Deficiencies (last 5 years)
Deficiencies (over 5 years)
7.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
5% occupied
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Capacity: 44
Deficiencies: 1
Date: Nov 14, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2025-11-03 regarding staff not assisting a resident with medical appointments.
Complaint Details
The complaint alleging staff did not assist a resident with medical appointments was substantiated based on interviews, observations, and record review.
Findings
The investigation substantiated the allegation that staff failed to assist a resident with a medical appointment, resulting in a missed doctor's appointment. The California Code of Regulations was cited accordingly.
Deficiencies (1)
CCR 87465(a)(1) requires the licensee to arrange or assist in arranging medical and dental care appropriate to residents' needs. The investigation found that a doctor's appointment was missed due to failure to assist the resident.
Report Facts
Facility Capacity: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melinda Hoffmann | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 2
Capacity: 44
Deficiencies: 0
Date: Oct 30, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff engaged in various forms of physical abuse with a resident in care.
Complaint Details
The complaint alleged staff engaged in various forms of physical abuse with a resident. The allegation was determined to be unsubstantiated after investigation.
Findings
The investigation found the allegation to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were issued during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
Inspection Report
Complaint Investigation
Census: 2
Capacity: 44
Deficiencies: 3
Date: Oct 30, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations including pest infestation, inappropriate staff behavior, and unsecured residents' personal property.
Complaint Details
The complaint investigation was substantiated based on evidence of pest infestation, inappropriate staff behavior, and inadequate personal property security.
Findings
The investigation substantiated the allegations, finding a roach and bed bug infestation, inappropriate staff conduct offering money to a resident to leave, and failure to maintain accurate records of residents' personal belongings.
Deficiencies (3)
CCR 87464(f) Basic services were not met as the Licensee did not sufficiently address the roach and bed bug infestation, resulting in unsafe living conditions for all residents.
CCR 87468.1(a)(1) Personal rights were violated when the Licensee offered $2000 to a resident to leave while serving an eviction notice, posing a potential health and safety risk.
CCR 87218(a)(1) The Licensee failed to ensure an adequate theft and loss program by not inventorying residents' personal property upon admission, creating a potential health and safety risk.
Report Facts
Capacity: 44
Census: 2
Residents affected: 24
Inspection Report
Census: 9
Capacity: 44
Deficiencies: 0
Date: Oct 29, 2025
Visit Reason
The visit was a case management health and safety check conducted by the Licensing Program Analyst to assess the status of residents and facility conditions.
Findings
The report notes that several residents were relocated to other facilities or hospitals, with two residents remaining at the facility pending medical assessment and planned relocation. No specific deficiencies or violations are detailed in the report.
Inspection Report
Census: 24
Capacity: 44
Deficiencies: 0
Date: Oct 28, 2025
Visit Reason
The visit was a case management health and safety check conducted by the Licensing Program Analyst at the facility.
Findings
The report notes that 14 residents were relocated during the visit, with 10 remaining residents either hospitalized, in jail, or still at the facility awaiting assessment. The Tulare County Mental Health team was present to assist with assessments and relocation.
Inspection Report
Census: 24
Capacity: 44
Deficiencies: 0
Date: Oct 27, 2025
Visit Reason
The visit was a health and safety case management visit conducted to assess the facility and residents.
Findings
The Licensing Program Analyst met with the facility administrator and licensee, observed the residents during a facility tour, and noted the presence of 24 residents and three staff members. No specific deficiencies or violations were detailed in the report.
Inspection Report
Census: 23
Capacity: 44
Deficiencies: 0
Date: Oct 26, 2025
Visit Reason
The visit was an unannounced case management health and safety check conducted to assess the facility's compliance and resident well-being.
Findings
The Licensing Program Analyst conducted a tour, confirmed meal delivery by Meals on Wheels, and informed the licensee that the facility's kitchen cannot be used for cooking food; any food provided must be catered.
Inspection Report
Census: 23
Capacity: 44
Deficiencies: 0
Date: Oct 25, 2025
Visit Reason
The visit was a case management health and safety check conducted to assess the facility's condition and resident well-being.
Findings
The facility had residents relocated due to bedbug treatment. Residents reported receiving meals from outside delivery and indicated the facility is closing with plans to move to another location. Only one staff member was on duty during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonio G. Ong | Administrator/Director | Named as facility administrator/director. |
| Ligaya Escario | Staff on duty during the visit and met with the Licensing Program Analyst. | |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager. |
| Les Xiong | Licensing Program Analyst | Named as Licensing Program Analyst conducting the visit. |
Inspection Report
Census: 23
Capacity: 44
Deficiencies: 18
Date: Oct 23, 2025
Visit Reason
The visit was an unannounced case management inspection to issue deficiencies observed during a prior case management – Health Checks inspection conducted on 09/24/2025.
