Deficiencies (last 6 years)
Deficiencies (over 6 years)
4.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
45% occupied
Based on a March 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 102
Capacity: 225
Deficiencies: 2
Date: Mar 25, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit to follow up on allegations of staff neglect resulting in resident injury from falls and staff leaving a resident unattended during hospital transport.
Complaint Details
The complaint involved allegations that staff neglect caused a resident to sustain injuries from multiple falls and that staff left a resident unattended during hospital transport. The investigation found the neglect allegation unsubstantiated but substantiated failures in care supervision and incident reporting. The resident had multiple falls, some resulting in injury and hospitalization, and incidents were not reported to the Department of Social Services as required.
Findings
Two allegations were investigated regarding staff neglect and failure to properly report incidents involving a resident. One allegation was found unsubstantiated, and two allegations were substantiated, resulting in two deficiencies cited related to failure to assess fall risk and failure to report incidents to the licensing agency.
Deficiencies (2)
CCR 87463(b): The reappraisal did not document significant changes in the resident's condition, as the resident was never assessed to be a fall risk despite multiple falls between May 2023 and January 2024. This constitutes an immediate risk to health and safety.
CCR 87211(a)(1): Multiple fall incidents resulting in injury and hospitalization were not reported to the licensing agency within seven days as required. This constitutes a potential risk to health and safety.
Report Facts
Facility Capacity: 225
Resident Census: 102
Fall Incidents: 5
Plan of Correction Due Date: Due date for correcting deficiencies is April 1, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Georgianna Mendez | Administrator | Facility administrator present during the inspection and assisted with the visit |
Inspection Report
Annual Inspection
Census: 96
Capacity: 225
Deficiencies: 6
Date: Mar 11, 2026
Visit Reason
The inspection was an unannounced required annual inspection of the Heritage Pointe Residential Care Facility for the Elderly.
Findings
The inspection found multiple deficiencies including staff without criminal background clearance, missing medications for residents, outdated resident reappraisals, a non-operational delayed egress door, lack of required staff training, and a kitchen staff member preparing food without a hairnet. Civil penalties were assessed for criminal background clearance violations.
Deficiencies (6)
CCR 87355(e) Criminal Record Clearance: Six staff members were not criminal background cleared or associated with the facility prior to working.
CCR 87465(a)(4) Incidental Medical and Dental Care Services: The facility did not have medications present for Resident #11 and three medications for Resident #12 despite active orders.
CCR 87303(a) Maintenance and Operation: One delayed egress door in the memory care portion was non-operational at the time of the visit.
HSC 1569.625(b)(2) Other Provisions: Staff #1 did not have any annual training on file for the year 2025.
CCR 87555(b)(15) General Food Service Requirements: One staff member was observed preparing food without a hairnet due to lack of available hairnets.
CCR 87463(a) Reappraisals: Reappraisals for Residents #2, #6, and #7 were outdated and needed updating.
Report Facts
Civil penalty amount: 3000
Number of staff without criminal background clearance: 6
Number of resident files reviewed: 10
Number of staff files reviewed: 10
Inspection Report
Complaint Investigation
Census: 108
Capacity: 225
Deficiencies: 0
Date: Jan 27, 2026
Visit Reason
The visit was an unannounced complaint investigation follow-up to assess multiple allegations received on 2022-02-17 regarding resident care and medication management at the facility.
Complaint Details
The complaint involved allegations that the facility did not notify the responsible party of a resident's change of condition, staff mismanaged residents' medication, and staff did not ensure residents were provided adequate water. The investigation included review of medication records, hospital reports, staff and resident interviews, and concluded all allegations were unsubstantiated.
Findings
The investigation found all allegations unsubstantiated, concluding that medication was administered adequately, responsible parties were notified appropriately, and no evidence supported claims of medication mismanagement or inadequate hydration.
