The Manse on Marsh, the San Luis Obispo assisted living facility from which an elderly man walked away and died in an accident, had been cited several times previously for admitting residents for whom it was not licensed to provide care.

According to the California Department of Justice, the Manse on Marsh was cited yearly from 2007 to 2009 for admitting residents who did not belong in the facility. The Manse on Marsh was also fined in 2008.

In July, the California Attorney General’s Office filed charges of involuntary manslaughter and elderly and dependent adult abuse against Christopher E. Skiff, 54, and Gary Potts, 63. Skiff, the owner of the Manse on Marsh, and Potts, a former employee, are accused of knowingly and willfully endangering Mauricio Edgar Cardenas, 65, and ultimately causing his death.

In Dec. 2014, Cardenas was attempting to cross Los Osos Valley Road in Los Osos when he was hit and killed by a 2010 Dodge Challenger driven by 26-year-old Ricardo Serafin. The CHP determined Serafin was not able to avoid Cardenas because of the darkness at the location Cardenas was crossing.

Prosecutors allege the Manse on Marsh admitted Cardenas as a resident, even though he had a dementia diagnosis and the facility lacked a waiver to handle such patients.

In a sworn affidavit recently unsealed by a San Luis Obispo judge, Sepcial Agent Sherry Zamanigan, an investigator for the state Department of Justice, stated that the Manse on Marsh regularly accepted elderly residents with conditions the facility was not licenses to care for, exposing the patients to circumstances in which they could likely suffer great bodily injury or death. Zamanigan detailed her interviews with five former employees of the facility in the sworn affidavit.

One employee said there were about 20 dementia-diagnosed residents at Manse on Marsh before she left the facility in late 2014. Other former workers said residents with dementia would repeatedly fall or wander the facility naked.

A previous director of wellness at the facility said that Potts would order facility staff to ask residents’ doctors to change their diagnoses so they could stay at the Manse on Marsh. One nurse cried because she was force to call a doctor’s office to get a diagnosis changed, the former wellness director said.

Another former worker said Potts persuaded Cardenas’ doctor to change his patient’s diagnosis so that he could be admitted to the Manse on Marsh. Former employees also said the decisions were financially driven, and the Manse on Marsh would try to fill as many beds as possible to maximize revenue.