Findings
The inspection found multiple deficiencies including broken equipment (air conditioning unit, refrigerators, walk-in freezer), unsafe food storage and service practices, pest infestations, inadequate cleaning and maintenance, insufficient staffing, incomplete resident and staff records, and locked bathrooms preventing resident access.
Deficiencies (18)
CCR 87555(a): The facility did not provide meals of good quality and quantity, served food past the best buy date, food from damaged containers, and stored food in a broken freezer.
CCR 87555(b)(9): The facility stored food in trash bags, did not use freezer-safe storage, failed to label food, and did not take safety precautions against pests during food preparation.
CCR 87555(b)(26): The facility was not supplied with a one-week supply of non-perishable foods and a two-day supply of perishable foods.
CCR 87555(b)(27): Roaches and spiders were observed in the pantry and walk-in freezer, indicating the kitchen was not kept clean and free of pests.
CCR 87555(b)(24): Insect killer, plant fertilizer, and paint were stored in the kitchen area.
CCR 87555(b)(29): Multiple refrigerators and the walk-in freezer were broken and used for food storage.
CCR 87555(b)(16): The facility did not designate a person responsible for food planning, preparation, and service.
CCR 87555(b)(6): Menus were not written or followed; food items served were close to expiration.
CCR 87411(a): Staffing was insufficient as the Licensee was the only staff on duty and unable to meet resident needs.
CCR 87303(a): The facility was not clean, safe, sanitary, or in good repair; broken equipment, dirty air filters, pest-contaminated curtains, non-operational shower, and a large hole in the laundry room wall were observed.
CCR 87303(c): Multiple window screens needed replacement or repair.
CCR 87307(a)(3): The facility lacked sufficient clean linens in good repair; residents used bedding stained with blood.
CCR 87307(b): Two bathrooms were locked preventing resident use, violating requirements for convenient access to toilets and showers.
CCR 87468.1(a)(1): The Licensee did not accord dignity and respect to residents and threw out resident belongings without permission.
CCR 87468.1(a)(2): Residents in room 22 were not relocated from a room with bed bugs, and refrigerators were locked.
CCR 87506(a): Resident records were incomplete and not current for all 22 residents in care.
CCR 87405(a): The Administrator was not present a sufficient number of hours to manage the facility adequately.
CCR 87412(a): Personnel records were incomplete and not current for all staff employed at the facility.
Report Facts
Census: 23
Total Capacity: 44
Deficiency count: 17
Plan of Correction Due Date: Oct 31, 2025
Inspection Report
Census: 24
Capacity: 44
Deficiencies: 0
Date: Sep 24, 2025
Visit Reason
The visit was an unannounced Case Management - Health Checks inspection conducted to perform a health and safety check at the facility.
Findings
A tour of the facility was conducted during the visit. Deficiencies observed will be cited at a later date.
Inspection Report
Census: 44
Capacity: 44
Deficiencies: 0
Date: Aug 19, 2025
Visit Reason
An informal meeting was held to discuss recently identified issues and concerns associated with the operation of the facility.
Findings
The report documents an informal meeting discussing topics including food service, buildings and grounds, and finances. No specific deficiencies or enforcement actions are detailed in the report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonio Ong | Administrator | Facility Administrator present at the informal meeting. |
| Lisa Ong | Licensee | Licensee present at the informal meeting. |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Les Xiong | Licensing Program Analyst | Named as Licensing Program Analyst on the report. |
Inspection Report
Annual Inspection
Census: 23
Capacity: 44
Deficiencies: 0
Date: Jul 30, 2025
Visit Reason
The inspection was an unannounced required one-year visit to evaluate the facility's compliance with licensing requirements.
Findings
The facility appeared clean and well-maintained with no obstructions or fire clearance issues. All required accommodations were observed in resident bedrooms, and safety equipment such as smoke detectors and fire extinguishers were operational. No deficiencies were observed during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonio G. Ong | Administrator/Director | Named as facility administrator/director. |
| Lisa Ong | Met with Licensing Program Analyst during inspection. | |
| Les Xiong | Licensing Program Analyst | Conducted the inspection visit. |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 44
Deficiencies: 0
Date: May 2, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by multiple allegations received on 2024-11-25 regarding facility cleanliness, staff training on medication dispensing, residents' dietary needs, inappropriate staff requests, and tampering with residents' mail.
Complaint Details
The complaint investigation addressed allegations that staff did not keep the facility clean, were not properly trained to dispense medication, did not meet residents' dietary needs, made inappropriate requests of residents, tampered with residents' mail, and forced residents to give staff their debit cards. All allegations were found to be unfounded or unsubstantiated.
Findings
The investigation found all allegations to be unfounded with evidence showing the facility is cleaned daily, staff are properly trained, residents do not have special dietary needs, and no inappropriate requests or mail tampering occurred. A separate allegation that residents were forced to give staff their debit cards was unsubstantiated due to lack of sufficient evidence.
