36 Reports
Inspection Report — Feb 4, 2026
Complaint Investigation
Date: Feb 4, 2026
Visit Reason
The inspection visit was an unannounced Case Management – Incident visit triggered by two self-reported incident reports and a subsequent incident death report regarding Resident #1 on 12/12/2025, 12/14/2025, and 01/06/2026, with a referral made to the Community Care Licensing Division's Investigation Branch.
Complaint Details
The complaint investigation was initiated due to two self-reported incident reports and a subsequent incident death report regarding Resident #1. An investigator has been assigned to the incident investigation. No immediate health and safety concerns were found during this visit.
Findings
During the visit, no immediate health and safety concerns were observed. A physical plant tour was conducted, an in-person interview with the Executive Director was held, and a file review for Resident #1 was completed. Further investigation is required.
Report Facts
Incident reports: 2
Incident death reports: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Remon Pagels | Executive Director | Met with Licensing Program Analyst during the inspection and involved in incident review |
| Erica Mosley | Licensing Program Analyst | Conducted the unannounced Case Management – Incident visit |
| Veronica Padilla | Investigator | Assigned to the incident investigation by the Community Care Licensing Division's Investigation Branch |
| Kasandra Lopez | Licensing Program Manager | Named in the report header |
Inspection Report — Jul 25, 2025
Complaint Investigation
Date: Jul 25, 2025
Visit Reason
The inspection was conducted as an unannounced subsequent Case Management – Incident visit following a self-reported incident and subsequent incident death report regarding Resident #1 involving a fall and discovery of a firearm on 05/11/2025.
Complaint Details
The visit was complaint-related due to a self-reported incident and death involving Resident #1. The complaint was investigated through interviews, file reviews, physical plant tours, and police report review. The complaint was substantiated as the cause of death was suicide with no foul play.
Findings
The investigation found that Resident #1 was highly independent with no history of suicidal ideation and no indication of possessing a firearm. Police reported no evidence of foul play or suspicious activity, and the cause of death was ruled as suicide. No deficiencies were cited related to this incident.
Report Facts
Incident dates: 2
Staff interviewed: 6
Resident interviews conducted: 2
Resident interviews attempted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Remon Pagels | Executive Director | Met with during inspection and provided information about Resident #1 |
| Erica Mosley | Licensing Program Analyst | Conducted the unannounced subsequent Case Management – Incident visit and investigation |
| Kelly Dulek | Licensing Program Analyst | Assisted in conducting the initial and subsequent unannounced visits |
Inspection Report — Jun 4, 2025
Complaint Investigation
Date: Jun 4, 2025
Visit Reason
The visit was an unannounced Case Management - Incident inspection triggered by a self-reported incident and subsequent incident death report regarding Resident #1 on 05/12/2025 and 05/13/2025.
Complaint Details
The visit was complaint-related based on a self-reported incident and incident death report concerning Resident #1. No substantiation status is provided in the report.
Findings
During the visit, Licensing Program Analysts conducted a physical plant tour to ensure no immediate health and safety concerns, interviewed the Executive Director, six staff members, and two residents, and reviewed pertinent documents related to the incident. Further investigation may be conducted if needed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Remon Pagels | Executive Director | Met with Licensing Program Analysts during the inspection and explained the reason for the visit. |
| Erica Mosley | Licensing Program Analyst | Conducted the inspection visit. |
| Kelly Dulek | Licensing Program Analyst | Conducted the inspection visit. |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report — May 22, 2025
Complaint Investigation
Date: May 22, 2025
Visit Reason
The inspection was a case management visit to continue the investigation into a self-reported incident/death involving a resident who died by suicide on 12/15/2024.
Complaint Details
The visit was complaint-related, investigating a self-reported incident/death report involving a resident who died by suicide. The investigation included review of medical records, interviews with staff and family, and review of facility policies.
Findings
The investigation found that the resident had a change in condition including hospitalization, UTI, catheter insertion, medication changes, and increased anxiety/depression, but the facility failed to conduct a required reappraisal or update the care plan. The facility did not complete a reassessment or obtain a new physician's report following the change in condition. The investigation did not find sufficient evidence that lack of care or supervision led to the resident's death.
