Inspection Reports for
Abria Del Cielo

CA, 92404

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Citations (last 5 years)

Citations (over 5 years) 3 citations/year

Citations are regulatory findings recorded during state inspections.

25% better than California average
California average: 4 citations/year

Citations per year

4 3 2 1 0
2021
2022
2023
2024
2025

Occupancy

Latest occupancy rate 56% occupied

Based on a November 2025 inspection.

Occupancy rate over time

40% 60% 80% 100% May 2021 Sep 2022 Sep 2023 Aug 2024 Mar 2025 Oct 2025 Nov 2025

Inspection Report

Complaint Investigation
Census: 134 Capacity: 240 Citations: 0 Date: Nov 6, 2025

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2025-07-25 regarding staff not feeding residents, mismanagement of residents' medications, and unsanitary facility conditions.

Complaint Details
The complaint investigation was unsubstantiated for all allegations: staff did not feed residents, staff mismanaged medications, and the facility was unsanitary. Evidence did not support the claims.
Findings
The investigation included interviews, record reviews, and facility tour. All allegations were found to be unsubstantiated based on staff and resident interviews, medication record reviews, and observations of the facility's cleanliness.

Report Facts
Capacity: 240 Census: 134

Employees mentioned
NameTitleContext
Criselda Espiritu SantoExecutive DirectorMet with during investigation and named in report
Renese Howell-SmallLicensing Program AnalystConducted the complaint investigation visit
Karen ClemonsSupervisorSupervisor named in report

Inspection Report

Complaint Investigation
Census: 140 Capacity: 240 Citations: 0 Date: Oct 8, 2025

Visit Reason
An unannounced visit was conducted to investigate a complaint received on 2023-05-22 alleging staff did not prevent physical abuse, did not provide adequate care and supervision, and did not prevent financial abuse of residents.

Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation included observations, document reviews, and interviews with staff and residents. The allegations were found to be unsubstantiated based on interviews where residents and staff confirmed adequate care, supervision, and prevention of abuse.

Report Facts
Residents interviewed: 11 Staff interviewed: 6

Employees mentioned
NameTitleContext
Criselda Espiritu SantoExecutive DirectorMet with during investigation and exit interview
Becky MannLicensing Program AnalystConducted the complaint investigation
Nedra BrownLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Complaint Investigation
Census: 145 Capacity: 240 Citations: 2 Date: Aug 29, 2025

Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to allegations received on 2025-07-01 regarding resident care and incident reporting at the facility.

Complaint Details
The complaint investigation was triggered by allegations that staff did not ensure resident diapering care needs were met, did not prevent a resident from hitting others, and did not report resident incidents appropriately. The diapering allegation was unsubstantiated, while the other two were substantiated with deficiencies cited.
Findings
The investigation found one allegation unsubstantiated regarding staff meeting residents' diapering care needs. Two allegations were substantiated: staff did not prevent a resident from hitting others, and staff failed to report resident incidents to appropriate parties. Deficiencies were cited related to personal rights and reporting requirements.

Citations (2)
Failure to ensure all clients are comfortable and safe, posing an immediate risk to residents' health and safety.
Failure to report incidents threatening the welfare, safety, or health of residents to the licensing agency.
Report Facts
Capacity: 240 Census: 145 Deficiencies cited: 2 Plan of Correction Due Date: Aug 30, 2025

Employees mentioned
NameTitleContext
Criselda Espiritu SantoExecutive DirectorMet with Licensing Program Analyst during investigation and named in findings
Renese Howell-SmallLicensing Program AnalystConducted the complaint investigation and authored the report
Karen ClemonsLicensing Program ManagerNamed as Licensing Program Manager overseeing the investigation

Inspection Report

Census: 144 Capacity: 240 Citations: 0 Date: Aug 14, 2025

Visit Reason
The visit was conducted to have the Administrator sign an amended Complaint Investigation Report (LIC 9099) #18-AS-20211008105248.

Findings
The report documents the signing of the amended Complaint Investigation Report by Licensing Program Analyst Javier Prieto and Administrator Criselda Espiritu Santo, with a copy left at the facility.

Employees mentioned
NameTitleContext
Criselda Espiritu SantoAdministratorFacility Administrator who signed the amended Complaint Investigation Report.
Javier PrietoLicensing Program AnalystLicensing Program Analyst who arrived to have the Administrator sign the amended Complaint Investigation Report.
Karen ClemonsLicensing Program ManagerNamed as Licensing Program Manager on the report.

Inspection Report

Complaint Investigation
Census: 144 Capacity: 240 Citations: 0 Date: Jul 2, 2025

Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations including staff not treating residents with dignity or respect, financial abuse by staff, failure to provide medication as prescribed, and failure to keep the facility free from pests.

Complaint Details
The complaint investigation was unsubstantiated for all allegations: staff did not treat resident with dignity or respect; resident was financially abused by staff; staff did not provide resident medication as prescribed; and staff did not keep the facility free from pests. Evidence did not support the allegations.
Findings
All allegations were found to be unsubstantiated after interviews, record reviews, and observations. Staff denied the allegations, records showed no discrepancies in medication administration, pest control was confirmed to be in place, and no evidence supported claims of financial abuse or disrespectful treatment.

Report Facts
Facility capacity: 240 Census: 144 Complaint control number: 56-AS-20240813084641

Employees mentioned
NameTitleContext
Criselda Espiritu SantoExecutive DirectorMet during investigation and named in findings discussion
Renese Howell-SmallLicensing Program AnalystConducted the complaint investigation visit
Karen ClemonsLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Complaint Investigation
Census: 144 Capacity: 240 Citations: 0 Date: Jun 30, 2025

Visit Reason
Licensing Program Analyst Javier Prieto arrived at the facility to interview additional staff relating to a complaint (18-AS-20211008105248).

