 2021 assault of Decedent at THE VILLAGE. This pattern of substandard care was
10 well known to the Frontier Defendants’ managing agents prior November 15, 2021, including but
11 not limited to THE VILLAGE’s Executive Director, SAMANTHA DAVIDSON, and other
12 managing agents.
13 36. Despite knowing of Decedent’s condition and her need for assistance, supervision an
Preview
1 KATHRYN A. STEBNER (SBN 121088) KARMAN GUADAGNI (SBN 267631) 2 DEENA ZACHARIN (SBN 141249) 3 KELSEY CRAVEN (SBN 337179) STEBNER GERTLER GUADAGNI & KAWAMOTO 4 A Professional Law Corporation 870 Market Street, Suite 1285 5 San Francisco, CA 94102 Tel: (415) 362-9800 6 Fax: (415) 362-9801 7 KIRSTEN FISH (SBN 217940) 8 NEEDHAM KEPNER & FISH LLP 1960 The Alameda, Suite 210 9 San Jose, CA 95126 Tel: (408) 244-2166 10 Fax: (408) 244-7815 11 Attorneys for Plaintiffs 12 13 SUPERIOR COURT OF THE STATE OF CALIFORNIA 14 IN AND FOR THE COUNTY OF KERN 15 BILLY CATES, Individually and as CASE NO. BCV-22-102864 Successor-In-Interest to the Estate of LOIS 16 CATES; BARBARA NEWTON, Individually; FIRST AMENDED COMPLAINT FOR and PAUL CATES, Individually, DAMAGES 17 Plaintiffs, (1) Elder Abuse; 18 (2) Negligence; vs. (3) Assault; 19 (4) Battery; THE VILLAGE AT SEVEN OAKS AL MC, LLC dba THE VILLAGE AT SEVEN OAKS (5) Wrongful Death; and 20 (6) Survivorship ASSISTED LIVING AND MEMORY CARE; 21 SEVEN OAKS AL & MC; FRONTIER MANAGEMENT LLC; FRONTIER SENIOR JURY TRIAL DEMANDED 22 LIVING, LLC; SAMANTHA DAVIDSON; KELLAND LANCASTER and DOES 1-50, 23 Inclusive, 24 Defendants. 25 Plaintiffs BILLY CATES, Individually and as Successor-In-Interest to the Estate of LOIS 26 CATES; BARBARA NEWTON, Individually; and PAUL CATES, Individually (collectively 27 “Plaintiffs”), allege against Defendants THE VILLAGE AT SEVEN OAKS AL MC, LLC dba THE -1 - FIRST AMENDED COMPLAINT FOR DAMAGES 1 VILLAGE AT SEVEN OAKS ASSISTED LIVING AND MEMORY CARE; SEVEN OAKS AL 2 & MC, FRONTIER MANAGEMENT LLC; FRONTIER SENIOR LIVING, LLC; SAMANTHA 3 DAVIDSON, KELLAND LANCASTER and DOES 1-50 (collectively “Defendants”) as follows: 4 INTRODUCTION 5 1. LOIS CATES (hereinafter “Decedent”) was at all times herein mentioned a resident 6 of the County of Kern, State of California. Decedent was at all times herein mentioned an elder who 7 was substantially more vulnerable than other members of the public because of her age and 8 disability, and actually suffered substantial physical, emotional, or economic damage resulting from 9 the conduct described below. 10 2. Plaintiff BILLY CATES is the surviving husband of Decedent and the successor-in- 11 interest to the Estate of LOIS CATES. Plaintiffs BARBARA NEWTON and PAUL CATES are the 12 surviving children of Decedent. Plaintiffs are and were at all times herein mentioned residents of the 13 State of California. 14 3. At all times relevant, Defendants THE VILLAGE AT SEVEN OAKS AL MC, LLC 15 dba THE VILLAGE AT SEVEN OAKS ASSISTED LIVING AND MEMORY CARE; SEVEN 16 OAKS AL & MC; FRONTIER MANAGEMENT LLC; FRONTIER SENIOR LIVING, LLC; 17 SAMANTHA DAVIDSON and DOES 1-25 (collectively the “Frontier Defendants”) own and 18 operate and are the licensees of THE VILLAGE AT SEVEN OAKS ASSISTED LIVING AND 19 MEMORY CARE (referred to herein as “THE VILLAGE” or “Facility”), a licensed Residential 20 Care Facility for the Elderly (“RCFE”) as defined in Health and Safety Code Section 1564, et seq., 21 located at 4301 Buena Vista Road, Bakersfield, CA 93311 in Kern County. 22 4. Defendant SAMANTHA DAVIDSON is and was the Executive Director of THE 23 VILLAGE at all relevant times listed herein. Plaintiffs are informed and believe, and accordingly 24 allege, that Defendant SAMANTHA DAVIDSON is and was at all times relevant to this complaint 25 a resident of the State of California. Plaintiffs are informed and believe, and accordingly allege, that 26 at all times relevant to this action, in her capacity as Executive Director, Defendant SAMANTHA 27 DAVIDSON is and was responsible for all operational activities of the Facility and for the day-to- -2 - FIRST AMENDED COMPLAINT FOR DAMAGES 1 day functions of the Facility, including the duty to ensure the Facility is adequately staffed to meet 2 the needs of the residents and the duty to make