Citations (1)
Failure to conduct a reappraisal following a significant change in condition including hospitalization, UTI, catheter, medication change, and increased anxiety/depression, which posed a potential health risk to persons in care.
Report Facts
Plan of Correction Due Date: Jun 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Remon Pagels | Executive Director | Met with Licensing Program Analyst during the visit and interviewed regarding the incident |
| Kelly Dulek | Licensing Program Analyst | Conducted the case management visit and investigation |
| Dennis Douglas | Investigator | Investigator assigned to the death investigation and conducted interviews and record reviews |
Inspection Report — May 13, 2025
Complaint Investigation
Date: May 13, 2025
Visit Reason
The visit was conducted as an unannounced Case Management - Incident inspection following receipt of a self-reported incident and subsequent incident death report regarding Resident #1 on 05/12/2025 and 05/13/2025.
Complaint Details
The visit was triggered by a complaint incident involving Resident #1, with a referral made to the Community Care Licensing Division's Investigation Branch. The report does not state substantiation status.
Findings
During the visit, Licensing Program Analysts conducted a physical plant tour to ensure no immediate health and safety concerns, interviewed the Executive Director, reviewed Resident #1's file, and obtained pertinent documents related to the incident. Further investigation may be conducted if needed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Remon Pagels | Executive Director | Met with Licensing Program Analysts during the inspection and involved in the incident file review. |
| Erica Mosley | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report — Apr 24, 2025
Annual Inspection
Date: Apr 24, 2025
Visit Reason
The Licensing Program Analyst conducted an unannounced required annual visit to evaluate the facility's compliance with Title 22 Regulations and ensure health and safety standards are met.
Findings
The facility was found to be in compliance with regulations, with no deficiencies cited. Observations included proper operation of elevators, functional fire safety equipment, well-maintained resident rooms, stocked restrooms, and compliant medication storage. Infection control and emergency disaster plans were up to date, and emergency drills were conducted as required.
Report Facts
Resident rooms toured: 12
Residents interviewed: 6
Staff interviewed: 3
Resident files reviewed: 5
Staff files reviewed: 5
Resident medications reviewed: 2
Water temperature range: 107.7 to 115.2
Last fire extinguisher service date: Jan 6, 2025
Last fire suppression system annual inspection: Jun 6, 2024
Last fire and life safety inspection: Jul 23, 2024
Last emergency disaster drill: Mar 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the annual inspection and authored the report |
| Remon Pagels | Executive Director | Met with Licensing Program Analyst during inspection |
| Hector Arjon | Maintenance Director | Accompanied Licensing Program Analyst during physical plant tour |
| Eden Tolentino | Administrator/Director | Facility Administrator named in report header |
Inspection Report — Apr 17, 2024
Annual Inspection
Date: Apr 17, 2024
Visit Reason
The inspection was an unannounced required annual visit to evaluate the facility's compliance with Title 22 Regulations and ensure there are no health and safety hazards.
Findings
The facility was found to be in compliance with no deficiencies cited at the time of the visit. Resident rooms, common areas, kitchen, restrooms, and outside areas were all observed to be well maintained and safe. Interviews with residents revealed no concerns.
Report Facts
Number of resident rooms toured: 8
Number of residents interviewed: 5
Water temperature range: 114
Water temperature range: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the inspection and signed the report |
| Remon Pagels | Executive Director | Met with Licensing Program Analyst during inspection |
| Hector Arjon | Maintenance Director | Participated in the physical plant tour during inspection |
| Desaree Perera | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report — Aug 29, 2023
Complaint Investigation
Date: Aug 29, 2023
Visit Reason
The visit was conducted to investigate a complaint alleging that staff were not present to administer medication to residents during certain hours.
Complaint Details
The complaint alleged that no medtech was available from 10am to 6am, causing residents to wait 30 minutes to an hour for medication. The allegation was deemed unsubstantiated based on interviews and schedule reviews.
