Jury orders Vallejo care facility to pay $15M in lawsuit over 96-year-old woman’s death

VALLEJO – A Solano County jury awarded over $15 million on Tuesday to the family of a 96-year-old woman who died after staying at the Windsor Vallejo Care Center on Tuolumne Street for a week in 2019.

Ruby Evans was a patient at the care center from Aug. 3 to Aug. 10, 2019. According to a lawsuit filed by Evans’ family, the facility’s severe neglect resulted in her developing a painful pressure ulcer — also known as a bedsore — on her lower back and buttocks, which she endured until her death on Oct. 2, 2019, at her home. 

The family’s attorneys from Dudensing Law and Buckley Law, led by lead counsel Matt Chisholm, argued that the care facility falsified records about Evans’ skin condition and concealed the severity of her wound from her family during her time at the facility. 

The lawsuit said that the facility owners “deliberately underfunded and understaffed” the care center in order to maximize profits and its owners were aware that they didn’t have enough staff, yet they continued to admit residents who had complex care needs and required larger care teams. 

The civil jury trial lasted eight weeks and involved calling over 30 witnesses. 

In the verdict, the jury found Windsor Vallejo Care Center, owner Lee Samson, and the corporate overseer S&F Management responsible for Evans’ death. They found that Windsor Vallejo failed to consistently reposition Evans and inspect her skin for bedsores, despite knowing she was at risk of developing them.

They awarded Evans’ family $15.75 million: $12 million in punitive damages and $3.75 million in compensatory damages. 

An attorney for the Windsor Vallejo Care Center and Lee Samson did not respond to requests for comment. 

Falsified records and elder abuse 

Evans was living on her own in a San Francisco apartment when she experienced a stroke on July 25, 2019. She was hospitalized at Sutter Solano. Sutter felt that she wasn’t a candidate for surgery and that she should go to a skilled nursing facility. But when she appeared to show signs of improvement, the family decided to send her to a short-term rehabilitation facility instead, according to the family’s lawsuit.

The lawsuit states that when Evans left the hospital on Aug. 3, 2019, she had no bedsores on her body. 

She was admitted to Windsor Vallejo on Aug. 3, 2019. According to the lawsuit, Windsor Vallejo assessed that she was at high risk for developing pressure ulcers because of her decreased mobility caused by the stroke. They said to avoid bedsores, she had to be repositioned every two hours and put her on a “turning/repositioning program.” 

From Aug. 3 to Aug. 8, Windsor staff repeatedly documented that Evans’ skin was “within normal limits,” meaning there were no skin issues like tears, moistness, or loss of elasticity, according to the lawsuit. On Aug. 5, a Windsor staff member noted that she had discoloration on her arms and hips, yet still listed her skin as normal.

On the morning of Aug. 9, Windsor staff noted that Evans had a wound on her lower back by her buttocks. They wrote that she “had an abrasion on her sacrum,” but there were “no complaints of pain” and “no signs and symptoms of infection,” the lawsuit states. Windsor Vallejo still listed her skin as normal, and told her son not to worry about it because it was just a “small tear,” the lawsuit alleges.

Evans’ children soon learned that was far from the truth. On Aug. 10, Evans’ family moved her out of Windsor because they were unhappy that they weren’t allowed to visit her after 8 p.m. Evans’ roommate had told them that she called for them throughout the night, according to the lawsuit. 

On Aug. 11, a new caregiver came to the house to examine Evans. They found that the wound on her lower back and buttocks was much more severe than Windsor Vallejo had claimed, according to the lawsuit. It was a Stage 3 bedsore, which is a serious skin injury that involves the loss of all skin layers and the exposure of the fatty tissue underneath, making the wound very painful and prone to infection. 

Horrified, Evans’ family sent her to the Sutter Solano emergency room. Evans lived with the painful wound until she died on Oct. 2, 2019, as a result of complications brought on by the stroke, according to the lawsuit. 

Windsor Vallejo failed state inspections

Windsor Vallejo has a history of health citations from the state.

California conducts yearly health and safety inspections of nursing homes to comply with Medicare and Medicaid regulations. Windsor Vallejo has a health inspection rating of one out of five stars. The facility’s inspection page shows that within the past three years, it’s received 189 complaints that resulted in a citation. 

In April 2019, four months before Evans stayed there, inspectors found that the facility had a total of 39 deficiencies. For comparison, an average number of deficiencies for a health facility in the U.S. is 9.6. 

Inspectors noted in the report that the facility failed to develop baseline care plans about how to prevent bedsores for vulnerable patients. The inspectors observed several patients who were at risk for bedsores, or who had bedsores already, but had no documented plan for how to treat them. One patient in particular was noted to have a bedsore on their right foot; nurses told inspectors that it later became infected and had to be amputated.

Other inspection write-ups included reports of residents being left in soiled clothes for hours, running out of oxygen in their tanks, having to eat mushy or lukewarm food, waiting hours before their call lights were answered, or not having a working call light at all.

In 2020, Windsor Vallejo also made the news when more than 1,700 people signed a petition calling for the facility’s closure after a COVID-19 outbreak led to 16 deaths.  The state Division of Occupational Safety and Health fined the facility $25,250 for violations relating to the COVID outbreak.

Chisholm said in an interview that during the trial, he argued that the case wasn’t about going after the nursing staff, but rather the owners and managers of the facility who allowed these conditions to persist. 

“The way that these facilities are managed, bad actors will understaff them to such a degree that there’s no way the nursing staff can provide the care that they're supposed to do,” Chisholm said. 

Higher than normal profits

Chisholm said that Windsor Vallejo owners were making profits that were much higher than the average facility. In some years, it was even “up to eight times the average profit of a skilled nursing facility of the same size,” he said. 

Despite these profits, some nurses testified that the owners didn’t even provide them with an appropriate amount of supplies, according to Chisholm. One nurse testified that staff had to cut up gowns because there were no wipes that they could use to clean the facility, Chisholm said. 

Chisholm said Windsor Vallejo’s owner, Lee Samson, ran around 40 care facilities from his office in West Hollywood. The attorneys found that in 2019, his compensation was around $8 million a year. 

Since then, Samson has sold all of his facilities, split between two operators. The half that included Windsor Care was sold for approximately $50 million. Chisholm said $20 million of that went to Samson and the other co-owners of Windsor Care, while $30 million was set aside for potential lawsuits. 

Chisholm said he expects the defendants to challenge the verdict and file several motions to appeal, as he said that tends to happen in these sorts of cases. “And we will defend that the entire way,” Chisholm said. 

He added it was never about the money for Evans’ family. “It was about getting justice for their mother,” Chisholm said. “The change they want is that they don’t want this to happen to other people.” 

Today the facility operates under new management as Solano Post Acute. A standard state inspection on Dec. 5, 2024 found that Solano Post Acute had 25 health deficiencies; inspectors also came out nine times in 2025 due to complaints.