Complaint Details
Investigation related to complaint number 18-AS-20211008105248; the report includes an interview with the Administrator and staff but does not state substantiation status.
Findings
The report documents the interview conducted with the Administrator Criselda Espiritu Santo as part of the complaint investigation. No specific deficiencies or findings are detailed in the report.

Employees mentioned
NameTitleContext
Criselda Espiritu SantoAdministratorMet with Licensing Program Analyst during complaint investigation interview.
Javier PrietoLicensing Program AnalystConducted interview related to complaint investigation.

Inspection Report

Complaint Investigation
Census: 141 Capacity: 240 Citations: 0 Date: May 30, 2025

Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not prevent verbal altercations between residents and did not provide a safe environment for residents.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not preventing verbal altercations and not providing a safe environment. Interviews with five staff and nine residents did not support these allegations.
Findings
The investigation included interviews with staff and residents and a review of records. Both allegations were found to be unsubstantiated based on interviews where staff and residents confirmed appropriate staff intervention and a safe environment.

Report Facts
Staff interviewed: 5 Residents interviewed: 9 Capacity: 240 Census: 141

Employees mentioned
NameTitleContext
Criselda Espiritu SantoExecutive DirectorMet with during investigation and named in report
Renese Howell-SmallLicensing Program AnalystConducted the complaint investigation
Karen ClemonsSupervisorSupervisor overseeing the investigation

Inspection Report

Annual Inspection
Census: 141 Capacity: 240 Citations: 1 Date: May 22, 2025

Visit Reason
The visit was an unannounced required annual inspection conducted by Licensing Program Analysts to evaluate compliance with licensing requirements at the Residential Care Facility for the Elderly.

Findings
The facility was found to be operating within approved capacity and generally in good repair with safe conditions for residents. One deficiency was cited related to improper storage of bleach and cleaning supplies with food, posing an immediate health and safety risk. Technical assistance was provided and a plan of correction was required.

Citations (1)
Bleach and cleaning supplies were not stored separate from food supplies, posing an immediate health, safety or personal rights risk to persons in care.
Report Facts
Resident units inspected: 6 Staff files reviewed: 5 Resident files reviewed: 6 Bottles of bleach observed: 6 Water temperature: 117 Facility temperature: 72

Employees mentioned
NameTitleContext
Criselda Espiritu SantoExecutive DirectorMet with Licensing Program Analysts during inspection and named in findings
Renese Howell-SmallLicensing Program AnalystConducted inspection and signed report
Becky MannLicensing Program AnalystConducted inspection
Karen ClemonsLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Complaint Investigation
Census: 147 Capacity: 240 Citations: 0 Date: Mar 17, 2025

Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff was financially abusing a resident.

Complaint Details
The complaint alleged that facility staff was financially abusing a resident. The allegation was investigated through interviews and record review and was determined to be unsubstantiated.
Findings
The investigation included interviews with staff, residents, and a resident's family member. The allegation of financial abuse was found to be unsubstantiated as there was no preponderance of evidence to prove the violation occurred.

Report Facts
Capacity: 240 Census: 147

Employees mentioned
NameTitleContext
Criselda Espiritu SantoExecutive DirectorMet with during the investigation and named in the report
Renese Howell-SmallLicensing Program AnalystConducted the complaint investigation visit
Karen ClemonsLicensing Program ManagerNamed in the report

Inspection Report

Complaint Investigation
Census: 143 Capacity: 240 Citations: 0 Date: Feb 6, 2025

Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff were not ensuring that a resident was receiving services prescribed by their physician.

Complaint Details
The complaint alleged that staff were not ensuring that a resident was receiving services prescribed by their physician. The allegation was unsubstantiated based on interviews and record review.
Findings
The allegation was found to be unsubstantiated after interviews with the resident and staff, and review of records showed that the resident was escorted to appointments and received prescribed services at the facility.

Report Facts
Capacity: 240 Census: 143

Employees mentioned
NameTitleContext
Criselda Espiritu SantoExecutive DirectorMet with during the investigation and named in the report
Renese Howell-SmallLicensing Program AnalystConducted the complaint investigation visit
Karen ClemonsLicensing Program ManagerNamed in the report as Licensing Program Manager

Inspection Report

Complaint Investigation
Census: 143 Capacity: 240 Citations: 0 Date: Dec 23, 2024

Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of illegal eviction received on 2024-09-11.

Complaint Details
The complaint alleged illegal eviction. The allegation was unsubstantiated as there was no preponderance of evidence to prove the violation occurred.
Findings
The investigation found that Resident #1 was currently living in the facility and had refused assistance with personal care multiple times. A 30-Day Eviction letter was issued to Resident #1 on 2024-09-10, consistent with the facility's eviction procedures and admissions agreement. The allegation of illegal eviction was unsubstantiated due to insufficient evidence.

Report Facts
Refusals of personal care: 19 Facility capacity: 240 Census: 143

Employees mentioned
NameTitleContext
Renese Howell-SmallLicensing Program AnalystConducted the complaint investigation and unannounced visit.
Criselda Espiritu SantoExecutive DirectorFacility representative met during the investigation.
Karen ClemonsLicensing Program ManagerNamed in the report as Licensing Program Manager.

Inspection Report

Census: 148 Capacity: 240 Citations: 1 Date: Dec 11, 2024

Visit Reason
The visit was a case management inspection initiated to investigate deficiencies related to staff certification compliance.

Findings
The inspection found that Staff #8 did not have the required Food Handlers Training certification, resulting in a deficiency being issued.