Report Facts
Facility Capacity: 225
Resident Census: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation |
| Georgianna Mendez | Executive Director | Facility representative present during inspection |
| Mike Silverman | Administrator | Facility administrator named in report header |
| Sheila Santos | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 225
Deficiencies: 1
Date: Jan 21, 2026
Visit Reason
The visit was an unannounced complaint investigation to follow up on eight allegations received on 08/19/2021 regarding resident care and facility practices.
Complaint Details
The complaint investigation was substantiated for two allegations: failure to notice a change in resident's condition and failure to dispense medication as prescribed. The other six allegations including failure to notify authorized representative, clean clothing, unauthorized medical test, pharmacy choice restriction, improper charges, and misappropriation of funds were unsubstantiated.
Findings
Two allegations were substantiated related to failure to notice a change in a resident's condition and failure to dispense medication as prescribed. The other six allegations were unsubstantiated due to lack of evidence.
Deficiencies (1)
Per CCR 87466, the licensee failed to ensure residents were regularly observed for changes in physical, mental, emotional, and social functioning as evidenced by four broken teeth in resident R1 going unnoticed until diagnosed by a dentist.
Report Facts
Capacity: 225
Census: 109
Laundry services occurrences: 22
Deficiency count: 1
Medication management delay: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Georgianna Mendez | Executive Director | Facility representative present during inspection |
| Tracii Brown | Healthcare Director | Spoken to during initial complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 225
Deficiencies: 0
Date: Sep 25, 2025
Visit Reason
The visit was an unannounced complaint investigation to follow up on an allegation that the facility does not implement adequate activities for residents in care.
Complaint Details
The complaint alleged inadequate activities for residents. The investigation included staff and resident interviews, observations of activities such as Bingo, musical entertainment, and chair yoga, and review of activity schedules. The allegation was unsubstantiated.
Findings
Based on observations, record reviews, and interviews with staff, residents, and witnesses, a variety of activities were offered and adapted to residents' needs. The allegation was found to be unsubstantiated due to insufficient evidence of inadequacy.
Report Facts
Capacity: 225
Census: 106
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Georgianna Mendez | Executive Director | Facility representative who granted entry and participated in the investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 225
Deficiencies: 2
Date: Jul 22, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted to deliver findings related to multiple allegations received on 02/09/2022 concerning care, supervision, dignity, oxygen equipment, and resident alert systems at the facility.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not provide adequate care and supervision and failed to accord residents with dignity, specifically regarding resident R1's oxygen equipment use and delayed assistance. Allegations about oxygen tanks being in working order and resident alert systems were found unsubstantiated and unfounded respectively.
Findings
The investigation substantiated that staff failed to provide adequate care and supervision and did not accord residents with dignity, particularly related to resident R1's difficulty operating oxygen equipment and delayed staff response. Other allegations regarding oxygen tank functionality and resident alert systems were found unsubstantiated or unfounded.
Deficiencies (2)
Per CCR Section 87618(b)(1) on Oxygen Administration, the licensee failed to monitor resident R1's ability to operate oxygen equipment and did not provide timely assistance, posing a potential risk to resident health and safety.
Per CCR 87464(f)(1) on Basic Services, the facility failed to provide adequate care and supervision as evidenced by excessive response times to resident R1's needs, constituting a potential risk to health and safety.
Report Facts
Census: 107
Total Capacity: 225
Deficiency Type B citations: 2
Response time delay: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Erin Palposi | Executive Director | Facility representative who met with the evaluator during the investigation |
| Tiffany Kennebrew | Licensed Vocational Nurse | Provided staff notes documenting resident care during the incident |
| Mike Silverman | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 225
Deficiencies: 2
Date: May 22, 2025
Visit Reason
The visit was an unannounced follow-up investigation of complaints alleging inappropriate staff behavior and delayed response to call signals at the facility.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not ensure residents were spoken to appropriately and did not respond timely to call signals. The allegation of rough handling was unsubstantiated. Staff member S1 was terminated due to inappropriate behavior.
Findings
The allegation that staff handled residents in a rough manner was found unsubstantiated due to lack of evidence. However, allegations that staff did not ensure residents were spoken to appropriately and did not respond timely to call signals were substantiated, resulting in two Type B deficiencies.