Report Facts
Facility Capacity: 44
Resident Census: 24
Inspection Report
Complaint Investigation
Census: 28
Capacity: 44
Deficiencies: 0
Date: Mar 13, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that staff did not follow physician’s laboratory orders for a resident.
Complaint Details
The complaint alleged that staff did not follow physician’s laboratory orders for a resident. The complaint was investigated and found to be unfounded.
Findings
The investigation found the allegation to be unfounded. Evidence showed the resident followed the physician's orders for lab work on the specified dates, and the complaint was dismissed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit. |
Inspection Report
Complaint Investigation
Capacity: 44
Deficiencies: 0
Date: Mar 3, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 2024-07-01 regarding staff behavior and facility conditions at Autumn Oaks.
Complaint Details
The complaint investigation was triggered by allegations of staff restricting resident belongings, threatening residents, failure to prevent smoking in non-smoking areas, assaulting residents, withholding resident funds, and failure to maintain the facility in good repair and fire safety compliance. All allegations were found unsubstantiated or unfounded due to lack of preponderance of evidence.
Findings
The investigation found all allegations unsubstantiated or unfounded due to insufficient evidence or contradictory findings. Allegations included staff restricting resident belongings, threatening residents, failure to prevent smoking in non-smoking areas, assault, withholding resident funds, and facility maintenance issues.
Report Facts
Facility Capacity: 44
Inspection Report
Complaint Investigation
Capacity: 44
Deficiencies: 0
Date: Mar 3, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that the facility was not providing residents with adequate food and had rodents in the kitchen and resident rooms.
Complaint Details
The complaint was investigated and found to be unfounded. Allegations included inadequate food provision and presence of rodents in the kitchen and resident rooms.
Findings
The investigation found the allegations to be unfounded. The Licensing Program Analyst observed adequate food and no rodents in the kitchen or resident rooms, leading to dismissal of the complaint.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit. |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 44
Deficiencies: 0
Date: Feb 26, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff did not provide adequate food service and did not ensure residents were served food of good quality.
Complaint Details
The complaint alleged inadequate food service and poor food quality. The investigation concluded the allegations were unsubstantiated.
Findings
The investigation found no expired food and inconsistent interview statements. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Inspection Report
Complaint Investigation
Census: 28
Capacity: 44
Deficiencies: 0
Date: Feb 26, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-06-07 regarding staff mismanagement of resident medication, lack of resident access to water, financial abuse of residents, and staff threats to residents.
Complaint Details
The complaint investigation addressed allegations of staff mismanaging resident medication, failure to ensure resident access to water, financial abuse of residents, and staff threatening residents. The medication and water access allegations were found unfounded, while the financial abuse and threat allegations were unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found the allegations of medication mismanagement and lack of water access to be unfounded, and the allegations of financial abuse and threats to residents to be unsubstantiated due to insufficient evidence.
Report Facts
Facility Capacity: 44
Resident Census: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Antonio G. Ong | Administrator | Facility administrator mentioned in the report |
Inspection Report
Complaint Investigation
Census: 26
Capacity: 44
Deficiencies: 1
Date: Feb 10, 2025
Visit Reason
This was an unannounced complaint investigation visit triggered by allegations that staff did not ensure residents received correct medications and were not dispensing medication as prescribed.
Complaint Details
The complaint was substantiated based on interviews, record reviews, and observations. The facility sent wrong medications to resident R1 during visits home on February 3, 4, and 5, 2025.
Findings
The investigation substantiated the allegations that the facility sent wrong medications for resident R1 on February 3, 4, and 5, 2025. Staff were retrained on medication administration procedures following discovery of the medication error.
Deficiencies (1)
CCR 87456(a)(4): The licensee failed to assist residents with self-administered medications as needed. LPA observed R2's medication was sent home with R1 on February 3, 4, and 5, 2025.
Report Facts
Facility Capacity: 44
Resident Census: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted complaint investigation visit |
| Antonio G. Ong | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 26
Capacity: 44
Deficiencies: 1
Date: Feb 10, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not ensure correct medications were dispensed to a resident in care.
Complaint Details
The complaint alleging incorrect medication dispensing was substantiated based on interviews, observations, and record reviews conducted during the investigation.
Findings
The investigation substantiated the allegation that the facility sent wrong medications for resident R1 during visits home on February 3, 4, and 5, 2025. Staff were retrained on medication administration procedures following discovery of the error.
Deficiencies (1)
CCR 87465(a)(4) requires the licensee to assist residents with self-administered medications as needed. This requirement was not met as medication intended for resident R2 was sent home with resident R1 on February 3, 4, and 5, 2025.
Report Facts
Facility Capacity: 44
Resident Census: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Antonio G. Ong | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Capacity: 44
Deficiencies: 0
Date: Feb 7, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that the facility did not safeguard residents' rooms and personal belongings and did not follow required eviction procedures, as well as an allegation of resident physical abuse.