Citations (1)
Staff #8 does not have the required Food Handlers Training certification, violating general food service requirements.
Report Facts
Capacity: 240 Census: 148 Plan of Correction Due Date: Dec 20, 2024

Employees mentioned
NameTitleContext
Criselda Espiritu SantoExecutive DirectorMet during inspection and named in report
Melody BrownLicensing Program AnalystConducted the inspection and authored the report
Efren MalagonLicensing Program ManagerSupervisor named in the report

Inspection Report

Complaint Investigation
Census: 148 Capacity: 240 Citations: 0 Date: Dec 11, 2024

Visit Reason
The inspection was conducted as an unannounced complaint investigation visit triggered by a complaint received on 2024-08-14 alleging that staff do not ensure residents are not eating expired or moldy food.

Complaint Details
The complaint alleged that staff do not ensure residents are not eating expired/moldy food. The allegation was found to be unsubstantiated based on interviews with residents and staff, observations of food supplies, and records review.
Findings
The investigation, which included interviews, observations, and file review, found no evidence to corroborate the allegation. Interviews with residents and staff, as well as observations of food supplies, confirmed that no expired or moldy food was served. The allegation was determined to be unsubstantiated.

Report Facts
Capacity: 240 Census: 148

Employees mentioned
NameTitleContext
Criselda Espiritu SantoExecutive DirectorFacility administrator contacted and informed of the visit; participated in exit interview
Melody BrownLicensing Program AnalystConducted the complaint investigation visit
Efren MalagonSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 140 Capacity: 240 Citations: 0 Date: Dec 5, 2024

Visit Reason
The inspection visit was conducted to interview additional residents relating to a complaint identified as 56-AS-20240805145702.

Complaint Details
The visit was triggered by complaint number 56-AS-20240805145702. No substantiation status is provided in the report.
Findings
Licensing Program Analyst Javier Prieto toured the facility and interviewed residents with the assistance of Administrator Alexandra Villacis. The report documents the completion of these activities without specifying any deficiencies or violations.

Employees mentioned
NameTitleContext
Javier PrietoLicensing Program AnalystConducted resident interviews and toured the facility during the complaint investigation.
Alexandra VillacisAdministratorAccompanied the Licensing Program Analyst during the facility tour and resident interviews.

Inspection Report

Complaint Investigation
Census: 143 Capacity: 240 Citations: 0 Date: Nov 7, 2024

Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of wrongful eviction received on 2024-08-01.

Complaint Details
The complaint alleged wrongful eviction of Resident 1 (R1). Interviews with staff and outside parties revealed unawareness of any eviction, and no written notice or record of eviction was found. The allegation was unsubstantiated.
Findings
The investigation included interviews and record reviews which found no evidence supporting the allegation of wrongful eviction. The allegation was determined to be unsubstantiated due to insufficient evidence.

Report Facts
Capacity: 240 Census: 143

Employees mentioned
NameTitleContext
Bernadette AllenLicensing Program AnalystConducted the complaint investigation and delivered findings
Criselda Espiritu SantoAdministratorFacility administrator met during the investigation
Karen ClemonsLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Complaint Investigation
Census: 134 Capacity: 240 Citations: 0 Date: Oct 14, 2024

Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff did not keep the facility free of bed bugs.

Complaint Details
The complaint alleged that staff did not keep the facility free of bed bugs. The allegation was unsubstantiated, meaning there was not a preponderance of evidence to prove the violation did or did not occur.
Findings
The allegation that staff did not keep the facility free of bed bugs was found to be unsubstantiated after a facility tour, interviews, observation, and record review. Mattresses and bedding were observed to be clean and covered with waterproof and anti-bed bug covers, and extermination services were documented.

Report Facts
Capacity: 240 Census: 134

Employees mentioned
NameTitleContext
Criselda Espiritu SantoExecutive DirectorMet with Licensing Program Analyst during the complaint investigation visit
Renese Howell-SmallLicensing Program AnalystConducted the complaint investigation visit
Karen ClemonsSupervisorSupervisor named in the report

Inspection Report

Complaint Investigation
Census: 138 Capacity: 240 Citations: 0 Date: Aug 27, 2024

Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of lack of supervision resulting in a physical altercation between residents.

Complaint Details
The complaint alleged lack of supervision resulting in a physical altercation between residents. The allegation was determined to be unsubstantiated based on interviews and record review.
Findings
The investigation included interviews and record reviews. The allegation was found to be unsubstantiated as there was no preponderance of evidence to prove the incident occurred as alleged. Residents and staff reported feeling safe and no past incidents were found.

Report Facts
Capacity: 240 Census: 138

Employees mentioned
NameTitleContext
Paola GuerreroLicensing Program AnalystConducted the complaint investigation visit
Efren MalagonLicensing Program ManagerNamed in report as Licensing Program Manager
Norma Alexandra VillacisFacility NurseMet with Licensing Program Analyst during investigation and received report
Criselda Espiritu SantoAdministratorFacility Administrator named in report

Inspection Report

Census: 134 Capacity: 240 Citations: 1 Date: Aug 15, 2024

Visit Reason
An unannounced visit was conducted to commence a Case Management Deficiency inspection to assess compliance with facility requirements.

Findings
The facility was found to be non-compliant due to the absence of the required carbon monoxide detectors, posing an immediate health, safety, and personal rights risk to residents.

Citations (1)
Facility does not have the required carbon monoxide detectors as mandated by Health and Safety Code 1569.311.
Report Facts
Plan of Correction Due Date: Aug 16, 2024

Employees mentioned
NameTitleContext
Criselda Espiritu SantoExecutive DirectorMet with Licensing Program Analysts during inspection and acknowledged deficiency
Melody BrownLicensing Program AnalystConducted inspection and identified deficiency
Raquel HernandezLicensing Program AnalystConducted inspection and identified deficiency
Efren MalagonSupervisorSupervisor overseeing the inspection

Inspection Report

Complaint Investigation
Census: 138 Capacity: 240 Citations: 0 Date: Aug 6, 2024

Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that staff were not allowing residents to have visitors in their rooms and were not providing comfortable accommodations for residents.