Deficiencies (2)
CCR 87468.1(a)(1) Personal Rights: Staff member S1 was responsible for inappropriate behavior towards residents, violating their dignity. S1 was terminated and no other staff were found to have interacted inappropriately.
CCR 878464(f)(1) Basic Services: Multiple instances of excessive response times to call signals were recorded, posing a risk to residents' health, safety, and personal rights.
Report Facts
Census: 118
Total Capacity: 225
Deficiencies cited: 2
Excessive response occurrences: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation |
| Jonathan Perles | Administrator | Facility administrator named in the report |
| Erin Palposi | Executive Director | Facility executive director present during inspection |
| Sheila Santos | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 225
Deficiencies: 1
Date: May 22, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by allegations that staff do not respond to residents' calls for assistance in a timely manner and do not ensure residents are provided with meals in a timely manner.
Complaint Details
The complaint investigation was substantiated for the allegation that staff do not respond to resident calls for assistance in a timely manner, with evidence of over four daily occurrences of excessive wait times exceeding 45 minutes. The allegation regarding timely meal service was unsubstantiated.
Findings
The allegation regarding delayed response to resident calls was substantiated with evidence of multiple instances where staff response time exceeded 45 minutes, posing a risk to residents. The allegation regarding timely meal provision was unsubstantiated as no incidents were evidenced during interviews and observations.
Deficiencies (1)
Per CCR 878464(f)(1) on Basic Services: care and supervision requirements were not met due to multiple instances of excessive response times to resident calls. This constitutes a potential risk to the health, safety, and personal rights of individuals in care.
Report Facts
Average pendant pushes per day: 116
Excessive response time pushes: 139
Civil penalty: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Erin Palposi | Executive Director | Facility representative present during the inspection visit |
| Jonathan Perles | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 225
Deficiencies: 0
Date: May 14, 2025
Visit Reason
The visit was an unannounced follow-up investigation of two allegations: improper infection control practices and insufficient staffing to meet resident needs.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations took place.
Findings
Both allegations were found to be unsubstantiated after review of infection control plans, staff and resident interviews, and staffing assignments. Precautions during COVID and norovirus outbreaks were sufficient, and staffing levels met resident needs.
Report Facts
Capacity: 225
Census: 118
Staff per shift: 6
Staff overnight shift: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation visit |
| Danielle Brahier | Business Office Manager | Present to assist with the visit |
| Erin Palposi | Executive Director | Notified via phone during the visit |
| Jonathan Perles | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 118
Capacity: 225
Deficiencies: 0
Date: May 14, 2025
Visit Reason
The visit was an unannounced required annual inspection to evaluate compliance with licensing requirements at the Heritage Pointe facility.
Findings
The facility was found to be in compliance with all applicable regulations with no deficiencies cited. The physical plant, safety systems, medication management, and resident records met regulatory standards.
Report Facts
Residents in care: 118
Facility capacity: 225
Residents reviewed for medication: 11
Units inspected: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Danielle Brahier | Business Office Manager | Present to assist during the inspection visit. |
| Erin Palposi | Executive Director | Notified via phone during the inspection. |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 225
Deficiencies: 3
Date: Apr 9, 2025
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff did not ensure medications were dispensed as prescribed, resident records were properly managed, and reporting requirements were followed.
Complaint Details
The complaint was substantiated based on staff interviews and record reviews. Medication administration errors, improper record management, and failure to follow reporting requirements were confirmed.
Findings
The investigation substantiated the allegations, finding multiple discrepancies in medication administration and record-keeping. Several residents had medications not administered as prescribed, missing or unsigned Medication Administration Records (MARs), and failure to submit incident reports timely.
Deficiencies (3)
HSC 1569.2(c): Residents' medications were not dispensed as prescribed, posing immediate health, safety, and personal rights risks.
CCR 87506(a): Resident records were incomplete, with four of nine MARs missing required information, posing potential health, safety, and personal rights risks.