Complaint Details
The complaint investigation was conducted following allegations that the facility failed to safeguard resident's rooms and personal belongings and did not follow eviction procedures, which were found unfounded. Another allegation of resident physical abuse was investigated and found unsubstantiated.
Findings
The investigation found the allegations that the facility did not safeguard residents' rooms and personal belongings and did not follow eviction procedures to be unfounded. The allegation of resident physical abuse was unsubstantiated due to insufficient evidence.
Report Facts
Facility Capacity: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Antonio G. Ong | Administrator | Facility administrator mentioned in report header |
Inspection Report
Complaint Investigation
Capacity: 44
Deficiencies: 0
Date: Feb 7, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-05-16 regarding facility staff not safeguarding resident’s personal property and not dispensing medication as prescribed, as well as handling residents in a rough manner.
Complaint Details
The complaint investigation was conducted based on allegations that facility staff did not safeguard resident’s personal property, did not dispense medication as prescribed, and handled residents in a rough manner. The first two allegations were found to be unfounded, and the third was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found the allegations that facility staff did not safeguard resident’s personal property and did not dispense medication as prescribed to be unfounded. The allegation that staff handled residents in a rough manner was unsubstantiated due to insufficient evidence.
Report Facts
Facility Capacity: 44
Inspection Report
Complaint Investigation
Capacity: 44
Deficiencies: 1
Date: Jan 27, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not ensure the facility was free from pests and that staff yelled at a resident.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not ensure the facility was free from pests, with roaches observed in room 17. The allegation that staff yelled at a resident was unsubstantiated due to insufficient evidence.
Findings
The allegation regarding pests was substantiated with evidence of roaches observed in room 17, posing an immediate health and safety risk. The allegation that staff yelled at a resident was unsubstantiated due to lack of sufficient evidence.
Deficiencies (1)
CCR 87303(a) requires the facility to be clean, safe, sanitary, and in good repair at all times. Roaches were observed in the facility, posing an immediate health and safety risk to clients.
Report Facts
Facility Capacity: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melinda Hoffmann | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 44
Deficiencies: 0
Date: Jan 23, 2025
Visit Reason
Unannounced complaint investigation visit conducted in response to an allegation of unlawful eviction received on 2024-12-23.
Complaint Details
The complaint alleging unlawful eviction was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
Findings
The investigation found the allegation of unlawful eviction to be unfounded after interviews and record reviews confirmed the resident resided at the facility until 2025-01-15. The complaint was dismissed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mai Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Lisa Ong | Licensee | Met with Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 44
Deficiencies: 0
Date: Jan 17, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the facility was not safeguarding residents' belongings.
Complaint Details
The complaint alleging that the facility is not safeguarding residents' belongings was investigated and determined to be unfounded.
Findings
The complaint was investigated and found to be unfounded. The investigation revealed that a recent deep cleaning occurred and residents were aware of items discarded during cleaning.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit. |
Inspection Report
Complaint Investigation
Capacity: 44
Deficiencies: 1
Date: Dec 18, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 2024-09-05 regarding staff mismanagement of medication, serving spoiled food, and failure to provide laundry service.
Complaint Details
The complaint investigation addressed three allegations: staff mismanages residents medication (unfounded), staff serves residents spoiled and rotten food (unsubstantiated), and staff not providing residents with laundry service (substantiated). The substantiated allegation was due to a malfunctioning dryer which has since been replaced.
Findings
The investigation found the allegations of medication mismanagement and serving spoiled food to be unfounded and unsubstantiated respectively. However, the allegation of failure to provide laundry service was substantiated due to a malfunctioning dryer.
Deficiencies (1)
CCR 87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. LPA observed dryer not turning on.
Report Facts
Facility Capacity: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Antonio G. Ong | Administrator | Facility administrator during the investigation |
| Lisa Ong | Met with Licensing Program Analyst during the investigation | |
| Melinda Hoffmann | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 44
Deficiencies: 1
Date: Dec 18, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 09/18/2024 regarding staff use of a padlock on exit doors and cleanliness of residents' rooms.
Complaint Details
The complaint investigation was substantiated for the allegation that staff utilized a padlock on the inside of exit doors. The allegation that staff did not ensure residents' rooms were clean was unsubstantiated.
Findings
One allegation regarding the use of a padlock on the inside of exit doors was substantiated, with the padlock observed and subsequently removed during the visit. Another allegation about staff not ensuring residents' rooms were clean was unsubstantiated due to lack of sufficient evidence.
Deficiencies (1)
CCR 87202(a) Fire Clearance requires all facilities to maintain a fire clearance approved by the appropriate fire authority. The facility's southwest exit door was locked with a padlock, violating this requirement.
