19 Reports
Inspection Report — Nov 20, 2025
Complaint Investigation
Date: Nov 20, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-05-26 regarding medication dispensing, management, and record accuracy at Rancho Mirage Terrace facility.
Complaint Details
The complaint included three allegations: 1) Staff are not trained to dispense medication; 2) Staff are mismanaging residents' medication; 3) Staff are not keeping accurate records of medication distribution. All allegations were investigated and found unsubstantiated due to insufficient evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations that staff were untrained to dispense medication, mismanaging residents' medication, or not keeping accurate medication records. All allegations were deemed unsubstantiated after interviews, record reviews, and observations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonine Richard | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Nathan Boese | Administrator | Facility administrator interviewed during the investigation |
Inspection Report — Sep 29, 2025
Annual Inspection
Date: Sep 29, 2025
Visit Reason
An unannounced annual required visit was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, well-maintained, and compliant with all licensing requirements. No deficiencies were cited during the visit.
Report Facts
Staff present: 17
Bedrooms: 110
Bathrooms: 126
Residents' medication reviewed: 4
Last fire drill date: Sep 22, 2025
Hot water temperature: 106
Fire marshal inspection date: Jan 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan W Boese | Executive Director | Met with Licensing Program Analysts during the inspection |
| Seo Jeon | Licensing Program Analyst | Conducted the inspection and signed the report |
| Janira Arreola | Licensing Program Analyst | Conducted the inspection |
Inspection Report — Sep 20, 2024
Annual Inspection
Date: Sep 20, 2024
Visit Reason
The inspection was an unannounced annual inspection conducted by Licensing Program Analysts to assess compliance with regulatory requirements.
Findings
The facility was found to be in compliance with all reviewed areas including resident records, physical plant safety, food service, employee records, and fire safety regulations. No deficiencies were cited during this inspection.
Report Facts
Food supply duration: 7
Food supply duration: 2
Water temperature: 109
Fire extinguisher last tested: Dec 8, 2023
Last disaster drill: Sep 18, 2024
Resident records reviewed: 6
Employee records reviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yolanda Delgado | Licensing Program Analyst | Conducted the annual inspection |
| Armando Perez | Licensing Program Analyst | Conducted the annual inspection |
| Jazmond D Harris | Licensing Program Manager | Oversaw the inspection process |
| Cory Reasons | Executive Director | Facility representative met during inspection |
| Monique Moreira | Administrator | Facility administrator with current certification |
Inspection Report — Mar 20, 2024
Complaint Investigation
Date: Mar 20, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff would not change a resident's diaper.
Complaint Details
The allegation was that staff would not change Resident One's diaper. Interviews with the resident and staff, as well as record review, showed that staff regularly check and assist with diaper changes. The allegation was unsubstantiated.
Findings
The investigation found that staff do check and assist the resident with diaper changes as needed, and the allegation was deemed unsubstantiated based on interviews and record review.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Monique Moreira | Executive Director | Met with the Licensing Program Analyst during the investigation |
| Jillian Ryan | Resident Service Coordinator | Provided information regarding resident care and diaper changes |
| Tricia Danielson | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report — Feb 29, 2024
Date: Feb 29, 2024
Visit Reason
The visit was an unannounced case management visit to obtain signatures for an amended case management report deficiency page dated 1/12/23.
Findings
No other citations or deficiencies were noted during this visit. An exit interview was conducted and a copy of the report and amended deficiency page was provided to the Executive Director.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monique Moreira | Executive Director | Met with Licensing Program Analyst during the case management visit and exit interview. |
| Crystal Colvin | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Rikesha Stamps | Licensing Program Manager | Named in the report header. |
Inspection Report — Sep 25, 2023
Annual Inspection
Date: Sep 25, 2023
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate compliance with state regulations and facility standards.
Findings
The facility was found to be clean, well-maintained, and in compliance with all applicable regulations. No deficiencies were observed during the inspection.