CCR 87211(a)(1): Incident reports for medication errors were not submitted within seven days, posing potential health, safety, and personal rights risks.
Report Facts
Census: 118
Total Capacity: 225
Medication discrepancies: 6
Resident MARs incomplete: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Gutierrez | Licensing Program Analyst | Conducted the complaint investigation |
| Erin Palposi | Executive Director | Met with Licensing Program Analyst during investigation |
| Jonathan Perles | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 225
Deficiencies: 0
Date: Jan 31, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 10/08/2021 regarding resident care and staff conduct at the facility.
Complaint Details
The complaint investigation addressed allegations including staff not allowing residents to leave or shower, threatening residents, forcing psychiatric treatment, not administering medications as prescribed, and violating resident privacy. The findings were that the first set of allegations were unfounded and the latter were unsubstantiated due to lack of evidence.
Findings
The investigation found the allegations that staff restricted residents from leaving, denied showers, threatened residents, forced psychiatric treatment, failed to administer medications properly, and violated privacy were either unfounded or unsubstantiated based on interviews and record reviews.
Report Facts
Facility Capacity: 225
Resident Census: 109
Inspection Report
Complaint Investigation
Census: 109
Capacity: 225
Deficiencies: 0
Date: Jan 31, 2025
Visit Reason
The visit was an unannounced complaint investigation into multiple allegations regarding resident care, including failure to turn a resident regularly, rough handling, delayed food provision, medication errors, lack of laundry and incontinent care, and failure to send correct health agent information to the hospital.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was no sufficient evidence to prove the alleged violations occurred.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff interviews, resident statements, and facility records indicated that care needs were met, including repositioning, medication administration, meal delivery, laundry, and incontinence care. The allegations were deemed unsubstantiated.
Report Facts
Facility Capacity: 225
Resident Census: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Andrea Mendivil | Licensing Program Analyst | Conducted the complaint investigation |
| Mike Silverman | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 225
Deficiencies: 0
Date: Jul 1, 2024
Visit Reason
The visit was conducted to investigate a complaint alleging that the facility was refusing to accept a resident back to the facility.
Complaint Details
The complaint alleged that the facility was refusing to accept the resident back. The allegation was found to be unsubstantiated after review of resident records, staff interviews, and confirmation that the resident was readmitted and no eviction was planned.
Findings
The investigation found that the resident was hospitalized for psychiatric evaluation following an incident and was readmitted to the facility's memory care unit in April 2024. No eviction was notified and no evidence was found to support the allegation, which was determined to be unsubstantiated.
Report Facts
Capacity: 225
Census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation visit |
| Erin Palposi | Administrator | Facility representative present during the investigation and exit interview |
| Jonathan Perles | Facility Administrator named in report header |
Inspection Report
Annual Inspection
Census: 123
Capacity: 225
Deficiencies: 1
Date: Mar 28, 2024
Visit Reason
The visit was an unannounced required annual inspection to evaluate the facility's compliance with licensing regulations.
Findings
One type B deficiency was cited related to care of persons with dementia due to outdated physician reports. Three Technical Assistance Advisory Notes were also provided.
Deficiencies (1)
CCR 87705(c)(6) Care of Persons with Dementia: The licensee did not conduct ongoing appraisals as two physician reports reviewed were more than a year old. This poses a potential health, safety, or personal rights risk to persons in care.
Inspection Report
Complaint Investigation
Census: 122
Capacity: 225
Deficiencies: 1
Date: Nov 28, 2023
Visit Reason
The visit was an unannounced follow-up investigation of complaints received on 2022-02-11 regarding the facility not providing resident records to the resident's responsible party and overcharging a resident.
Complaint Details
The complaint investigation was triggered by allegations that the facility did not provide resident records to the resident's responsible party and that the facility overcharged a resident. The records allegation was found to be unfounded, while the overcharging allegation was substantiated.
Findings
The allegation that the facility overcharged a resident was substantiated due to additional tray service charges during COVID-19 waiver periods. The allegation that the facility did not provide resident records was found to be unfounded after documentation was provided during a prior follow-up visit.