Report Facts
Facility Capacity: 44
Resident Census: 28
Deficiency Count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Antonio G. Ong | Administrator | Facility administrator mentioned in the report |
Inspection Report
Census: 27
Capacity: 44
Deficiencies: 1
Date: Nov 15, 2024
Visit Reason
The visit was a case management visit involving a tour of the facility conducted by the licensing evaluator.
Findings
The facility was found to have bed bugs and a mattress cover that was not in good repair, posing an immediate health and safety risk to clients in care.
Deficiencies (1)
CCR 87303a: The facility shall be clean, safe, sanitary and in good repair at all times. The facility had bed bugs and a mattress cover was not in good repair, posing an immediate health and safety risk.
Report Facts
Plan of Correction Due Date: Nov 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Evaluator | Conducted the case management visit and signed the report |
| Melinda Hoffmann | Supervisor | Supervisor named in the report |
Inspection Report
Annual Inspection
Census: 22
Capacity: 44
Deficiencies: 0
Date: Sep 26, 2024
Visit Reason
The visit was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate the facility's compliance with licensing requirements.
Findings
The facility appeared clean with no obstructions or fire clearance issues. All common areas and resident bedrooms met required accommodations, and the kitchen had adequate food supplies for residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matilde Garcia | Met with Licensing Program Analyst during the inspection. | |
| Antonio G. Ong | Administrator/Director | Named as facility administrator/director. |
| Les Xiong | Licensing Program Analyst | Conducted the unannounced annual inspection. |
| Melinda Hoffmann | Supervisor | Supervisor named in the report. |
Inspection Report
Capacity: 44
Deficiencies: 0
Date: Jun 14, 2024
Visit Reason
An informal conference was conducted at the Fresno Adult/Senior Regional Office to discuss issues regarding food, finance, and medications. The Technical Support Program (TSP) was offered and accepted by the Licensee and Administrator.
Findings
The report documents a meeting addressing concerns about food, finance, and medication management at the facility. No specific deficiencies or violations are detailed in the report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonio G. Ong | Administrator | Facility Administrator present during the meeting. |
| Lisa Ong | Licensee present during the meeting. | |
| Matilda Garcia | Staff | Staff member present during the meeting. |
| Melinda Hoffmann | Licensing Program Manager | Licensing Program Manager present during the meeting. |
| Les Xiong | Licensing Program Analyst (LPA) | Licensing Program Analyst present during the meeting. |
Inspection Report
Census: 25
Capacity: 44
Deficiencies: 0
Date: May 22, 2024
Visit Reason
The visit was a case management visit conducted by the licensing evaluator to tour the facility and interview residents.
Findings
A tour of the facility was conducted and residents were interviewed. The visit ended early due to the licensee having a meeting appointment with the Tulare County Ombudsman.
Inspection Report
Complaint Investigation
Census: 24
Capacity: 44
Deficiencies: 1
Date: Apr 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2024-01-19 regarding facility disrepair, unsanitary conditions, odor issues, and resident access to toxic chemicals.
Complaint Details
The complaint investigation was substantiated for facility disrepair and unsanitary conditions. Allegations of odor and resident access to toxic chemicals were unsubstantiated.
Findings
The investigation substantiated allegations of facility disrepair and unsanitary conditions, specifically noting a wall in the shower/bathroom not completely repaired and a toilet that was not flushing. Allegations of facility odor and resident access to toxic chemicals were unsubstantiated.
Deficiencies (1)
CCR 87303 Maintenance and Operation: A wall in the shower/bathroom across from the laundry room was not completely repaired and the toilet was not flushing. The wall has since been repaired and the toilet is now working properly.
Report Facts
Deficiency Type B: 1
Capacity: 44
Census: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Antonio G. Ong | Administrator | Facility administrator named in the report |
| Lisa Ong | Licensee met with during the investigation | |
| Sergiy Pidgirny | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 44
Deficiencies: 1
Date: Apr 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2024-03-22 regarding pest control, freezer pad lock, bedding cleanliness, and expired food storage.
Complaint Details
The complaint investigation involved allegations that staff did not keep the facility free from insects, the facility owner placed a pad lock on the freezer, staff were not ensuring residents had clean bedding, and the facility was storing expired food. The insect and freezer pad lock allegations were found unfounded. The bedding allegation was unsubstantiated. The expired food allegation was substantiated.
Findings
The investigation found two allegations unfounded regarding pest control and freezer pad lock. One allegation about bedding cleanliness was unsubstantiated due to insufficient evidence. One allegation about storing expired food was substantiated with observed expired bread and canned goods.
Deficiencies (1)
CCR 87555(8) General Food Service Requirements. LPA observed expired bread in the facility.
Report Facts
Facility Capacity: 44
Resident Census: 24
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit and findings |
Inspection Report
Complaint Investigation
Capacity: 44
Deficiencies: 0
Date: Feb 28, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations of staff interacting inappropriately with a resident and withholding resident's medication and personal belongings, as well as not meeting residents' dietary needs.