sure the persons working in the Facility were 3 adequately trained to meet the needs of the residents. Plaintiffs are informed and believe, and 4 accordingly allege, that at all times relevant to this action, in her capacity as Executive Director, 5 Defendant SAMANTHA DAVIDSON exercised substantial discretionary authority over decisions 6 that ultimately determined the Frontier Defendants’ policies and procedures without getting 7 approval for those decisions from anyone else. For example, as the Executive Director of the 8 Facility, SAMANTHA DAVIDSON was more than a mere supervisory employee of the Frontier 9 Defendants, but rather had responsibility and authority over their corporate policies and procedures 10 at the Facility. For example, Plaintiffs are informed and believe, and accordingly allege, that the 11 Frontier Defendants held SAMANTHA DAVIDSON out to the California Department of Social 12 Services, Community Care Licensing Division (“DSS/CCL”) and everyone at the Facility as 13 belonging to the Frontier Defendants’ leadership group of officers, directors and managing agents 14 by giving her the responsibility and authority to sign Statements of Deficiencies on the Frontier 15 Defendants’ behalf and to approve the Frontier Defendants’ Plans of Correction as submitted to 16 DSS/CCL on their behalf. 17 5. Plaintiffs allege, upon information and belief, that the Frontier Defendants owned, 18 leased, licensed, operated, administered, managed, directed, and/or controlled and are “managing 19 agents” of THE VILLAGE and actively participated in and controlled the business of the Facility 20 during Decedent’s admission. Defendant FRONTIER SENIOR LIVING, LLC and Defendant 21 FRONTIER MANAGEMENT LLC both have their principal place of business at 7420 Bridgeport 22 Rd. #105 in Portland, Oregon. FRONTIER SENIOR LIVING, LLC is registered with the California 23 Secretary of State as a “Senior housing management company,” and FRONTIER MANAGEMENT 24 LLC is registered with the California Secretary or State as a business that exists for “senior 25 community living.” Plaintiffs are informed and believe, and accordingly allege, that FRONTIER 26 SENIOR LIVING, LLC and/or FRONTIER MANAGEMENT LLC must approve budgets, 27 marketing costs and other expenditures for all of the Frontier Defendants’ facilities, including THE -3 - FIRST AMENDED COMPLAINT FOR DAMAGES 1 VILLAGE. Defendant SEVEN OAKS AL & MC is registered with the California Department of 2 Health, Community Care Licensing as the licensees of THE VILLAGE. Plaintiff is informed and 3 believes that FRONTIER SENIOR LIVING, LLC created FRONTIER MANAGEMENT LLC to 4 oversee operations at their RCFE facilities, including THE VILLAGE. Plaintiffs are informed and 5 believe that the Frontier Defendants acted jointly to make decisions regarding their facilities, 6 including THE VILLAGE. Plaintiffs are informed and believe that there was a Management 7 Agreement between THE VILLAGE and FRONTIER MANAGEMENT LLC, stating that 8 FRONTIER MANAGEMENT LLC will manage THE VILLAGE. Plaintiffs are informed and 9 believe that the Frontier Defendants drove the operations at THE VILLAGE, and that the Frontier 10 Defendants, and each of them, were aware of the laws, regulations and best practices related to 11 resident safety, and staffing procedures, yet failed to implement them despite knowing this would 12 put residents at the Facility at great risk. Plaintiffs are informed and believe that at all relevant times 13 the Frontier Defendants were participating in a joint venture, acting under an express or implied 14 agreement for a common purpose with a community of pecuniary purpose wherein each of the 15 Frontier Defendant has an equal right to a voice in the direction of the joint venture. Plaintiffs 16 allege that each of these Frontier Defendants was responsible in some capacity for the events alleged 17 herein or is a necessary party for obtaining relief. 