Deficiencies (1)
CCR 87507(g)(3)(B)(2) states that a separate charge may only be assessed if included in the admission agreement. The facility charged tray service fees despite COVID-19 waivers, constituting a risk to residents' rights.
Report Facts
Capacity: 225
Census: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation and inspection visit |
| Georgianna Mendez | Chief Executive Officer | Facility representative who met with the evaluator during the visit |
| Mike Silverman | Administrator | Facility administrator named in the report |
Inspection Report
Follow-Up
Census: 122
Capacity: 225
Deficiencies: 0
Date: Nov 28, 2023
Visit Reason
The visit was an unannounced follow-up investigation to review allegations received on 05/31/2022 regarding resident care issues including soiled clothing, medication administration, and food service adequacy.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included residents left in soiled clothing causing rash, medication not administered as prescribed, and inadequate food service. Evidence did not support these claims.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Resident interviews, record reviews, and staff interviews confirmed that residents were not left in soiled clothing, medications were administered as prescribed, and food service was adequate.
Report Facts
Capacity: 225
Census: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation and follow-up visit |
| Georgianna Mendez | Chief Executive Officer | Facility representative who met with the Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 225
Deficiencies: 0
Date: Nov 2, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted to follow up on five allegations regarding hazardous items accessibility, diapering products availability, medication order adherence, staffing schedule accuracy, and timely medication administration.
Complaint Details
The complaint involved five allegations about staff practices related to hazardous items, diapering products, medication orders, staffing schedules, and medication administration timeliness. The investigation concluded all allegations were unfounded.
Findings
The investigation found that hazardous items were properly secured, residents had access to diapering products through various sources, medication orders were followed with documented administration, and staffing schedules were accurately posted. All five allegations were determined to be unfounded and dismissed.
Report Facts
Capacity: 225
Census: 126
Inspection Report
Complaint Investigation
Census: 126
Capacity: 225
Deficiencies: 1
Date: Nov 2, 2023
Visit Reason
The inspection was conducted as a case management visit to investigate complaint 22-AS-20230911091528 regarding medication management for a resident.
Complaint Details
The visit was triggered by complaint 22-AS-20230911091528. The deficiency was substantiated and resulted in a Type B citation with an immediate civil penalty due to a repeat offense.
Findings
The facility failed to place resident R1 under Medication Management despite an assessment requiring assistance with medication administration. A Type B deficiency was cited with an immediate civil penalty due to a repeat offense.
Deficiencies (1)
CCR 87464(f) on Basic Services requires ongoing assistance with ADLs including medication. Resident R1 was left out of Medication Management after being assessed to require assistance with medication.
Report Facts
Census: 126
Total Capacity: 225
Plan of Correction Due Date: Nov 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the inspection and cited the deficiency |
| Sheila Santos | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 225
Deficiencies: 0
Date: Oct 25, 2023
Visit Reason
The visit was an unannounced complaint investigation follow-up to address allegations including charging a resident for services not rendered, missing personal items, and failure to keep an inventory list for the resident.
Complaint Details
The complaint involved allegations that a resident was charged for services not rendered, personal items were missing, and the facility was not keeping an inventory list for the resident. The investigation concluded these allegations were unfounded.
Findings
The investigation found the allegations to be unfounded based on interviews, observations, and document reviews. No deficiencies were cited during the visit.
Report Facts
Facility capacity: 225
Resident census: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation |
| Mike Silverman | Administrator | Named in the report as facility administrator |
| Georgianna Mendez | Executive Director | Met with evaluator during inspection |
| Tami Olsen | Executive Director Assistant | Met with evaluator during inspection and exit interview |
| Tracii Brown | Former Director of Health Care | Referenced in investigation findings |
| Alisa Ortiz | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 225
Deficiencies: 0
Date: Oct 25, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the facility was overcharging a resident while in care.
Complaint Details
The complaint alleged that the facility was overcharging a resident. After investigation, including interviews and document review, the allegation was deemed unfounded, meaning it was false or without reasonable basis.