Complaint Details
The complaint alleged staff interacted inappropriately with a resident, withheld resident's medication, did not ensure residents' dietary needs were met, and withheld resident's personal belongings. The allegations were found to be unsubstantiated or unfounded due to lack of evidence.
Findings
The investigation found the allegations of inappropriate staff interaction, withholding medication and personal belongings, and failure to meet dietary needs to be unsubstantiated or unfounded based on interviews and records review.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings. |
| Antonio G. Ong | Administrator | Facility administrator named in the report. |
| Matilde Garcia | Staff member met with during the investigation. | |
| Sergiy Pidgirny | Supervisor | Supervisor overseeing the investigation. |
Inspection Report
Complaint Investigation
Capacity: 44
Deficiencies: 0
Date: Feb 28, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2023-11-29 regarding staff communication with residents' responsible parties and financial abuse of residents.
Complaint Details
The complaint investigation was unannounced and addressed allegations that staff were not communicating with residents' responsible parties and financially abusing residents. Both allegations were found unsubstantiated. An additional allegation that staff were not safeguarding resident's personal belongings was found unfounded.
Findings
The investigation found the allegations of staff not communicating with residents' responsible parties and financial abuse to be unsubstantiated due to lack of preponderance of evidence. A separate allegation regarding staff not safeguarding resident's personal belongings was found to be unfounded as the belongings were still in the resident's room awaiting their return from rehab.
Report Facts
Facility Capacity: 44
Inspection Report
Complaint Investigation
Capacity: 44
Deficiencies: 0
Date: Feb 28, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2023-11-13 regarding medication dispensing and room conditions at the facility.
Complaint Details
The complaint investigation addressed allegations that staff did not dispense medication as prescribed and that the resident's room was malodorous. The allegations were unsubstantiated due to lack of evidence. Additional complaints about assistance with medical appointments, equipment repair, and room cleaning were found unfounded and dismissed.
Findings
The investigation found the allegations unsubstantiated and unfounded. There was no preponderance of evidence to prove staff failed to dispense medication as prescribed or that the resident's room was malodorous. Additionally, complaints about staff not assisting with medical appointments, equipment repair, and room cleaning were dismissed as unfounded.
Report Facts
Facility Capacity: 44
Inspection Report
Annual Inspection
Census: 24
Capacity: 44
Deficiencies: 0
Date: Nov 7, 2023
Visit Reason
The visit was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean and well-maintained with no deficiencies observed. All COVID-19 guidelines were in place, safety equipment was operational, and adequate food supplies were available.
Inspection Report
Complaint Investigation
Census: 24
Capacity: 44
Deficiencies: 0
Date: Aug 24, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not prevent an altercation between residents resulting in injury.
Complaint Details
The complaint alleged that staff failed to prevent an altercation between residents that resulted in a resident's injury. The allegation was unsubstantiated based on interviews and records review.
Findings
The investigation found the allegation unsubstantiated due to contradicting and insufficient evidence, with no preponderance of proof that the alleged violation occurred.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Lisa Ong | Licensee met with the investigator during the visit. | |
| Antonio G. Ong | Administrator | Facility administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 44
Deficiencies: 1
Date: Jul 24, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2023-07-20 regarding the facility's air conditioner being in disrepair.
Complaint Details
The complaint regarding the facility's air conditioner being in disrepair was substantiated based on interviews, observations, and record reviews.
Findings
The investigation substantiated the complaint that air conditioning units in the facility were not functioning properly, with the north/northeast units failing around July 18 and the south/southwest units failing around July 10. The facility has taken steps to service and repair the units, including relocating residents temporarily and ordering parts.
Deficiencies (1)
CCR 87303(b)(2) requires the facility to cool rooms to a comfortable range between 78 and 85 degrees Fahrenheit or 30 degrees less than outside temperature in extreme heat. The air conditioning units at the south/southeast part of the facility were not working and parts were ordered with an expected arrival by 7/31. Residents in that area were temporarily relocated to the north/northeast part of the facility.
Report Facts
Capacity: 44
Census: 27
Plan of Correction Due Date: Aug 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonio Ong | Administrator | Met during the complaint investigation |
| Lisa Ong | Vice President | Met during the complaint investigation |
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sergiy Pidgirny | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Census: 27
Capacity: 44
Deficiencies: 1
Date: Jun 7, 2023
Visit Reason
An informal conference was held to address issues including a complaint, facility annual renewal fees, and the licensee's suspended status with the Franchise Tax Board.
Complaint Details
The visit addressed Complaint #24-AS-20230525144800 among other issues.
Findings
The facility was found deficient in administrator qualifications and duties, specifically knowledge of and ability to conform to applicable laws, rules, and regulations. The licensee was given deadlines to correct these deficiencies and bring fees and license status up to date.
Deficiencies (1)
CCR 87405(d)(2) Administrator qualifications and duties. The administrator must have specified qualifications and conform to applicable laws, rules, and regulations. The facility failed to meet these requirements.