18 6. The Frontier Defendants, by and through their corporate officers and directors, and 19 others presently unknown to Plaintiffs, acted recklessly and egregiously and later ratified the 20 conduct of their co-defendants in that they were aware that there was both an insufficient number of 21 staff and that the staff present at THE VILLAGE was not adequately trained, and were aware of the 22 relationship between understaffing and sub-standard provision of care to residents of the Facility, 23 including Decedent, which resulted in numerous poor outcomes, and numerous statements of 24 deficiencies being issued to the Facility by the California Department of Social Services. This 25 knowing flouting of regulations was part of the Frontier Defendants’ pattern and practice to cut 26 costs, thereby endangering the Facility’s elderly and dependent residents, including, but not limited 27 to, Decedent. Plaintiffs allege, upon information and belief, that the misconduct of the Frontier -4 - FIRST AMENDED COMPLAINT FOR DAMAGES 1 Defendants which led to the injury to Decedent and Plaintiffs as alleged herein, was the direct result 2 and product of the financial and control policies and practices forced upon THE VILLAGE by the 3 financial limitations imposed upon the Facility by and through the Frontier Defendants’ corporate 4 officers, directors and managing agents. 5 7. KELLAND LANCASTER was a resident at THE VILLAGE who assaulted 6 Decedent on or about November 15, 2022 at the Facility. Plaintiffs are informed and believe that 7 KELLAND LANCASTER is and was at all times herein mentioned a resident of the County of 8 Kern, State of California. 9 8. Plaintiffs are ignorant of the true names and capacities, whether individual, corporate, 10 associate or otherwise and the true involvement of those defendants named and sued herein as 11 DOES 1-50, and for that reason has sued said defendants by such fictitious names. Plaintiffs will 12 seek leave to amend this complaint to reflect their true names when ascertained. Plaintiffs are 13 informed and believe, and accordingly allege, that each of the defendants sued herein as DOES 1-50 14 is responsible in some manner for the occurrences alleged in this action and that these defendants 15 proximately caused the harms suffered by Decedent and Plaintiffs. 16 9. Plaintiffs are further informed and believe, and accordingly allege, that at all relevant 17 times each of the Frontier Defendants was the employer, employee, agent, servant, alter ego, 18 principal, or subsidiary of the other Frontier Defendants and at all times acted within the course and 19 scope of such employment or agency and with the knowledge and approval of said co-defendants. 20 In particular, at all times material hereto, the Frontier Defendants individually and through their 21 officers, directors, and/or managing agents, (i) had advance knowledge of the unfitness of their 22 employees and employed said employees with a conscious disregard of the rights and safety of 23 others, (ii) authorized the wrongful conduct alleged in this complaint, and/or (iii) were personally 24 guilty of oppression, fraud, malice and/or recklessness. 25 10. Plaintiffs are further informed and believe, and accordingly allege, that at all relevant 26 times the Frontier Defendants, and each of them, were participating in a joint venture, acting under 27 an express or implied agreement for a common purpose with a community of pecuniary purpose -5 - FIRST AMENDED COMPLAINT FOR DAMAGES 1 wherein each defendant has an equal right to a voice in the direction of the joint venture. 2 JURISDICTION AND VENUE 3 11. This Court has jurisdiction under Code of Civil Procedure §410.10. Plaintiff’s 4 damages exceed the jurisdictional minimum of this Court. 5 12. Venue is proper in Kern County under Code of Civil Procedure §395(a) because the 6 Frontier Defendants are doing business in this County, THE VILLAGE is situated in Bakersfield, 7 California, in Kern County, the incident described herein occurred in Kern County, and defendant 8 KELLAND LANCASTER is and at all times was a resident of Kern County. 9 FIRST CAUSE OF ACTION 10 (By BILLY CATES, as Successor-In-Interest to the Estate of LOIS CATES, for Elder Abuse 11 against the Frontier Defendants) 12 13. Plaintiffs refer to, and incorporate herein by this reference, all preceding paragraphs 13 and incorporates them into this First Cause of Action as though fully set forth herein. 