Inspection Reports for
Autumn Ridge Assisted Living
14280 W STANISLAUS AVE, KERMAN, CA, 93630
Back to Facility ProfileCitations (last 3 years)
Citations (over 3 years)
3.7 citations/year
Citations are regulatory findings recorded during state inspections.
8% better than California average
California average: 4 citations/yearCitations per year
12
9
6
3
0
Occupancy
Latest occupancy rate
81% occupied
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 44
Capacity: 54
Citations: 1
Date: Jan 12, 2026
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that a resident was left unattended and that due to lack of care and supervision a resident sustained injury.
Complaint Details
The complaint investigation was substantiated for the allegation that a resident was left unattended and left the facility premises without staff supervision on 01/06/26. The allegation that a resident sustained injury due to lack of care was unsubstantiated.
Findings
One allegation was substantiated where a resident left the facility unsupervised, posing immediate health and safety risks. Another allegation regarding injury due to lack of care was found unsubstantiated after review of staff schedules and interviews.
Citations (1)
CCR 87413(a)(2) requires care and supervision of residents without abuse or exploitation. This was not met as a resident left the facility unsupervised, posing immediate health and safety risks.
Report Facts
Capacity: 54
Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Dhaliwal | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Mai Yang | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 54
Citations: 0
Date: Sep 12, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-07-15 regarding resident care and facility conditions.
Complaint Details
The complaint alleged severe pressure injuries due to staff neglect, inadequate food service, failure to provide resident documents to authorized representatives, and unclean facility conditions. The investigation found these allegations unsubstantiated.
Findings
The investigation found that the resident receiving hospice care had pressure injuries unrelated to staff neglect, staff provided adequate feeding assistance, requested documents were provided to the resident's authorized representative, and the facility was clean and odor-free. All allegations were unsubstantiated.
Report Facts
Facility Capacity: 54
Resident Census: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Dhaliwal | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Mai Yang | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 54
Citations: 0
Date: Aug 22, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation of neglect and lack of care resulting in a resident having scabies.
Complaint Details
The complaint alleged neglect and lack of care and supervision resulting in a resident having scabies. The allegation was found to be unsubstantiated based on interviews and records reviewed.
Findings
The investigation found that the resident developed skin rashes that were not diagnosed as scabies. The facility notified the resident's physician and provided treatment. The allegation was found to be unsubstantiated.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Dhaliwal | Administrator | Met with Licensing Program Analyst during complaint investigation. |
| Mai Yang | Licensing Program Analyst | Conducted the complaint investigation visit. |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 54
Citations: 1
Date: Jun 17, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2025-05-13 regarding expired medications not being discarded and other allegations related to resident care.
Complaint Details
The complaint investigation was substantiated for expired medications not being discarded properly. Other allegations about rough handling, timely response to calls, laundry services, and medication errors were unsubstantiated.
Findings
The investigation substantiated that expired and discontinued medications were stored unlogged and not disposed of since March 2025, posing potential health and safety risks. Other allegations regarding rough handling, laundry, and medication errors were found to be unsubstantiated.
Citations (1)
CCR 87465(i) Prescription medications not taken with the resident upon termination were not returned, retained, or disposed of properly. Medications for expired residents and discontinued medications were not logged or destroyed, backdating to March 2025.
Report Facts
Facility Capacity: 54
Resident Census: 37
Deficiency Count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Dhaliwal | Administrator | Met during investigation and named in medication disposal deficiency |
| Diane Cramer | Licensed Vocational Nurse | Met during investigation and involved in medication handling |
Inspection Report
Annual Inspection
Census: 37
Capacity: 54
Citations: 3
Date: Jun 17, 2025
Visit Reason
The visit was an unannounced required annual inspection conducted to evaluate compliance with licensing requirements at Autumn Ridge Assisted Living Facility.
Findings
The facility was generally clean, well-maintained, and safe with proper storage and functioning equipment. However, deficiencies were cited related to medication administration, medication recordkeeping, and use of full bed rails without proper orders, resulting in a civil penalty assessment.