Report Facts
Annual renewal fees due: 4309
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonio Ong | Administrator | Named in relation to administrator qualification deficiencies. |
| Les Xiong | Licensing Program Analyst | Licensing evaluator involved in the inspection. |
| Sergiy Pidgirny | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 44
Deficiencies: 1
Date: Jun 7, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation of unlawful eviction received on 2023-05-25.
Complaint Details
The complaint investigation was substantiated. The facility unlawfully evicted resident R1 by refusing to accept R1 from the hospital without an approved 3-day eviction notice.
Findings
The allegation of unlawful eviction was substantiated. The facility refused to accept resident R1 from the hospital upon discharge despite R1 being stable and lacked an approved 3-day eviction notice as required by regulation.
Deficiencies (1)
CCR 87224(b) Eviction Procedures. The licensee did not have an approved 3-day eviction notice and refused to accept resident R1 even if R1 was stable.
Report Facts
Capacity: 44
Census: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonio Ong | Administrator | Named in relation to the eviction finding |
| Les Xiong | Licensing Evaluator | Conducted the complaint investigation |
| Sergiy Pidgirny | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 44
Deficiencies: 1
Date: May 3, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations including illegal eviction and staff abandoning a resident.
Complaint Details
The complaint investigation was substantiated for illegal eviction related to refusal to pick up a resident from the hospital and failure to provide proper eviction notice. The allegation of staff abandonment was unsubstantiated.
Findings
The investigation substantiated the allegation that the facility refused to pick up a resident from the hospital upon discharge and failed to provide proper eviction notice. The allegation of staff abandoning a resident was found unsubstantiated due to lack of evidence.
Deficiencies (1)
CCR 87224(a) Eviction Procedures; The facility failed to give the resident and responsible party proper eviction notice despite the resident's needs changing and the facility's inability to meet those needs.
Report Facts
Capacity: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonio G. Ong | Administrator | Named in relation to the eviction finding and facility management |
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation |
| Sergiy Pidgirny | Supervisor | Supervisor of the investigation |
Inspection Report
Complaint Investigation
Capacity: 44
Deficiencies: 0
Date: Apr 4, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff left residents unattended.
Complaint Details
The complaint alleged that staff left residents unattended. The allegation was investigated and found to be unsubstantiated.
Findings
The investigation found the allegation to be unsubstantiated due to inconsistent evidence and lack of a preponderance of proof that the alleged violation occurred.
Inspection Report
Complaint Investigation
Capacity: 44
Deficiencies: 0
Date: Mar 24, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that drugs were being used at the facility.
Complaint Details
The complaint alleging drug use at the facility was investigated and found to be unfounded.
Findings
The investigation determined the allegation that drugs were being used at the facility was unfounded. No illegal drugs were found or being used at the facility, and the complaint was dismissed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Sanchez | Med. Tech | Interviewed during complaint investigation |
| Antonio Ong | Administrator | Spoke on the phone informing about the purpose of the visit |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 44
Deficiencies: 0
Date: Dec 16, 2022
Visit Reason
The visit was conducted as an unannounced complaint investigation following a complaint alleging that residents were left unsupervised at the facility.
Complaint Details
The complaint alleged that residents were left unsupervised at the facility. The allegation was investigated and found to be unsubstantiated.
Findings
The investigation found conflicting evidence regarding the allegation. Based on interviews and records review, the allegation that residents were left unsupervised was unsubstantiated due to lack of preponderance of evidence.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit and delivered investigation findings. |
| Lisa Ong | Licensee met with the investigator during the complaint investigation. | |
| Antonio G. Ong | Administrator | Named as facility administrator. |
Inspection Report
Capacity: 44
Deficiencies: 0
Date: Dec 7, 2022
Visit Reason
The visit was a case management visit conducted to review and request documentation related to a resident's fall and associated care plans and assessments.
Findings
The facility was instructed to fax or email various documents related to resident R1's fall, including fall appraisals, physician reports, incident reports, and staff training records. The resident R1 was identified as a high risk for falls following a previous fall and hospitalization.
Inspection Report
Complaint Investigation
Census: 23
Capacity: 44
Deficiencies: 1
Date: Jul 26, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2022-04-14 regarding resident neglect, multiple resident falls, and call button accessibility.
Complaint Details
The complaint investigation was substantiated for neglect resulting in a resident fall and fracture. Other complaints about multiple resident falls and call button accessibility were unsubstantiated and unfounded respectively.
Findings
One complaint alleging resident neglect resulting in a fall and fracture was substantiated with evidence that staff delayed seeking medical attention. Two other complaints regarding multiple resident falls and call button accessibility were unsubstantiated or unfounded after investigation.
Deficiencies (1)
CCR 87468.2(a)(4) requires care, supervision, and services to meet individual needs by competent staff. This requirement was not met as resident R1 fell several times on 4/9/22 and staff did not seek timely medical attention until the last fall resulting in a fracture.