14 14. THE VILLAGE is licensed as a residential care facility for the elderly (“RCFE”) as 15 defined in Health and Safety Code §1564, et seq. Pursuant to Section 1569.2(1) of the California 16 Health and Safety Code, “‘[r]esidential care facility for the elderly’ means a housing arrangement 17 chosen voluntarily by persons 60 years of age or over, or their authorized representative, where 18 varying levels and intensities of care and supervision, protective supervision, personal care, or 19 health-related services are provided, based upon their varying needs, as determined in order to be 20 admitted and to remain in the facility.” The law governing RCFEs is in large part set forth in 21 sections 1569 through 1569.87 of the California Health and Safety Code, and sections 87100 22 through 87730 of Title 22 of the California Code of Regulations. 23 15. Each adult resident of THE VILLAGE is a dependent adult and/or an elder as defined 24 by Welfare and Institutions Code §§15610.27 and 15610.23, respectively. The Frontier Defendants 25 knew or should have known that their conduct, as described below, was directed to one or more 26 senior citizens or dependent adults. 27 16. At all times mentioned, Decedent was an elder within the meaning of Welfare & -6 - FIRST AMENDED COMPLAINT FOR DAMAGES 1 Institutions Code §15610, et seq. 2 17. Decedent, who was 89-years-old at the time of her injury at THE VILLAGE and who 3 suffered from dementia, was an elder who was substantially more vulnerable than other members of 4 the public to the conduct of Defendants because of her age, medical condition and cognitive 5 impairment, and Decedent actually suffered substantial physical, emotional, and economic damage 6 resulting from the conduct of Defendants, as described below. 7 18. At all times herein mentioned, the Frontier Defendants were providing for the care 8 and custody of Decedent and were “care custodians” under Welfare & Institutions Code §15610.17. 9 19. Decedent was admitted to THE VILLAGE on approximately May 12, 2019. During 10 Decedent’s admission to THE VILLAGE, she had multiple medical diagnoses, including, but not 11 limited to, chronic kidney disease, hypertension, hypothyroidism, ventricular tachycardia, and 12 vascular dementia. The Frontier Defendants knew at the time of Decedent’s admission to THE 13 VILLAGE that Plaintiff, due to her diagnoses, her age and her need for assistance with activities of 14 daily living, supervision and protection, was at risk for assault and required assistance and/or 15 supervision with her activity of daily living. However, Plaintiffs are informed and believe, and on 16 that basis allege, that no procedures were put in place by the Frontier Defendants to ensure Decedent 17 was not assaulted while a resident at THE VILLAGE and that the custodial care promised and 18 required to meet Decedent’s basic needs, including but not limited to care and supervision to protect 19 her from health and safety hazards, was not provided to her at THE VILLAGE. 20 20. Despite the Frontier Defendants’ knowledge of Decedent’s care needs, vulnerability, 21 risk for injury, and need for care and supervision due to her dementia, they did not take adequate 22 steps to prevent assaults at THE VILLAGE, to provide requisite supervision, monitoring, assistance 23 or protections, to properly assess or adequately care for Decedent, or to keep her safe and free from 24 health and safety hazards and injury at THE VILLAGE. Plaintiffs are informed and believe that the 25 Frontier Defendants’ Residence and Services Agreement for their Memory Care Unit states that 26 Defendants will provide for close monitoring of physical whereabouts and condition, as well as 27 behavior modification intervention and additional levels of programming support, staffing and staff -7 - FIRST AMENDED COMPLAINT FOR DAMAGES 1 training. 