Citations (3)
CCR 87465(c)(2) Medication was not administered according to physician's directions for residents R3 and R4, posing an immediate health and safety risk.
CCR 87465(h)(6) Centrally stored medication records for resident R3 were incomplete, posing a potential health and safety risk.
CCR 87608(a)(5)(B) Residents R1 and R2 on hospice care had full bed rails without doctor’s orders, posing a potential health and safety risk.
Report Facts
Capacity: 54
Census: 37
Plan of Correction Due Date: Jun 18, 2025
Plan of Correction Due Date: Jun 20, 2025
Plan of Correction Due Date: Jun 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Dhaliwal | Administrator | Met during inspection and received report |
| Diane Cramer | Licensed Vocational Nurse | Met during inspection |
| Mai Yang | Licensing Program Analyst | Conducted inspection and signed report |
Inspection Report
Census: 37
Capacity: 54
Citations: 0
Date: May 19, 2025
Visit Reason
The visit was an unannounced case management inspection to check on the health and safety of the clients in care at the facility.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst met with the Administrator and confirmed that an excluded individual was no longer associated with the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Dhaliwal | Administrator | Met with Licensing Program Analyst during the inspection. |
| Mai Yang | Licensing Program Analyst | Conducted the case management visit. |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 54
Citations: 0
Date: May 9, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2025-05-08 regarding staff not ensuring resident safety, inadequate staff training, and insufficient laundry services.
Complaint Details
The complaint allegations were unsubstantiated after investigation including interviews, facility tour, and record review.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff completed required trainings, residents were redirected appropriately, and laundry services were provided as scheduled.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Dhaliwal | Administrator | Met during investigation and received complaint findings |
| Diane Cramer | Licensed Vocational Nurse | Met during investigation and involved in staff training discussion |
Inspection Report
Census: 37
Capacity: 54
Citations: 1
Date: May 9, 2025
Visit Reason
The visit was an unannounced case management deficiency inspection to address medication errors reported by the facility.
Findings
The inspection found that a staff member (S1) administered medications prescribed for one resident to another resident on two occasions, posing immediate health and safety risks. A deficiency was cited and a civil penalty assessed.
Citations (1)
CCR 87465(c)(2) requires medication to be given according to physician's directions. S1 administered oxycodone-acetaminophen prescribed for R3 to R4 and hydrocodone-acetaminophen prescribed for R1 to R2, posing immediate health and safety risks.
Report Facts
Civil penalty: A civil penalty was assessed related to the medication error deficiency.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Dhaliwal | Administrator | Met during inspection and received report. |
| Diane Cramer | Licensed Vocational Nurse | Met during inspection. |
| Mai Yang | Licensing Program Analyst | Conducted the inspection and signed the report. |
Inspection Report
Complaint Investigation
Capacity: 54
Citations: 1
Date: May 9, 2025
Visit Reason
An unannounced initial complaint investigation was conducted following a complaint regarding medication storage.
Complaint Details
The visit was triggered by a complaint and was an unannounced initial complaint investigation. The deficiency cited was substantiated based on observation.
Findings
The investigation found a medication tablet unlocked and accessible in a resident's room, violating California Code of Regulations, Title 22, Division 6. This posed an immediate health, safety, or personal rights risk to the resident.
Citations (1)
CCR 87465(h)(2) requires centrally stored medicines to be kept in a safe and locked place not accessible to persons other than employees. The licensee failed to comply when an unlocked medication tablet was observed on a bedside table in a resident's room, posing an immediate risk.
Report Facts
Facility Capacity: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Dhaliwal | Administrator | Met during the investigation and received the report |
| Mai Yang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 54
Citations: 1
Date: Apr 16, 2025
Visit Reason
Unannounced complaint investigation visit triggered by a complaint received on 2025-04-11 regarding staff not responding to clients' calls for assistance in a timely manner.
Complaint Details
The complaint alleging staff not responding to clients' calls for assistance in a timely manner was substantiated based on observations and record reviews during the investigation.
