7 Reports
Inspection Report — Apr 8, 2025
Annual Inspection
Date: Apr 8, 2025
Visit Reason
The inspection was an unannounced required annual visit conducted by the Licensing Program Analyst to evaluate compliance with licensing requirements.
Findings
The facility was found to be generally in good condition with no obstructed exits, working smoke and carbon monoxide detectors, and proper storage of hazardous materials. However, deficiencies included the lack of emergency food and water supply, insufficient details in the disaster drill documentation, and the need for an updated floor plan with utility shut-off locations.
Citations (4)
No supply of emergency food and water observed.
Disaster drill documentation lacks sufficient information; more details requested in Emergency and Disaster Plan.
Updated floor plan with location of utility shut-offs not provided; requested by Licensing.
Staff area with washer and dryer requires better cleaning and maintenance to avoid lint build-up.
Report Facts
Fire and Emergency Drill Date: Mar 2, 2025
Fire Extinguisher Service Date: Feb 7, 2025
Temperature Setting: 73
Hot Water Temperature: 115
Form Submission Deadline: Apr 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marilen Gonzales | Administrator/Director | Responded to assist with the inspection visit |
| Daiquiri Boyd | Licensing Program Analyst | Conducted the inspection visit |
| Ann Lorio | Staff member who assisted during the inspection | |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report — Apr 15, 2024
Annual Inspection
Date: Apr 15, 2024
Visit Reason
The visit was an unannounced required 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, well-maintained, and in compliance with safety and health standards. Resident rooms, kitchen, and outdoor areas were inspected and found satisfactory. Safety equipment such as smoke and carbon monoxide detectors and fire extinguishers were operational and up to date.
Report Facts
Hot water temperature: 115.4
Fire extinguisher service date: Feb 5, 2024
Last fire drill date: Feb 2, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marilen Gonzales | Licensee/Administrator | Responded to the facility to assist with the visit |
| Ann Lorio | Staff | Met with Licensing Program Analyst and participated in exit interview |
| Shawna Doucette | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report — Nov 28, 2023
Annual Inspection
Date: Nov 28, 2023
Visit Reason
The visit was an unannounced required annual inspection conducted by the Licensing Program Analyst to evaluate compliance with licensing regulations.
Findings
The facility was generally found to be clean, safe, and well-maintained with proper food storage, functioning smoke and carbon monoxide detectors, and up-to-date fire extinguisher service and drills. However, a deficiency was cited regarding non-compliance with postural support bed rail requirements for six residents, posing potential health and safety risks.
Citations (1)
A bed rail that extends from the head half the length of the bed and used only for assistance with mobility was not compliant in 6 residents, posing potential health, safety, or personal rights risks.
Report Facts
Residents affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marilen Gonzales | Licensee / Administrator | Present during the annual inspection and named in the deficiency plan of correction |
| Miriam Flores | Licensing Program Analyst | Conducted the inspection and signed the report |
| Sergiy Pidgirny | Licensing Program Manager | Named as supervisor in the report |
Inspection Report — Aug 25, 2022
Complaint Investigation
Date: Aug 25, 2022
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2022-08-19 alleging that staff do not have required training.
Complaint Details
The complaint alleging staff do not have required training was substantiated.
Findings
The Licensing Program Analyst observed that 5 of 7 staff files reviewed did not have the required training, substantiating the allegation. A health and safety check was completed on residents, and residents were observed visiting family outside and in common areas.
Citations (1)
5 of 7 staff files reviewed did not have the required training, posing a potential health and safety/personal rights risk to residents in care.
Report Facts
Staff files lacking required training: 5
Total staff files reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Garza | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Marilen Gonzales | Administrator | Facility administrator present during the investigation |
Inspection Report — Mar 28, 2022
Annual Inspection
Date: Mar 28, 2022
Visit Reason
The visit was an unannounced required 1-year infection control inspection conducted to assess compliance with COVID-19 infection control procedures.
Findings
The Licensing Program Analyst observed compliance with required infection control practices including symptom screening, PPE usage, hand hygiene, and visitation protocols. No deficiencies were noted related to infection control.
Report Facts
Residents with 30-day supply of medications: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marilen Gonzales | Administrator | Administrator contacted and interviewed during inspection |
| Mary Garza | Licensing Program Analyst | Conducted the infection control inspection |
Inspection Report — Jun 21, 2021
Annual Inspection
Date: Jun 21, 2021
Visit Reason
The visit was an unannounced required 1-year infection control inspection conducted to evaluate compliance with infection control practices and other regulatory requirements.
Findings
The facility was found not in compliance with required infection control practices, resulting in a technical advisory and citation. Multiple deficiencies were identified including un-fingerprinted staff working in the facility, residents' door locks taped preventing access, a resident's room lacking a bed, and disabled auditory alarms on exit doors posing safety risks.
Citations (4)
Staff was observed working in the facility without fingerprint clearance or association to the facility, posing an immediate health, safety, or personal rights risk.
Residents' door locks were taped preventing residents from accessing them, posing an immediate health, safety, or personal rights risk.
Resident's room lacked a bed and only had a couch, posing a potential health, safety, or personal rights risk.
Front entry door, back sliding door, and garage door entry had auditory alarms turned off, posing a potential health, safety, or personal rights risk.
Report Facts
Civil penalty: 100
Plan of Correction Due Date: Jun 22, 2021
Plan of Correction Due Date: Jun 28, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marilen Gonzales | Administrator | Interviewed during inspection and involved in plans of correction. |
| Mary Garza | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Melinda Hoffmann | Licensing Program Manager | Supervisor overseeing the inspection. |
Report — June 1, 2026
June 1, 2026
Viewing
Loading inspection reports...