Complaint Details
The complaint investigation was unsubstantiated based on interviews with the CEO, residents, and staff, and review of facility policies. The allegations regarding visitor restrictions and uncomfortable accommodations were not supported by evidence.
Findings
The investigation found that the facility allows residents to have visitors according to the visitation policy and provides comfortable accommodations for residents, including designated visiting areas and appropriate spaces for spiritual services. The allegations were deemed unsubstantiated.

Report Facts
Capacity: 240 Census: 138

Employees mentioned
NameTitleContext
Javier PrietoLicensing Program AnalystConducted the complaint investigation
Edna MedranoPresident CEOInterviewed during the investigation and provided facility policies

Inspection Report

Complaint Investigation
Census: 129 Capacity: 240 Citations: 0 Date: Jul 11, 2024

Visit Reason
Unannounced complaint investigation visit conducted due to allegations of staff physically assaulting and verbally abusing residents.

Complaint Details
The complaint involved allegations that staff physically assaulted residents resulting in injuries and verbally abused residents. The investigation concluded these allegations were unsubstantiated due to lack of corroborating evidence.
Findings
The investigation found no substantiated evidence of physical assault or verbal abuse by staff towards residents. Interviews with residents and staff denied the allegations, and the complaint was determined to be unsubstantiated.

Report Facts
Capacity: 240 Census: 129

Employees mentioned
NameTitleContext
Paola GuerreroLicensing Program AnalystConducted the complaint investigation
Efren MalagonLicensing Program ManagerNamed in report as Licensing Program Manager
Norma VillacisFacility LVNMet with Licensing Program Analyst during investigation
Criselda Espiritu SantoAdministratorFacility Administrator named in report

Inspection Report

Complaint Investigation
Census: 144 Capacity: 240 Citations: 0 Date: Jun 19, 2024

Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff sexually assaulted a resident.

Complaint Details
The complaint alleged that staff sexually assaulted a resident. The allegation was investigated and found to be unsubstantiated due to lack of corroborating evidence.
Findings
The investigation included interviews with staff and the resident, as well as a review of records. All parties denied the allegation, and based on the evidence, the allegation was determined to be unsubstantiated.

Report Facts
Capacity: 240 Census: 144

Employees mentioned
NameTitleContext
Paola GuerreroLicensing Program AnalystConducted the complaint investigation and unannounced visit
Criselda Espiritu SantoFacility DirectorMet with Licensing Program Analyst during the investigation
Efren MalagonLicensing Program ManagerNamed as Licensing Program Manager on the report

Inspection Report

Annual Inspection
Census: 144 Capacity: 240 Citations: 0 Date: May 17, 2024

Visit Reason
The visit was an unannounced required comprehensive annual inspection of the Residential Care Facility for Elderly (RCFE).

Findings
The facility was found to be operating within its licensed capacity and in good repair with safe conditions for residents. No deficiencies were cited during the inspection, and all reviewed resident and staff files were in compliance with regulations.

Report Facts
Resident files reviewed: 5 Staff files reviewed: 5

Employees mentioned
NameTitleContext
Criselda Espiritu SantoExecutive DirectorFacility Administrator met during inspection and named in report
Paola GuerreroLicensing Program AnalystConducted the inspection visit
Efren MalagonLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Census: 144 Capacity: 240 Citations: 0 Date: May 17, 2024

Visit Reason
An unannounced visit was conducted for the purpose of a Health & Safety check to assess the facility's compliance with health and safety standards.

Findings
No imminent health and/or safety concerns or hazards were observed inside or outside the facility. Sufficient staff were present to provide care, and food supplies were adequate to meet residents' needs.

Report Facts
Perishable food supply days: 3 Non-perishable food supply days: 7

Employees mentioned
NameTitleContext
Paola GuerreroLicensing Program AnalystConducted the unannounced visit and inspection
Criselda Espiritu SantoExecutive DirectorMet with Licensing Program Analyst during inspection

Inspection Report

Census: 133 Capacity: 240 Citations: 0 Date: Apr 19, 2024

Visit Reason
Licensing Program Analyst Paola Guerrero conducted an unannounced visit to the facility on 4/19/2024 at 11:45 AM for the purpose of a Health & Safety check.

Findings
No imminent health and/or safety concerns were observed during the visit. The facility had sufficient staff and adequate food supplies to meet the needs of the residents in care.

Report Facts
Food supply duration: 3 Food supply duration: 7

Employees mentioned
NameTitleContext
Criselda Espiritu SantoExecutive DirectorMet with Licensing Program Analyst during inspection
Paola GuerreroLicensing Program AnalystConducted the unannounced visit and inspection
Efren MalagonLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Complaint Investigation
Capacity: 240 Citations: 1 Date: Mar 27, 2024

Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that the facility failed to notify a resident's authorized representative about medical treatment.

Complaint Details
The complaint alleged failure to notify a resident's authorized representative about medical treatment. The allegation was found unsubstantiated after review of records and interviews.
Findings
The investigation found that the resident's representative was receiving communication about the resident's condition and was aware of the medical treatment situation. The allegation was determined to be unsubstantiated.

Citations (1)
Facility failed to notify resident authorized representative about medical treatment.
Report Facts
Capacity: 240

Employees mentioned
NameTitleContext
Anna FannellLicensing Program AnalystConducted the complaint investigation visit
Criselda Espiritu SantoAdministratorFacility administrator present during the visit
Edna MedranoLicenseeAdvised of the purpose of the visit

Inspection Report

Complaint Investigation
Capacity: 240 Citations: 0 Date: Dec 7, 2023

Visit Reason
The visit was an unannounced complaint investigation initiated due to allegations received on 2023-11-30 regarding staff assistance with resident transfers, medication administration, and authority over resident's social security payee and power of attorney.