2 21. On or about November 15, 2021, Defendants’ Facility staff called Decedent’s 3 daughter, BARBARA NEWTON, and told her that a “verbal altercation” had taken place involving 4 her mother and Facility resident KELLAND LANCASTER and that Decedent was going to be 5 moved to the Hoffman Hospice facility located at 4401 Buena Vista Road, a building directly south 6 of the main Facility building. BARBARA NEWTON came to visit her mother on or about November 7 20, 2022 and found that Decedent was suffering from several serious bruises on her face, breasts, and 8 chest and had multiple open wounds on both of her forearms, as shown below: 9 10 11 12 13 14 15 16 17 18 19 20 21 22 22. Due to Decedent’s dementia, she was only able to tell BARBARA NEWTON that 23 “the bad man hurt me.” BARBARA NEWTON transported Decedent to the hospital on or about 24 November 20, 2022 in order to screen for any internal injuries, which the Frontier Defendants had 25 not done in violation of 22 C.C.R. § 87465(g). BARBARA NEWTON also called the Bakersfield 26 Police Department, something else the Frontier Defendants had not done in violation of 22 C.C.R. § 27 87465(g). The Bakersfield Police Department spoke to SAMANTHA DAVIDSON, the Executive -8 - FIRST AMENDED COMPLAINT FOR DAMAGES 1 Director of the Facility, who stated that both Decedent and KELLAND LANCASTER were housed 2 in the Memory Care Unit at the Facility which is specifically designated for subjects who suffer 3 from dementia and Alzheimer’s. SAMANTHA DAVIDSON stated that she was informed of an 4 incident that occurred on November 15, 2021 at approximately 8:30 p.m. SAMANTHA 5 DAVIDSON stated that she was informed that an on duty caregiver identified as Heidi Shaefer 6 heard a loud verbal altercation down one of the hallways to the Memory Care Unit. SAMANTHA 7 DAVIDSON stated that when Shaefer went to investigate, she found KELLAND LANCASTER on 8 top of Decedent inside Decedent’s room as she was laying on her back in her bed. Shaefer told the 9 police department that KELLAND LANCASTER “was hitting on [Decedent]” and that “it was just 10 a crazy night [at the Facility].” 11 23. The California Department of Social Services, Community Care Licensing Division 12 (“DSS/CCL”) also investigated the attack on Decedent at the Frontier Defendants’ Facility. 13 DSS/CCL found that, on the night of the attack on Decedent – November 15, 2021, only 4 staff 14 members were on duty to supervise 36 residents in the Memory Care unit. Moreover, one staff 15 member was on break during the attack, “which only left Staff S1 and Staff S2 on duty the evening 16 of the incident.” According to the DSS/CCL investigation, Staff S1 “was able to pry Resident R2’s 17 hands off of [Decedent] to break up the altercation.” DSS/CCL found that the Frontier Defendants 18 sought emergency respite care for Decedent two days after the incident and that Decedent was taken 19 to the hospital five days after the incident occurred, but “[Decedent] had not yet been evaluated by 20 medical staff.” Based on its investigation, DSS/CCL found that “the facility did not provide care and 21 supervision which resulted in injury to [Decedent]” and that the “Facility did not call 9-1-1 after the 22 resident’s assault which poses an immediate Health, Safety and/or Personal Rights risk to residents 23 in care.” As a result, the Frontier Defendants were issued a statement of deficiency by DSS/CCL for 24 violating 22 C.C.R. § 87468.1(a)(3) by failing to ensure that Decedent was free from abuse, which 25 “pose[d] an immediate risk to residents in care.” The Frontier Defendants were also issued a 26 statement of deficiency by CCL for violating 22 C.C.R. § 87465(g) when “911 was not called and 27 medical attention was not received for [Decedent] until 5 days after the incident” and “[m]edical -9 - FIRST AMENDED COMPLAINT FOR DAMAGES 1 treatment and police reporting was initiated by family of the resident,” which “pose[d] an immediate 2 risk to residents in care.” CCL also issued an immediate civil penalty to the Frontier Defendants 3 pursuant to Health & Safety Code § 1569.49(c)(1). 4 24. As a result of the November 15, 2021 assault and battery of Decedent at THE 5 VILLAGE, Decedent suffered numerous serious bruises and lacerations on her face, breasts, chest 6 and arms and was unable to ambulate afterwards. Decedent was also extremely upset, fearful and 7 disturbed by the traumatic experience of being attacked and beaten in her bed by a male resident at 8 the Facility. Decedent’s condition went dramatically downhill following the November 15, 2021 9 physical attack at THE VILLAGE and as a result, she died on July 20, 2022. 