Findings
The investigation found insufficient evidence to support the allegation. Interviews with residents and staff, as well as a review of staffing schedules, confirmed that a medtech was available during the night shift to administer pain medication as needed.
Report Facts
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Executive Director | Met with Licensing Program Analyst during investigation |
| Brian A Larios | Administrator | Facility administrator named in report header |
Inspection Report — Mar 14, 2023
Complaint Investigation
Date: Mar 14, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2022-12-08 regarding staff not following resident's admissions agreement, not providing an itemized list of fees, and not providing rent increase notice within 60 days.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not following resident admissions agreements, not providing itemized fee lists, and failing to provide rent increase notices within 60 days. Interviews and record reviews did not support these claims.
Findings
The investigation found insufficient evidence to support any of the allegations. Residents reported activities are offered but would like more frequent options; bills are itemized and communicated; and rent increase notices were sent timely except for a few new residents. All allegations were deemed unsubstantiated.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation and visits |
| Adam Syncheff | Executive Director | Met with Licensing Program Analyst during investigation |
| Brian A Larios | Administrator | Facility administrator named in report header |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report — Feb 28, 2023
Complaint Investigation
Date: Feb 28, 2023
Visit Reason
The visit was conducted to conclude an investigation regarding an incident that occurred on 08/24/2022 involving a physical altercation between a resident and a staff member.
Complaint Details
The complaint involved an incident where Resident #1 reportedly kicked Staff #1, who later alleged being punched by the resident. Interviews and inspections found no evidence of abuse. The complaint was not substantiated and no further follow-up was required.
Findings
The investigation found conflicting statements about the incident, with no physical evidence of injury on the resident. The staff member denied abuse, and although fault was not determined, the staff member was terminated to avoid future issues. No deficiencies were cited.
Report Facts
Incident date: Aug 24, 2022
Investigation start date: Sep 6, 2022
Telephonic interview date: Feb 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Executive Director | Met with Licensing Program Analyst during the investigation |
| Martha Arroyo | Licensing Program Analyst | Conducted the unannounced Case Management – Incident visit and investigation |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report — Feb 10, 2023
Annual Inspection
Date: Feb 10, 2023
Visit Reason
The Licensing Program Analyst Elsie Campos arrived unannounced to conduct a required annual visit to ensure compliance with Title 22 Regulations and to check for health and safety hazards.
Findings
The facility was generally clean, well maintained, and in compliance with infection control and safety regulations. However, some maintenance issues were noted including broken cabinets in the memory care unit and a broken sugar bin in the kitchen. One staff member was found not properly associated with the facility, resulting in a civil penalty.
Citations (2)
One staff member was not associated to the facility, posing an immediate health and safety risk.
Kitchen drawer in the memory care unit, cabinet under the aquarium in memory care unit, broken towel rack in room #242 shower, and broken sugar bin in main kitchen were in disrepair, posing potential health and safety risks.
Report Facts
Civil penalty amount: 500
Water temperature range: 117.8
Water temperature range: 119.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elsie Campos | Licensing Program Analyst | Conducted the inspection and authored the report |
| Brian Larios | Executive Director | Met with Licensing Program Analyst during inspection |
| Adam Syncheff | Administrator | Facility Administrator named in report header |
Inspection Report — Nov 10, 2022
Complaint Investigation
Date: Nov 10, 2022
Visit Reason
An unannounced Case Management - Deficiencies visit was conducted due to a deficiency discovered during a complaint investigation related to a COVID-19 outbreak that was not reported to Community Care Licensing.
Complaint Details
The visit was triggered by a complaint investigation. The deficiency was substantiated as the Administrator failed to report the COVID-19 outbreak to Community Care Licensing.
Findings
The facility failed to report a COVID-19 outbreak in August 2022 affecting approximately nine residents and one staff member to Community Care Licensing, which poses a potential health, safety, and personal rights risk to residents in care.
Citations (1)
Failure to report a COVID-19 outbreak to Community Care Licensing as required by reporting regulations.