Complaint Details
The complaint involved four allegations: staff not assisting resident with transfers, not giving medications for two years, attempting to become resident's social security payee, and becoming resident's power of attorney without consent. All allegations were unsubstantiated based on evidence and interviews.
Findings
All allegations were found to be unsubstantiated after review of records and staff interviews. The resident was able to transfer independently, had refused medication services since August 2023, and the facility denied attempting to become the resident's payee or filing power of attorney without consent.

Report Facts
Facility capacity: 240

Employees mentioned
NameTitleContext
Anna BuenoLicensing Program AnalystConducted the complaint investigation and authored the report
Javier PrietoLicensing Program AnalystAssisted in conducting the complaint investigation
Criselda Espiritu SantoAdministratorFacility administrator interviewed during the investigation
Nedra BrownLicensing Program ManagerNamed as Licensing Program Manager on the report

Inspection Report

Complaint Investigation
Census: 143 Capacity: 240 Citations: 1 Date: Sep 12, 2023

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that a resident sustained pressure injuries due to neglect and that staff left a resident in a soiled adult brief.

Complaint Details
The complaint investigation was substantiated for the allegation that Resident #1 sustained pressure injuries due to neglect. The resident developed a Stage 4 pressure injury and was not provided adequate wound care or assistance with home health services as ordered. The allegation that staff left the resident in a soiled adult brief was unsubstantiated due to insufficient evidence.
Findings
The allegation that a resident sustained pressure injuries due to neglect was substantiated based on interviews and record reviews, including failure to assist the resident with home health services and inadequate wound care. The allegation that staff left a resident in a soiled adult brief was unsubstantiated due to insufficient evidence.

Citations (1)
Failure to follow doctor's orders and assist Resident #1 with obtaining home health services, posing a potential health, safety, and personal rights risk.
Report Facts
Civil penalty: 500 Plan of Correction due date: Sep 26, 2023

Employees mentioned
NameTitleContext
Javina GeorgeLicensing Program AnalystConducted the complaint investigation and delivered findings.
Joel EsquivelLicensing Program ManagerOversaw the complaint investigation.
Criselda Espiritu SantoAdministratorFacility administrator met during investigation and exit interview.
Kevin VillacorteAssistant Living CoordinatorInterviewed regarding failure to assist resident with home health services.

Inspection Report

Complaint Investigation
Census: 138 Capacity: 240 Citations: 0 Date: Aug 16, 2023

Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 08/08/2023 alleging that staff violated resident's confidentiality.

Complaint Details
The complaint alleging staff violated resident's confidentiality was investigated and found to be unsubstantiated.
Findings
The investigation found that two whiteboards with residents' names, room numbers, dates, and facility names were observed behind the medication room counter, but no diagnoses were listed. Staff and resident interviews confirmed that returning residents discuss discharge paperwork with licensed staff in the medication room, with other residents ushered out or staying outside partially closed doors. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

Report Facts
Capacity: 240 Census: 138

Employees mentioned
NameTitleContext
Anna BuenoLicensing Program AnalystConducted the complaint investigation
Edna MedranoAdministratorMet with the Licensing Program Analyst during the investigation

Inspection Report

Complaint Investigation
Census: 147 Capacity: 240 Citations: 0 Date: Jul 17, 2023

Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 2023-06-27 regarding financial abuse, medication not sent with resident upon move, and presence of bed bugs at the facility.

Complaint Details
The complaint investigation addressed three allegations: 1) Financial abuse involving unauthorized withdrawal of $3009 from a resident's government benefit account, which was found unsubstantiated; 2) Staff did not send medication with resident when resident moved, which was unsubstantiated as the resident was discharged with medication and personal items; 3) Facility has bed bugs, which was unsubstantiated after inspection and review of pest control records.
Findings
The investigation found all allegations to be unsubstantiated after reviewing records, conducting interviews, and inspecting the facility. No deficiencies were cited during the visit.

Report Facts
Financial amount involved: 3009 Capacity: 240 Census: 147

Employees mentioned
NameTitleContext
Anna BuenoLicensing Program AnalystConducted the complaint investigation and authored the report
Kevin VillacorteAssistant AdministratorMet with Licensing Program Analyst during investigation
Criselda Espiritu SantoAdministratorNamed as facility administrator
May CabreraAdministratorParticipated in exit interview and received report copy

Inspection Report

Annual Inspection
Census: 143 Capacity: 240 Citations: 0 Date: Jun 14, 2023

Visit Reason
The visit was an unannounced required comprehensive annual inspection of the Residential Care Facility for the Elderly (RCFE) to assess compliance with licensing regulations.

Findings
The facility was found to be operating within its licensed capacity and in good repair with safe conditions for clients. No deficiencies were cited during the inspection. The facility had sufficient staff coverage, proper record keeping, and appropriate medication management.

Report Facts
Client files reviewed: 8 Staff files reviewed: 4

Employees mentioned
NameTitleContext
Criselda Espiritu SantoFacility AdministratorMet with Licensing Program Analyst during inspection and participated in exit interview
Paola GuerreroLicensing Program AnalystConducted the unannounced annual inspection visit
Efren MalagonLicensing Program ManagerNamed in report header and signature section

Inspection Report

Complaint Investigation
Capacity: 240 Citations: 1 Date: May 8, 2023

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-05-02 regarding allegations of rough handling of residents, inappropriate speech by staff, and failure to maintain personnel records.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff handling residents roughly, staff speaking inappropriately to residents, and failure to maintain personnel records. Interviews and record reviews did not support these allegations.
Findings
The investigation found all allegations to be unsubstantiated after interviews with residents and staff, observations, and record reviews. Staff were not found to handle residents roughly or speak inappropriately, and personnel records were maintained as required, though a technical assistance was issued regarding staff training documentation.