10 25. Prior to the November 15, 2021 physical attack on Decedent at the Facility, the 11 Frontier Defendants knew that Decedent was not able to care for or defend herself from attacks and 12 needed increased care and supervision due to her dementia. Plaintiffs are also informed and believe 13 that KELLAND LANCASTER had a history of violent behavior prior to the attack on Decedent that 14 was well known to the Frontier Defendants. Specifically, Plaintiffs are informed and believe that 15 KELLAND LANCASTER had been violent with his wife at home, which is why he was placed in 16 the Facility. In addition, Plaintiffs are informed and believe that prior to the attack on Decedent, 17 KELLAND LANCASTER had injured two other staff members at the Facility and that the Frontier 18 Defendants were therefore aware of his violent outbursts. However, despite this knowledge, the 19 Frontier Defendants consciously and recklessly failed to take any actions necessary to ensure 20 Decedent’s safety at THE VILLAGE, failed to protect her from health and safety hazards, and 21 subjected her to abuse, which caused her injury and death. While Decedent was a resident at THE 22 VILLAGE, Decedent was egregiously neglected, abused, and mistreated as set forth herein. The 23 Frontier Defendants failed to provide Decedent with a safe environment at the Facility, failed to 24 prevent health and safety hazards at the Facility and did not put safety interventions in place at the 25 Facility to keep her free from injury and assault. The Frontier Defendants failed to properly assess 26 Decedent and failed to provide her with the necessary care and assistance that she required to keep 27 her safe. -10- FIRST AMENDED COMPLAINT FOR DAMAGES 1 26. Pursuant to California law, the Frontier Defendants are required to provide an elder, 2 such as Decedent, “basic services” including, at a minimum, safe and healthful living 3 accommodations and services, regular observation of the resident, arrangements to meet the health 4 needs of a resident, adequately trained and sufficiently staffed employee levels necessary to provide 5 minimum services and oversight of residents, policies and procedures to ensure that basic services 6 and oversight are implemented to assure health and safety of residents, employment and training of 7 staff such that staff is experienced and competent to perform the job duties necessary to assure 8 safety and oversight of residents, accepting, training and employing staff in a manner that avoids “a 9 revolving door” of crucial managerial employees such that there is little or no continuity and/or an 10 absence of crucial managerial employees at critical times. 11 27. The Frontier Defendants failed to ensure that Decedent was provided with continuing 12 supervision and assessment of her care needs while at THE VILLAGE and failed to protect 13 Decedent from known health and safety hazards. This failure by the Frontier Defendants had a 14 direct relationship to the health and safety of Decedent and proximately caused her injuries and 15 death, as described herein. 16 28. At the time that Decedent was admitted to THE VILLAGE, the Frontier Defendants 17 knew that according to their plan to increase profits at the expense of residents such as Decedent, the 18 operation of THE VILLAGE was neither designed, administered, nor funded in a manner 19 reasonably necessary to provide adequate care, oversight and integration Decedent into the Facility. 20 The Frontier Defendants and their managing agents had knowledge of, ratified and/or otherwise 21 authorized all of the acts or omissions, which caused the injuries to Decedent. The Frontier 22 Defendants and their managing agents knew that their operation was designed in a manner so as to 23 maximize profitability by circumventing the legal duty to assure the health, safety and oversight of 24 residents such as Decedent, and, in particular, the duty to provide oversight and management of 25 Decedent during her residency at THE VILLAGE. The Frontier Defendants, and each of them, 26 knew or should have known that THE VILLAGE’s operations were designed and operated by the 27 Frontier Defendants in