Report Facts
Residents affected by COVID-19 outbreak: 9
Staff affected by COVID-19 outbreak: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian A Larios | Administrator | Named in relation to the failure to report the COVID-19 outbreak |
| Kasandra Lopez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Desaree Perera | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report — Sep 20, 2022
Complaint Investigation
Date: Sep 20, 2022
Visit Reason
The visit was conducted as a complaint investigation regarding an allegation that a resident was fed food against their religious beliefs.
Complaint Details
The allegation was that Resident #1 was intentionally tricked into eating pork against their religion. The investigation included interviews, record reviews, and observations, concluding there was insufficient evidence to substantiate the claim.
Findings
The investigation found that the resident in question had moved out over two years ago, and residents choose their meals daily with accommodations made if they are unhappy. Staff continuously check with residents about their food preferences, and no evidence was found to support the allegation. The complaint was deemed unsubstantiated.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Denise Wadkins | Memory Care Director | Met with Licensing Program Analyst during the visit |
| Sarah Dodd | Administrator | Facility administrator named in the report |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report — Sep 6, 2022
Complaint Investigation
Date: Sep 6, 2022
Visit Reason
The visit was conducted to investigate an incident reported by the facility regarding Resident #1, alleging that Staff #1 punched them in the right calf area of their leg.
Complaint Details
The visit was complaint-related, investigating an incident of alleged physical abuse by staff against a resident. Substantiation status is not stated.
Findings
The Licensing Program Analyst conducted an unannounced case management incident visit including interviews, a plant tour, and a resident file review. Further investigation is required prior to issuing findings.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Dodd | Executive Director | Met with Licensing Program Analyst during investigation of incident involving Resident #1. |
| Martha Arroyo | Licensing Program Analyst | Conducted the unannounced case management incident visit and investigation. |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report — Jul 29, 2022
Complaint Investigation
Date: Jul 29, 2022
Visit Reason
The visit was an unannounced case management incident investigation conducted to investigate an elopement incident involving Resident #1 that occurred on 2022-07-17.
Complaint Details
The visit was complaint-related, investigating an elopement incident of Resident #1 on 2022-07-17. The facility reported the incident the following day. Resident #1 was found outside the facility unassisted, contrary to the physician's report stating the resident cannot leave unassisted.
Findings
The investigation found that Resident #1 eloped from the facility unassisted on 2022-07-17, despite the presence of a front desk clerk and memory care staff training on elopement protocols. The facility failed to supervise the resident, posing an immediate health and safety risk.
Citations (1)
87464 Basic services (f)(1)(c) 'Care and supervision' means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as Resident #1 left the facility unassisted which poses an immediate health and safety risk to persons in care.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Dodd | Executive Director | Met with Licensing Program Analyst during investigation |
| Martha Arroyo | Licensing Program Analyst | Conducted the unannounced case management incident visit and investigation |
| Desaree Perera | Licensing Program Manager | Supervisor and named in the report |
Inspection Report — Apr 1, 2022
Complaint Investigation
Date: Apr 1, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2021-09-17 regarding multiple concerns about resident care and staff conduct at the facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff causing a resident to expose himself, staff hitting a resident, failure to accord privacy, multiple falls, staff leaving a resident on the floor, delayed response to call buttons, and failure to assist with medical appointments. Investigations included interviews with staff, residents, and review of records. No citations were issued.
Findings
The investigation found insufficient evidence to substantiate any of the allegations, including staff causing a resident to expose himself, staff hitting a resident, failure to accord privacy, multiple falls, delayed response to call buttons, and failure to assist with medical appointments. All allegations were deemed unsubstantiated.
Report Facts
Number of allegations: 8
Staff interviews: 5
Resident interviews: 4
Resident interviews: 3
Routine checks on high fall risk resident: 3
Notification interval: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Guzman-Chavez | Licensing Program Analyst | Conducted the complaint investigation and visits |
| Sarah Dodd | Executive Director | Facility administrator met during investigation |
| Elijah Soltan | Med-Tech | Interviewed during investigation |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report — Mar 24, 2022
Annual Inspection
Date: Mar 24, 2022
Visit Reason
The Licensing Program Analyst arrived unannounced to conduct a required annual visit with a specific emphasis on infection control practices and procedures.