Citations (1)
Facility has a separate training book for in-service training which does not always include subjects covered by the training.
Report Facts
Capacity: 240

Employees mentioned
NameTitleContext
Anna BuenoLicensing EvaluatorConducted the complaint investigation and authored the report
Criselda Espiritu SantoAdministratorFacility administrator met during the investigation and exit interview

Inspection Report

Complaint Investigation
Census: 133 Capacity: 240 Citations: 0 Date: Apr 10, 2023

Visit Reason
The visit was an unannounced complaint investigation initiated due to a complaint received on 2023-04-07 alleging that staff did not prevent a resident from attacking another resident while in care.

Complaint Details
The complaint alleged that staff did not prevent Resident 2 from attacking Resident 1 while in care. The allegation was found to be unfounded based on staff interviews and record reviews.
Findings
The investigation found that Resident 1 was residing at the facility from 2014 to 2019, but Resident 2 was not known to staff and never lived at the facility. Staff denied the allegation and no incident reports involving Resident 2 were found. The allegation was determined to be unfounded.

Report Facts
Capacity: 240 Census: 133

Employees mentioned
NameTitleContext
Anna BuenoLicensing Program AnalystConducted the complaint investigation and unannounced visit
May CabreraAdministratorMet with the evaluator during the investigation
Kevin VillacorteAssistant AdministratorInformed of the purpose of the visit and received the report

Inspection Report

Complaint Investigation
Capacity: 240 Citations: 2 Date: Apr 6, 2023

Visit Reason
The visit was an unannounced investigation to deliver findings related to complaint number 56-AS-20230330134902.

Complaint Details
Complaint number 56-AS-20230330134902 was investigated; technical violations were substantiated.
Findings
Technical violations were found including 8 medications scheduled for evening or bedtime marked as already administered in Resident 1's medication record, and the facility lacking a modified menu for residents with diabetes.

Citations (2)
8 medications scheduled for the evening or bedtime were marked as already administered in Resident 1's medication record.
Facility does not have a modified menu for residents with diabetes.
Report Facts
Medications marked as administered: 8 Facility capacity: 240

Employees mentioned
NameTitleContext
Anna BuenoLicensing Program AnalystConducted the unannounced visit and investigation
May CabreraAdministratorMet with Licensing Program Analyst during the visit and received report and appeal rights

Inspection Report

Capacity: 240 Citations: 0 Date: Apr 6, 2023

Visit Reason
The visit was a Case Management - Incident type, unannounced, to address incidents involving residents who had been issued 30 day notices due to observed illegal drugs and a resident pulling a knife on staff.

Findings
The report documents incidents involving Resident 1 observed with illegal drugs in their room and Resident 2 pulling a knife on a staff member. Licensing staff advised the facility to proceed with the eviction process ensuring compliance with regulations.

Employees mentioned
NameTitleContext
Anna BuenoLicensing Program AnalystNamed in relation to the incident involving residents and eviction process advice.
Kevin VillacorteAssistant AdministratorNamed in relation to the incident involving residents and eviction process advice.
May CabreraMet with during the visit regarding residents issued 30 day notices.
Criselda Espiritu SantoAdministratorFacility administrator named in the report header.

Inspection Report

Complaint Investigation
Capacity: 240 Citations: 0 Date: Dec 29, 2022

Visit Reason
Licensing Program Analyst Anna Bueno conducted an unannounced visit to deliver an amended report of complaint control number 56-AS-20220808095722 regarding allegations against staff.

Complaint Details
Complaint control number 56-AS-20220808095722 involved allegations that staff took money from a resident and did not treat the resident with dignity and respect; both allegations were unsubstantiated.
Findings
The findings for the complaint remain unchanged; allegations that staff took money from a resident and did not treat the resident with dignity and respect were found to be unsubstantiated.

Employees mentioned
NameTitleContext
Criselda Espiritu SantoAdministratorMet with Licensing Program Analyst during the visit and signed the amended report.
Anna BuenoLicensing Program AnalystConducted the unannounced visit and delivered the amended complaint report.
Nedra BrownLicensing Program ManagerNamed as Licensing Program Manager on the report.

Inspection Report

Complaint Investigation
Census: 131 Capacity: 240 Citations: 0 Date: Nov 17, 2022

Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to allegations received on 2022-09-12 regarding sexual, physical, and financial abuse of a resident while in care.

Complaint Details
The complaint involved allegations that a resident (R1) was sexually abused by unknown individuals, physically abused by a named individual, and financially abused by another resident (R2). All allegations were investigated and found unsubstantiated.
Findings
The investigation included staff, witness, and resident interviews and records review. All allegations of sexual, physical, and financial abuse were found to be unsubstantiated based on the evidence and interviews conducted.

Report Facts
Facility capacity: 240 Resident census: 131

Employees mentioned
NameTitleContext
Anna BuenoLicensing Program AnalystConducted the complaint investigation
Amber ColemanLicensing Program AnalystConducted the complaint investigation
Kevin VillacorteAssistant AdministratorMet with investigators during the visit
Criselda Espiritu SantoAdministratorFacility administrator involved in exit interview
Nedra BrownLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Complaint Investigation
Capacity: 240 Citations: 0 Date: Nov 17, 2022

Visit Reason
An unannounced complaint investigation was conducted following allegations that facility staff did not dispense resident's medication as prescribed, did not ensure timely medication refills, and failed to transport a patient to a medical appointment.