a manner to circumvent their legal duty to comply with applicable statutes -11- FIRST AMENDED COMPLAINT FOR DAMAGES 1 and regulations so as to maximize profitability. That knowledge was exclusively in the possession 2 of the Frontier Defendants and their managing agents. Neither Decedent nor Plaintiffs had any such 3 knowledge, or the opportunity to obtain such knowledge and information. Decedent and her family 4 believed that the Frontier Defendants’ business operations were, as represented by the Frontier 5 Defendants, properly run in compliance with the law and that the care afforded to its residents was 6 within all State guidelines. In particular, they understood that the management and staff of THE 7 VILLAGE were “experts” and were readily familiar, capable, able and committed to the care and 8 oversight of residents with dementia such as Decedent. 9 29. The Frontier Defendants, and each of them, had responsibility for meeting the basic 10 needs of Decedent, including her health and safety. Although the Frontier Defendants knew of 11 conditions that made Decedent unable to provide for her own basic needs and safety as described 12 herein, the Frontier Defendants denied and withheld goods or services necessary to meet Decedent’s 13 basic needs as described herein. The Frontier Defendants denied and withheld this basic care to 14 Decedent despite the knowledge that by doing so, injury was substantially certain to befall Decedent 15 or with conscious disregard of the high probability of such injury. The Frontier Defendants’ 16 reckless and egregious denial and withholding of basic care to Decedent caused her injuries and 17 death as described herein. 18 30. Specifically, the Frontier Defendants, and each of them, recklessly and egregiously 19 failed to take necessary precautions to protect Decedent from assaults and serious injury, and these 20 failures caused her injury and death. The Frontier Defendants failed to provide Decedent with 21 supervision and assistance that she required, failed to provide her with comprehensive assessments, 22 failed to provide her with assistance for activities of daily living, and failed to protect her from 23 health and safety hazards, which caused her injury and death. The Frontier Defendants failed to 24 implement timely and adequate interventions, which caused her injury and death. 25 31. At all times relevant, the Frontier Defendants, and each of them, knew of Decedent’s 26 condition and the critical need to monitor and treat her condition properly and to provide adequate 27 custodial care and supervision to her at all times. However, the Frontier Defendants recklessly and -12- FIRST AMENDED COMPLAINT FOR DAMAGES 1 egregiously failed to provide custodial care to Decedent despite her condition, including her known 2 history of dementia. The Frontier Defendants’ conduct, as detailed herein, was reckless, egregious 3 and in conscious disregard of Decedent’s rights and safety. 4 32. As a result of the acts and omissions of Defendants, and each of them, Decedent was 5 violently attacked and suffered trauma which required hospitalization and hospice care and which 6 caused her severe pain and a significant decline in condition and caused her untimely death. 7 33. As described in detail herein, the Frontier Defendants recklessly failed to use 8 ordinary care, and such other care as is prescribed by law, regarding the care and protection of 9 Decedent while a resident of THE VILLAGE. In particular, and without limiting the generality of 10 the foregoing, Plaintiffs are informed and believes that the Frontier Defendants: 11 a. Failed to provide comprehensive care and supervision to its residents at THE 12 VILLAGE, including Decedent, as defined in 22 C.C.R. § 87101(c)(3) and Health 13 and Safety Code § 1569.2(c) and as required by 22 C.C.R. § 87464(f)(1); 14 b. Failed to maintain RCFE personnel in sufficient numbers at all times at THE 15 VILLAGE, and competent to provide the services necessary to meet resident needs, 16 including Decedent’s, as required by 22 C.C.R. § 87411; 17 c. Failed to provide safe accommodations to Decedent at THE VILLAGE in violation 18 of 22 C.C.R. § 87468.1(a)(2); 19 d. Failed to maintain dignity and