Inspection Reports for
Almond Grove Assisted Living

The department followed up on the incident report sent by the facility and confirmed that law enforcement and the long term care ombudsman were notified. The case is under review with no citations issued at this time per Title 22 Regulations.

The facility took appropriate action regarding the incident involving residents R1 and R2. Both residents were at their baseline with no other related incidents, and the facility notified all required parties. No deficiencies were cited due to this incident.

The complaint involved an incident on 05/01/2025 where one resident grabbed another by the shirt and threw a cup of ice. The incident was reported by the facility on 05/02/2025. The complaint was substantiated as the incident occurred, but no injuries resulted.

The facility timely reported the incident to the Department, law enforcement, family members, and physicians. No injuries were sustained by the residents involved, and no deficiencies were issued in this report.

The complaint involved an allegation by resident R1 of abuse while in care. The facility notified R1's responsible party, law enforcement, and the Long-Term Care Ombudsman. The complaint is currently under review with no substantiation or citations issued at this time.

The department interviewed resident R1 and staff regarding the alleged abuse incident. Facility records showed no visible injuries to R1 and that R1 was at their baseline. No citations were issued during this visit, and the case remains under review with further follow-up if warranted.

The facility was found to be clean, safe, sanitary, and in good condition with no deficiencies observed or cited. Staff and resident files were reviewed and found to be compliant, medications were properly managed and secured, and required drills and safety measures were in place.

The visit was related to a case management incident involving resident R1. The case is under review and no substantiation status is provided.

No visible injuries were found on resident R1 after the incident, and R1 was at their baseline. The department interviewed involved parties and requested related documents, with no citations issued at this time.

The visit was complaint-related due to an incident where resident R1 left the facility unattended. The incident was substantiated as the facility failed to provide adequate supervision, posing an immediate risk to resident safety.

The facility failed to provide proper care and supervision to resident R1, who has dementia and cannot leave unassisted, resulting in R1 leaving the facility unattended. Immediate civil penalties were assessed due to repeat violations of the same regulation within 12 months.

The complaint investigation revealed that resident R1 had fall incidents on 07/20/23 and 10/12/23 and was placed in a Skilled Rehab Facility from 06/26/23 to 07/19/23. Resident R2 had an AWOL incident on 06/23/24 and was found unattended 0.5 miles from the facility. Both incidents were not reported to the Department as required.

The facility failed to report multiple incidents involving residents R1 and R2 to the Department within the required timeframes, violating Title 22 Regulation 87211. Citations were issued for these reporting deficiencies.

The complaint involved an alleged fall of resident R1 in a non-medical ambulance during transport. The allegation was investigated through interviews, footage review, and resident assessment. The complaint remains under review with no substantiation or citations issued at this time.

The department found no evidence of a fall after reviewing transportation footage and assessing the resident, who refused ambulance assessment but was advised to visit the ER. No injuries were observed and no citations were issued.

The inspection found multiple deficiencies including unsecured access to chemicals in the laundry room, incomplete personnel and resident records, lack of required staff training and certifications, and missing required resident appraisals and medical assessments for dementia care.

The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited during this inspection.

The facility was generally found to be properly furnished and maintained, with operational smoke and carbon monoxide detectors and fire extinguishers. However, deficiencies included one fire extinguisher needing service, a non-operational door sensor, debris and tools in the courtyard, missing items in staff and resident files, and sinks missing hand washing signs and covered trash receptacles. The facility was instructed to correct these issues within 7 days.

The applicant/administrator successfully completed the Component II evaluation via telephone, demonstrating understanding of Title 22 regulations, facility operation, staff qualifications, program policies, and other licensing requirements. No deficiencies or violations were noted in the report.