Complaint Details
The complaint was unsubstantiated as there was no preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found no evidence to support the allegations. Medication records showed all prescribed medications were administered as prescribed, medication refills were timely, and transportation services were provided as scheduled. The complaint was determined to be unsubstantiated.

Report Facts
Facility capacity: 240 Appointments scheduled: 6 Appointments attended: 5

Employees mentioned
NameTitleContext
Amber ColemanLicensing Program AnalystConducted the complaint investigation
Kevin VillacorteAssistant AdministratorInterviewed during investigation and provided information on medication and transportation
Criselda Espiritu SantoAdministratorFacility administrator informed of the investigation and present during visit
Nedra BrownLicensing Program ManagerNamed as Licensing Program Manager on the report

Inspection Report

Complaint Investigation
Census: 133 Capacity: 240 Citations: 0 Date: Oct 24, 2022

Visit Reason
An unannounced complaint investigation was conducted following allegations that staff did not ensure residents attended medical appointments and did not provide transportation services to residents in care.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to ensure residents attended medical appointments and failure to provide transportation services. The facility demonstrated transportation was provided and clients managed their own appointments.
Findings
The investigation found that the client manages their own medical appointments and the facility provides transportation services up to three times a week, including third-party transportation. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

Report Facts
Residents transported: 8 Transportation frequency: 3

Employees mentioned
NameTitleContext
Kevin VillacorteAssistant ManagerMet with Licensing Program Analysts during the investigation and provided information
Anna BuenoLicensing EvaluatorConducted the complaint investigation
Amber ColemanLicensing Program AnalystParticipated in the complaint investigation

Inspection Report

Complaint Investigation
Census: 135 Capacity: 240 Citations: 1 Date: Sep 13, 2022

Visit Reason
An unannounced case management visit was conducted for a Health & Safety check in conjunction with complaint control number 56-AS-20220912152449.

Complaint Details
Visit was conducted in conjunction with complaint control number 56-AS-20220912152449. No substantiation status explicitly stated.
Findings
No imminent health and safety concerns were observed. One physician's record was found not up to date, resulting in a technical advisory being issued as the facility has a pre-scheduled appointment for the resident.

Citations (1)
One physician's record is not up to date.

Employees mentioned
NameTitleContext
Criselda Espiritu SantoExecutive DirectorMet with Licensing Program Analyst during the visit and discussed the nature of the visit and findings.
Anna BuenoLicensing Program AnalystConducted the unannounced case management visit.
Nedra BrownLicensing Program ManagerNamed in the report as Licensing Program Manager.

Inspection Report

Complaint Investigation
Census: 143 Capacity: 240 Citations: 0 Date: Aug 17, 2022

Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following a complaint alleging that the facility did not issue a 30 day notice.

Complaint Details
The complaint alleged that the facility did not issue a 30 day notice. The allegation was found to be unfounded.
Findings
The Licensing Program Analyst verified that the facility had sent a 30 day eviction notice for Resident 1 prior to the complaint being filed. The allegation was determined to be unfounded.

Report Facts
Capacity: 240 Census: 143

Employees mentioned
NameTitleContext
Anna BuenoLicensing Program AnalystConducted the complaint investigation and unannounced visit
Criselda Espiritu SantoAdministratorFacility administrator met during the investigation

Inspection Report

Annual Inspection
Census: 141 Capacity: 240 Citations: 0 Date: Jun 23, 2022

Visit Reason
Licensing Program Analyst Anna Bueno conducted an unannounced visit to the facility for a required annual inspection, with an emphasis on the infection control domain.

Findings
No deficiencies were cited during the inspection. The facility has implemented COVID-19 mitigation measures including universal entry screening, symptom checks, and adequate PPE supplies. Fire safety equipment was verified and hand sanitizer was observed throughout the facility.

Report Facts
Capacity: 240 Census: 141

Employees mentioned
NameTitleContext
Criselda Espiritu SantoAdministratorMet with Licensing Program Analyst during inspection and confirmed facility conditions
Anna BuenoLicensing Program AnalystConducted the unannounced annual inspection visit

Inspection Report

Complaint Investigation
Census: 142 Capacity: 240 Citations: 0 Date: Oct 12, 2021

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of staff verbal abuse, rescheduling of resident appointments without family or medical professional consultation, and lack of assistance with transportation for health appointments.

Complaint Details
The complaint included allegations of verbal abuse by staff, improper rescheduling of resident appointments without family or medical professional input, and failure to assist with transportation for health appointments. The complaint was investigated and found to be unsubstantiated.
Findings
The investigation found no evidence to support the allegations. Interviews and documentation reviewed indicated that staff were not verbally abusive, appointments were properly managed and confirmed with medical professionals, and transportation logs were maintained. The allegations were deemed unsubstantiated.

Report Facts
Capacity: 240 Census: 142

Employees mentioned
NameTitleContext
Javier PrietoLicensing Program AnalystConducted the complaint investigation and signed the report
Criselda Espiritu SantoAdministratorFacility administrator involved in interviews and providing documentation
Karen ClemonsLicensing Program ManagerNamed as Licensing Program Manager on the report

Inspection Report

Complaint Investigation
Census: 162 Capacity: 240 Citations: 0 Date: Jul 28, 2021

Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that a resident was sexually assaulted by facility staff.

Complaint Details
The complaint alleged that a resident was sexually assaulted by facility staff. The allegation was found to be unsubstantiated based on investigation findings and police report.
Findings
The investigation included interviews and records review. The resident could not provide consistent statements regarding the allegation, and staff reported the resident has a history of delusions and false allegations. Police records indicated no further action was required. The allegation was determined to be unsubstantiated due to lack of evidence.