Report Facts
Staff members present: 26
Client records reviewed: 5
Employee records reviewed: 5
Food supply duration: 1
Food supply duration: 2
Water temperature: 108
Fire extinguishers: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monique Moreira | Administrator | Conducted the facility tour during the inspection |
| Sandra Zendejas | Business Director | Completed the facility tour and received a copy of the report |
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the annual inspection |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report — May 22, 2023
Complaint Investigation
Date: May 22, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff were financially abusing a resident.
Complaint Details
The complaint alleged financial abuse by facility staff involving resident #1's bank account. The allegation was substantiated based on evidence that staff member S1 received a $150 check from the resident, violating facility policy. Other allegations about medication and dignity were unsubstantiated.
Findings
The investigation substantiated that a staff member accepted money from a resident in violation of facility policy, specifically involving cashed checks. Two other allegations regarding medication administration and resident dignity were found unsubstantiated.
Citations (1)
Facility did not ensure that resident #1's checkbook was safeguarded from staff #1, posing a potential health, safety, and personal rights violation.
Report Facts
Check amount: 150
Check amount: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rayshaun Nickolas | Licensing Program Analyst | Conducted the complaint investigation |
| Monique Moreira | Executive Director | Interviewed during investigation and met during inspection |
| Karen Clemons | Licensing Program Manager | Oversaw complaint investigation |
| Vicki Mariger | Administrator | Facility administrator named in report header |
| S1 | Staff member who accepted money from resident in violation of policy |
Inspection Report — May 9, 2023
Complaint Investigation
Date: May 9, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 2023-05-05 regarding lack of supervision resulting in resident injuries from falls, failure to provide planned activities, and unmet care needs.
Complaint Details
The complaint was unsubstantiated due to insufficient evidence to prove the alleged violations occurred. Allegations included lack of supervision causing falls, failure to provide planned activities, and unmet care needs for Resident One (R1).
Findings
The investigation found insufficient evidence to substantiate the allegations. Resident One (R1) sustained two falls but no injuries were observed, and R1 declined interviews. Staff reported encouraging R1 to participate in activities and assisting with care needs, though R1 sometimes refused assistance.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monique Moreira | Executive Director | Met with Licensing Program Analyst during investigation |
| Stephanie Torres | Licensing Program Analyst | Conducted the complaint investigation |
| Jazmond D Harris | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report — Mar 17, 2023
Date: Mar 17, 2023
Visit Reason
The visit was an unannounced case management visit regarding an eviction process taking place at the facility.
Findings
During the visit, staff and a resident were interviewed, and resident and facility records were reviewed to ensure the eviction process complied with Title 22, California Code of Regulations. No deficiencies were noted at the time of the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chinwe Nwogene | Licensing Program Analyst | Conducted the case management visit |
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the case management visit |
| Monique Moreira | Executive Director | Met with during the visit and received the report |
| Deborah Mullen | Licensing Program Manager | Named in the report |
Inspection Report — Jan 23, 2023
Date: Jan 23, 2023
Visit Reason
An office meeting was held to discuss the current management team in place at Gladwell Rancho Mirage and to confirm the managing members identified on the Administrative Organization form submitted in 2019 are still current.
Findings
The meeting confirmed the current management team and requested submission of a current Personnel Report by January 27, 2023. Contact information for the assigned Licensing Program Analyst was provided, and an exit interview was conducted with the Regional Vice President.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Mullen | Licensing Program Manager | Participated in the office meeting regarding management team discussion. |
| Jesse Gardner | Licensing Program Analyst | Participated in the office meeting regarding management team discussion. |
| Nicole Wentworth | Regional Vice President | Met during the office meeting and received the report. |
Inspection Report — Jan 17, 2023
Complaint Investigation
Date: Jan 17, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2020-07-06 alleging inadequate staff response to resident pull cords, insufficient staffing, poor food quality and quantity, and improper staff training.