Report Facts
Civil penalty: 500
Capacity: 44
Census: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Evaluator | Conducted the complaint investigation. |
| Antonio G. Ong | Administrator | Facility administrator named in the report. |
Inspection Report
Annual Inspection
Census: 23
Capacity: 44
Deficiencies: 1
Date: Jul 26, 2022
Visit Reason
An unannounced Annual Required Infection Control Inspection was conducted to assess compliance with licensing regulations.
Findings
The facility was generally compliant with infection control and safety requirements, but was found to lack a 2-day supply of perishable food as required. Other safety equipment such as fire extinguishers and smoke detectors were operational.
Deficiencies (1)
CCR 87555(b)(26): Facility did not have a 2-day supply of perishable food available at the time of inspection. This poses a potential health, safety, or personal rights risk to persons in care.
Report Facts
Capacity: 44
Census: 23
Inspection Report
Census: 24
Capacity: 44
Deficiencies: 0
Date: Jun 27, 2022
Visit Reason
The visit was a Case Management inspection related to concerns reported to the Department during an unrelated Complaint Investigation.
Findings
No deficiencies were cited during the visit. The Licensing Program Analysts toured the facility and indicated a follow-up inspection will be conducted for further investigation.
Inspection Report
Complaint Investigation
Census: 27
Capacity: 44
Deficiencies: 0
Date: Aug 31, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that a resident sexually abused another resident while in care.
Complaint Details
Complaint allegation of resident sexual abuse was investigated and found to be unfounded based on information obtained and police investigation.
Findings
The investigation included interviews and review of a police report. The facility took corrective actions by contacting pertinent agencies and relocating the resident's room for increased supervision. The complaint was found to be unfounded and dismissed with no deficiencies cited.
Report Facts
Capacity: 44
Census: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Antonio Ong | Administrator | Facility administrator involved in discussion of findings |
Inspection Report
Annual Inspection
Census: 27
Capacity: 44
Deficiencies: 0
Date: Jul 29, 2021
Visit Reason
The inspection was an unannounced Annual Infection Control Inspection conducted to assess compliance with infection control practices, including COVID-19 protocols.
Findings
The facility was found to be in compliance with required infection control practices. No deficiencies were cited during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonio Ong | Administrator | Identified as the Infection Control Lead and met with Licensing Program Analyst during inspection. |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 44
Deficiencies: 0
Date: Apr 23, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that facility staff caused injuries to a resident and left residents unsupervised.
Complaint Details
The complaint alleged that facility staff caused injuries to a resident and left residents unsupervised. The investigation included interviews and review of police reports. The allegations were found to be unfounded or unsubstantiated, and the complaint was dismissed.
Findings
The investigation found no evidence to support the allegations. Witnesses and police reports confirmed no assaults occurred, and the complaint was determined to be unfounded or unsubstantiated. No deficiencies were cited.
Report Facts
Facility Capacity: 44
Resident Census: 25
Inspection Report
Complaint Investigation
Census: 25
Capacity: 44
Deficiencies: 1
Date: Apr 21, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that a resident eloped from the facility and that facility staff did not report the resident missing in a timely manner.
Complaint Details
The complaint investigation was substantiated regarding the resident eloping from the facility. The facility was unaware of the resident's whereabouts until contacted by the Porterville Police Department. The complaint about failure to report the resident missing in a timely manner was unfounded as the facility submitted the required incident report within seven days.
Findings
The complaint that a resident eloped from the facility was substantiated, with the facility unaware of the resident's whereabouts until notified by the police. The complaint regarding failure to report the resident missing in a timely manner was found to be unfounded as the facility submitted the required Unusual Incident Report within seven calendar days.
Deficiencies (1)
CCR 87468.2(a)(4): Facility failed to provide care, supervision, and services that meet individual needs and are delivered by sufficient staff, as evidenced by unawareness of resident whereabouts until police notification.
Report Facts
Capacity: 44
Census: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonio Ong | Administrator | Met with during investigation and named in findings |
| Melinda Medina | Licensing Program Analyst | Conducted complaint investigation |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 44
Deficiencies: 1
Date: Apr 19, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that a resident left the facility unsupervised.
Complaint Details
The complaint was substantiated. The resident left the facility unsupervised and was returned by the Porterville Police Department after a neighbor reported the resident on their property.
Findings
The complaint was substantiated as the resident left the facility unassisted and was returned by the police after being found on a neighbor's property. The facility failed to provide adequate supervision as required by regulations.
Deficiencies (1)
CCR 87464(f)(1): Basic services including care and supervision were not met as the resident left the facility unassisted and was found off-site.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonio Ong | Administrator | Met with during investigation and discussed allegation |
| Melinda Medina | Licensing Program Analyst | Conducted complaint investigation |
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