prevent mental and physical abuse of Decedent at 20 THE VILLAGE as required by 22 C.C.R. § 87468.1(a)(3); 21 e. Failed to immediately telephone 911 if an injury or other circumstance has resulted in 22 an imminent threat to a resident’s health including, but not limited to, an apparent 23 life-threatening medical crisis as required by 22 C.C.R. § 87465(g) and 22 C.C.R. § 24 87211; 25 f. Failed to adhere to 22 C.C.R. 87455 with respect to KELLAND LANCASTER, 26 which states “No resident shall be accepted or retained if any of the following apply: 27 (3) The resident's primary need for care and supervision results from either: (A) An -13- FIRST AMENDED COMPLAINT FOR DAMAGES 1 ongoing behavior, caused by a mental disorder, that would upset the general resident 2 group; 3 g. Failed to adhere to 22 C.C.R. § 87461 with respect to KELLAND LANCASTER, 4 which states that “The facility shall determine the amount of supervision necessary by 5 assessing the mental status of the prospective resident to determine if the individual: 6 (5) has a documented history of behaviors which may result in harm to self or 7 others”; and 8 h. Made false and/or misleading statements regarding the services and staffing the 9 Frontier Defendants would provide in violation of 22 C.C.R. § 87207. 10 The foregoing regulations define the duties of care owed to the residents of RCFEs such as 11 Decedent. The Frontier Defendants’ violations of these regulations constitute a negligent failure to 12 exercise the care that a similarly situated reasonable person would exercise and/or a failure to protect 13 Decedent from health and safety hazards. Further, the Frontier Defendants promoted, advertised, 14 and held their Memory Care unit at THE VILLAGE out in their marketing materials as specifically 15 being a safe and secure environment for residents such as Decedent. 16 34. During Decedent’s admission to THE VILLAGE, the Frontier Defendants recklessly 17 and egregiously created a dangerous situation at the Facility that exposed all residents, including 18 Decedent, to harm. Plaintiffs are informed and believe that all of the residents at the Facility suffer 19 from memory impairment or other cognitive issues. Plaintiffs are informed and believe that many of 20 the residents lack the ability to control their behavior and can, and have, lashed out at other 21 residents, resulting in a dangerous environment for the Facility’s residents, including Decedent. Yet 22 despite the Frontier Defendants’ knowledge that residents need to be observed, monitored, and kept 23 engaged to prevent physical harm to the residents, the Frontier Defendants failed to adequately staff 24 the Facility, failed to adequately train staff and gave residents unfettered access to each other by 25 allowing residents to roam the Facility unattended to, unsupervised, and unengaged. As a result, a 26 dangerous situation was created that resulted in direct harm to Decedent. Plaintiffs are informed and 27 believe that the Frontier Defendants were aware of the high needs of their residents, including -14- FIRST AMENDED COMPLAINT FOR DAMAGES 1 Decedent, yet failed to provide a sufficient number of trained staff to provide care for their residents. 2 As a result of this failure, the Frontier Defendants exposed all of their residents to the ongoing risk 3 of serious harm and death. As a result of this failure by the Frontier Defendants and their managing 4 agents, Decedent was harmed and died. 5 35. The acts and omissions by the Frontier Defendants, as described herein, were not 6 only to Decedent, but, instead, were part of a continual pattern at THE VILLAGE in failing to 7 provide adequate care and supervision, failing to provide a safe and secure environment, and other 8 inadequacies that resulted in residents assaulting people at THE VILLAGE even prior to the 9 November 15, 2021 assault of Decedent at THE VILLAGE. This pattern of substandard care was 10 well known to the Frontier Defendants’ managing agents prior November 15, 2021, including but 11 not limited to THE VILLAGE’s Executive Director, SAMANTHA DAVIDSON, and other 12 managing agents. 13 36. Despite knowing of Decedent’s condition and her need for assistance, supervision an