Findings
No deficiencies were observed during the inspection. The facility was found to be in compliance with Title 22 regulations, infection control practices, and visitation requirements. Adequate supplies of food, PPE, and properly maintained safety equipment were noted.
Report Facts
Water temperature: 109.4
Water temperature: 111.4
Fire extinguisher last serviced: Mar 22, 2022
Date of last positive COVID case: Mar 2, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Dodd | Administrator | Met with Licensing Program Analyst during inspection |
| Martha Guzman Chavez | Licensing Program Analyst | Conducted the inspection |
| Desaree Perera | Licensing Program Manager | Named in report header |
| Lupe Ambriz | Signed the report during exit interview |
Inspection Report — Dec 13, 2021
Complaint Investigation
Date: Dec 13, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not appropriately care for a resident.
Complaint Details
The complaint alleged that staff did not appropriately care for Resident #1. Interviews with the resident, responsible party, other residents, and staff did not substantiate the claim. The allegation was deemed unsubstantiated.
Findings
The investigation found insufficient evidence to support the allegation that staff failed to appropriately care for Resident #1. Resident and responsible party interviews did not corroborate the claims, and residents reported feeling comfortable and well cared for. No deficiencies were cited.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Sarah Dodd | Executive Director | Met with Licensing Program Analyst during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report — Aug 26, 2021
Annual Inspection
Date: Aug 26, 2021
Visit Reason
An unannounced required 1-year inspection was conducted focusing on infection control and compliance with Title 22 regulations.
Findings
The inspection found no deficiencies. The facility was in compliance with health and safety regulations, infection control practices were observed, and safety equipment was operational. The facility had adequate PPE supplies and housekeeping was actively maintaining cleanliness.
Report Facts
Resident files reviewed: 8
Staff records reviewed: 3
Fire extinguisher last serviced: Jan 22, 2021
Water temperature range (degrees F): 109.4-111.2
COVID-19 positive cases: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Dodd | Administrator | Met with Licensing Program Analyst during inspection |
| Martha Guzman Chavez | Licensing Program Analyst | Conducted the inspection |
| Desaree Perera | Licensing Program Manager | Named in report header |
Inspection Report — Aug 26, 2021
Date: Aug 26, 2021
Visit Reason
An unannounced Case Management - Other visit was conducted to discuss the serious illness/injury reporting requirement as per regulation 87211(a)(1)(D).
Findings
The facility failed to submit unusual incident/injury reports within the required seven days on multiple occasions, posing a potential health and safety risk to residents.
Citations (1)
Failure to submit incident reports of four residents within seven days of occurrence as required by regulation 87211(a)(1)(D).
Report Facts
Incident reports late: 4
POC Due Date: Aug 30, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Dodd | Administrator | Met during visit and named in relation to failure to ensure timely incident reporting. |
| Martha Guzman Chavez | Licensing Program Analyst | Conducted the inspection visit and authored the report. |
| Desaree Perera | Licensing Program Manager | Supervisor named in the report. |
| Carthel Mercado | Resident Services Coordinator | Met during visit to discuss reporting requirements. |
Report — July 15, 2026
July 15, 2026
Report — April 8, 2026
April 8, 2026
Report — April 6, 2026
April 6, 2026
Report — July 25, 2025
July 25, 2025
Report — June 4, 2025
June 4, 2025
Report — May 22, 2025
May 22, 2025
Report — May 13, 2025
May 13, 2025
Report — April 24, 2025
April 24, 2025
Report — April 17, 2024
April 17, 2024
Report — February 28, 2023
February 28, 2023
Report — February 10, 2023
February 10, 2023
Report — November 10, 2022
November 10, 2022
Report — September 6, 2022
September 6, 2022
Report — July 29, 2022
July 29, 2022
Report — March 24, 2022
March 24, 2022
Report — August 26, 2021
August 26, 2021
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