Findings
The investigation found that staff did not respond to residents' call pendants in a timely manner, with an average response time exceeding 49 minutes, posing potential health and safety risks. The allegation was substantiated based on observations and record reviews.
Citations (1)
CCR 87411(d)(3) Personnel Requirements were not met as staff failed to respond to residents' call pendants in a timely manner, with an average response time of 49.78 minutes posing health and safety risks.
Report Facts
Average staff response time to residents' call pendants: 49.78
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Dhaliwal | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Mai Yang | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 54
Citations: 1
Date: Mar 24, 2025
Visit Reason
An unannounced complaint investigation was conducted due to a complaint regarding the facility's front automatic door being locked.
Complaint Details
The visit was triggered by an unannounced complaint investigation. The deficiency was substantiated as the front automatic door was locked, posing an immediate risk. An immediate civil penalty of $500 was assessed.
Findings
The Licensing Program Analyst observed that the front automatic door was locked upon arrival, which posed an immediate health, safety, or personal rights risk to persons in care. A deficiency was cited and an immediate civil penalty of $500 was assessed.
Citations (1)
CCR 87202(a) requires all facilities to maintain a fire clearance approved by the appropriate fire authority. The licensee did not comply when the front automatic door was locked, posing an immediate health, safety, or personal rights risk to persons in care.
Report Facts
Civil Penalty: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Dhaliwal | Administrator | Met with Licensing Program Analyst during inspection and acknowledged receipt of report. |
| Mai Yang | Licensing Program Analyst | Conducted the unannounced complaint investigation and authored the report. |
| See Moua | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 54
Citations: 1
Date: Mar 12, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2025-03-11 regarding the facility's maintenance of appliances and food contamination.
Complaint Details
The complaint investigation was substantiated regarding the freezer maintenance issue and unsubstantiated regarding food contamination.
Findings
The investigation substantiated that the facility did not have a working freezer for over two weeks, posing potential health and safety risks. Refrigerators were operational and food was stored properly with no contamination found for the second allegation.
Citations (1)
CCR 87555(b)(21) Freezers of adequate size must be maintained at 0 degrees F and refrigerators at a maximum of 40 degrees F. The facility did not have a working freezer for over two weeks, posing potential health and safety risks.
Report Facts
Deficiency cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Dhaliwal | Administrator | Met during investigation and named in report |
| Mai Yang | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Follow-Up
Census: 34
Capacity: 54
Citations: 1
Date: Nov 7, 2024
Visit Reason
The visit was an unannounced case management follow-up inspection regarding three incident reports related to medication administration errors previously reported to the department.
Findings
The inspection found that medications were not administered as ordered by a physician, including one instance where medications were put on hold without a doctor's order and two instances where medications were administered to the wrong residents. A deficiency was cited for failure to follow medication orders.
Citations (1)
CCR 87465(c)(2) requires medications to be given according to physician's directions. This was not met as medications were put on hold without a doctor's order and wrong medications were administered to residents, posing immediate health and safety risks.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Dhaliwal | Administrator | Met during inspection and named in medication administration findings |
Inspection Report
Original Licensing
Census: 27
Capacity: 54
Citations: 0
Date: Aug 9, 2024
Visit Reason
The inspection was an unannounced pre-licensing evaluation and Component III inspection for Change of Ownership at Autumn Ridge Assisted Living Facility.
Findings
The applicant met all pre-licensing requirements. The facility was found to have proper safety equipment, adequate food supplies, functional bathrooms, secure medication storage, and complete resident and staff files.
Inspection Report
Census: 28
Capacity: 54
Citations: 0
Date: Jul 29, 2024
Visit Reason
The visit was an office type announced inspection related to a Change of Ownership application for the Residential Care Facility for the Elderly.
Findings
The applicant and administrator participated in a COMP II telephone interview to verify identification and confirm understanding of California Code Title 22 regulations, including facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and pre-licensing readiness.
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