Report Facts
Capacity: 240 Census: 162

Employees mentioned
NameTitleContext
Stephanie WilliamsLicensing Program AnalystConducted the complaint investigation and authored the report
Criselda Espiritu SantoAdministratorMet with Licensing Program Analyst during investigation
Efren MalagonLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Complaint Investigation
Census: 163 Capacity: 240 Citations: 1 Date: Jul 12, 2021

Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the licensee did not notify the person responsible for a resident within seven days of the occurrence of an unexplained absence.

Complaint Details
The complaint was substantiated based on evidence that the licensee did not notify the responsible party within seven days of the unexplained absence of Resident #1. A missing person's report was filed with the police. The preponderance of evidence standard was met.
Findings
The investigation found that the facility attempted to notify the responsible party via email two days after the resident's absence, but the email address was incorrect and no timely follow-up was made, resulting in notification occurring 17 days later. The allegation was substantiated.

Citations (1)
Failure to submit a written report to the licensing agency and responsible party within seven days of an unexplained absence of a resident, as required by CCR 87211(1)(D).
Report Facts
Capacity: 240 Census: 163 Deficiencies cited: 1 Plan of Correction Due Date: Jul 26, 2021

Employees mentioned
NameTitleContext
Javina GeorgeLicensing Program AnalystConducted complaint investigation and authored report
Joel EsquivelLicensing Program ManagerOversaw complaint investigation
Criselda Espiritu SantoAdministratorFacility administrator involved in investigation and exit interview

Inspection Report

Complaint Investigation
Census: 163 Capacity: 240 Citations: 1 Date: Jun 24, 2021

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility has pests.

Complaint Details
The complaint was substantiated based on observations, interviews, and record review. The allegation of pest infestation was found valid by the preponderance of the evidence standard.
Findings
The investigation substantiated the complaint of pest infestation, including bed bugs, roaches, and mice. Observations included fresh bites on a resident, dead cockroach in a staff office, bait traps in the kitchen, and a mouse trap in a resident's room. The administrator was informed and a plan of correction was required.

Citations (1)
The facility has an ongoing infestation of pests, posing an immediate health and safety risk to residents.
Report Facts
Capacity: 240 Census: 163 Deficiency count: 1 Plan of Correction Due Date: 1 Combat bait traps observed: 5

Employees mentioned
NameTitleContext
Javina GeorgeLicensing Program AnalystConducted the complaint investigation and authored the report
MaCriselda Espiritu SantoAdministratorFacility administrator met during investigation and informed of findings
Joel EsquivelSupervisorSupervisor named in the report

Inspection Report

Complaint Investigation
Census: 150 Capacity: 240 Citations: 0 Date: May 26, 2021

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 08/27/2020 regarding resident safety, treatment, and facility conditions.

Complaint Details
The complaint included nine allegations: failure to safeguard resident possessions, unlawful eviction, staff yelling at resident, resident not treated with dignity, facility infested with pests, resident not afforded privacy, facility failed to provide a safe environment, resident not permitted to reject medical care, and unlawful eviction. All allegations were found to be unsubstantiated or unfounded after investigation.
Findings
All allegations investigated, including failure to safeguard resident possessions, unlawful eviction, staff yelling at residents, lack of dignity in treatment, pest infestation, privacy concerns, safe environment, and medical care refusal rights, were found to be unsubstantiated or unfounded based on interviews, observations, and document reviews.

Report Facts
Capacity: 240 Census: 150 Number of allegations: 9

Employees mentioned
NameTitleContext
Javina GeorgeLicensing Program AnalystConducted the complaint investigation and delivered findings
Joel EsquivelLicensing Program ManagerOversaw the complaint investigation
Criselda Espiritu SantoAdministratorFacility administrator met during investigation and exit interview

Inspection Report

Complaint Investigation
Census: 160 Capacity: 240 Citations: 2 Date: May 26, 2021

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility failed to provide adequate medical treatment and failed to report an incident.

Complaint Details
The complaint was substantiated based on evidence that the facility failed to provide adequate medical treatment to Resident #1 and failed to report the incident to the responsible party, the Public Guardian, instead notifying a sibling. The preponderance of evidence standard was met for both allegations.
Findings
The investigation substantiated both allegations. Resident #1 experienced a serious medical incident related to untreated high blood sugar and a bump that was not properly addressed. Additionally, the facility failed to report the incident to the responsible party in a timely manner, notifying a sibling instead of the Public Guardian conservator.

Citations (2)
Based on 1 out of 1 resident was not provided assistance with getting their medical needs met, posing a potential health, safety and personal rights risk.
One incident was not reported to the responsible party within seven days as required, posing a potential health, safety and personal rights risk.
Report Facts
Capacity: 240 Census: 160 Deficiencies cited: 2 Plan of Correction Due Date: Jun 8, 2021

Employees mentioned
NameTitleContext
Javina GeorgeLicensing Program AnalystConducted the complaint investigation and authored the report
Joel EsquivelLicensing Program ManagerOversaw the complaint investigation
MaCriselda Espiritu SantoAdministratorFacility administrator met during investigation and named in findings

Inspection Report

Annual Inspection
Census: 160 Capacity: 240 Citations: 0 Date: May 26, 2021

Visit Reason
An unannounced annual inspection was conducted focused on infection control at the facility.

Findings
No deficiencies were cited during the inspection. Technical assistance was provided regarding proper logging of daily temperature checks.

Employees mentioned
NameTitleContext
MaCriselda Espiritu SantoAdministratorMet with Licensing Program Analyst during the inspection and received a copy of the report.
Javina GeorgeLicensing Program AnalystConducted the unannounced annual inspection focused on infection control.
Joel EsquivelLicensing Program ManagerNamed in the report as Licensing Program Manager.

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