Complaint Details
The complaint included allegations that staff do not respond to residents' pull cords in a timely manner, the facility lacks adequate staffing, food quality and quantity are inadequate, and staff are not properly trained. All allegations were found unsubstantiated due to insufficient evidence.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Staff responded to pull cords within 15 minutes, staffing levels were adequate, food quality and quantity met standards, and staff were properly trained.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rayshaun Nickolas | Licensing Program Analyst | Conducted the complaint investigation and made findings |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Vicki Mariger | Administrator | Facility administrator named in the report |
Inspection Report — Jan 12, 2023
Date: Jan 12, 2023
Visit Reason
The Licensing Program Analyst conducted an unannounced case management visit to follow up on information needed by the Department.
Findings
A deficiency was cited because the Assistant Executive Director (Interim Administrator), April Princesa, was not properly associated with the facility in the clearance roster, posing a potential health and safety risk. No other citations were noted during the visit.
Citations (1)
Assistant Executive Director (Interim Administrator) April Princesa was not associated to Gladwell Rancho Mirage in the clearance roster, violating personnel requirements related to criminal record review.
Report Facts
Plan of Correction Due Date: Jan 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| April Princesa | Assistant Executive Director (Interim Administrator) | Named in deficiency for not being associated with the facility in clearance roster |
| Sandra Zendejas | Business Director | Met with Licensing Program Analyst during the visit |
Inspection Report — Sep 23, 2022
Annual Inspection
Date: Sep 23, 2022
Visit Reason
The inspection was an unannounced annual inspection limited to infection control due to an active COVID-19 outbreak at the facility.
Findings
The inspection focused on COVID-19 infection control practices, confirming availability of hand sanitizer, PPE supplies, staff training on infection control, symptom screening of residents, staff, and visitors, and adherence to COVID-19 mitigation protocols.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Zendeias | Community Business Director | Met with Licensing Program Analyst during inspection and confirmed infection control practices. |
| Monique Moreira | Administrator | Participated via telephone during inspection and confirmed infection control practices. |
| Crystal Colvin | Licensing Program Analyst | Conducted the annual inspection focused on infection control. |
| Joel Esquivel | Licensing Program Manager | Named in the report header. |
Inspection Report — Sep 29, 2021
Annual Inspection
Date: Sep 29, 2021
Visit Reason
An unannounced annual inspection was conducted with an emphasis on infection control.
Findings
The inspection found sufficient hand hygiene supplies, cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead responsible for tracking COVID-19 cases and ensuring adequate PPE and staff training.
Report Facts
Staff present: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jonathan Karp | Executive Director | Met with Licensing Program Analyst during inspection and discussed infection control practices |
| Jesse Gardner | Licensing Program Analyst | Conducted the inspection visit |
| Reyna Lacey | Licensing Program Manager | Named in the report header |
Inspection Report — Jul 30, 2021
Complaint Investigation
Date: Jul 30, 2021
Visit Reason
This unannounced visit was conducted to investigate a complaint alleging that a resident fell while in care and sustained scrapes and bruises on his knees.
Complaint Details
Complaint allegation was unsubstantiated due to lack of preponderance of evidence to prove the alleged violation occurred.
Findings
The investigation found insufficient evidence to corroborate or refute the allegation. Resident notes, incident reports, and employee interviews did not confirm that the resident had a fall or injury while in care. The complaint was determined to be unsubstantiated.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jonathan Karp | Executive Director | Met with during investigation and furnished report copy |
| Amy Goldenberg | Licensing Program Analyst | Conducted the complaint investigation |
| Anna Bueno | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Nedra Brown | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report — Nov 4, 2020
Date: Nov 4, 2020
Visit Reason
The visit was a case management telephone call conducted due to COVID-19 to verify that an individual named in a Confirmation of Removal letter was not present, employed, or residing at the facility.
Findings
The Licensing Program Analyst verified that the individual named in the Confirmation of Removal letter was not present at the facility. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Wiggins | Licensing Program Analyst | Conducted the case management visit and verified removal of individual. |
| Leslie Mendiveles | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Juliet Ugalde | Community Business Manager | Facility representative who participated in the visit. |
| Vicki Mariger | Administrator | Facility administrator who stated understanding of background check process. |
Report — June 25, 2026
June 25, 2026
Report — May 12, 2026
May 12, 2026
Report — May 12, 2026
May 12, 2026
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