Findings
The investigation included interviews and document reviews and found that the allegation of overcharging was unfounded. The facility had not overcharged the resident, and fees were consistent with documented agreements and policies.
Report Facts
Monthly fee: 4010
Care points amount: 4400
Total monthly amount: 8450
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Mike Silverman | Administrator | Former Executive Director who provided information regarding resident fees. |
| Tracii Brown | Former Director of Health Care | Provided information on reassessment of residents and fee increases. |
| Georgianna Mendez | Executive Director | Met with Licensing Program Analyst during the investigation. |
| Tami Olsen | Executive Director Assistant | Met with Licensing Program Analyst and participated in exit interview. |
Inspection Report
Complaint Investigation
Capacity: 225
Deficiencies: 0
Date: Oct 19, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted to follow up on allegations that staff did not prevent a resident from harming another resident and did not seek timely medical attention for a resident.
Complaint Details
The complaint was unsubstantiated. Allegations included staff failing to prevent resident harm and failing to seek timely medical attention. Evidence did not confirm the harm incident, and medical attention was provided as per facility protocol.
Findings
The investigation found conflicting accounts regarding the alleged resident altercation with no corroborating evidence, resulting in the allegation being unsubstantiated. The allegation that staff did not seek timely medical attention was also found unsubstantiated based on interviews and records showing transportation was provided according to the facility's schedule.
Report Facts
Facility Capacity: 225
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation |
| Georgianna Mendez | Chief Executive Officer | Met with during the investigation |
| Mike Silverman | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 225
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that hot water was not available to residents in care.
Complaint Details
The complaint alleged that hot water was not available to residents. The allegation was investigated and found unsubstantiated due to conflicting information and insufficient evidence.
Findings
The investigation found conflicting information regarding the hot water availability. Some residents reported a temporary shutdown of hot water, but testing showed adequate hot water temperatures and residents reported taking warm showers. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 225
Census: 130
Hot water temperature range: 105.4
Hot water temperature range: 111.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alvaro Ramirez Jr. | Licensing Program Analyst | Conducted the complaint investigation |
| Georgianna Mendez | Executive Director | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 225
Deficiencies: 1
Date: Jun 2, 2023
Visit Reason
The visit was an unannounced follow-up investigation of a complaint received on 2023-03-23 regarding allegations including toxic chemicals accessible to residents, staff qualifications to administer medication and give doctor's orders, and staff ability to meet resident needs.
Complaint Details
The complaint investigation was substantiated for the allegation of toxic chemicals accessible to residents, while allegations about staff qualifications and ability to meet resident needs were unsubstantiated.
Findings
The allegation that toxic chemicals were accessible to residents was substantiated with a type A deficiency cited but corrected by the follow-up visit. The allegations regarding staff qualifications to administer medication and give doctor's orders, and staff ability to meet resident needs were found to be unsubstantiated based on training records and staffing level reviews.
Deficiencies (1)
California Code of Regulations Section 87705(f)(2) was violated as over-the-counter medication and toxic substances were accessible in two Memory Care bathrooms. The deficiency was corrected and cleared at the time of the follow-up visit.
Report Facts
Facility Capacity: 225
Resident Census: 129
Inspection Report
Complaint Investigation
Census: 128
Capacity: 225
Deficiencies: 1
Date: Apr 26, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted to deliver findings related to multiple allegations received on 2022-02-18 concerning resident visitation, mail delivery, phone call access, and phone system functionality.
Complaint Details
The complaint investigation was triggered by allegations that the facility did not allow resident visitors, residents did not receive their mail, residents were not allowed to receive phone calls, and the facility phone system was not working. The phone system allegation was substantiated, while the others were unsubstantiated.
Findings
The investigation found the allegation that the facility phone system was not working to be substantiated, with evidence of multiple phone outages during 2022. The other allegations regarding visitor restrictions, mail delivery, and phone call access were deemed unsubstantiated due to lack of preponderance of evidence. The phone system was operational at the time of the visit and the cited deficiency was cleared.
Deficiencies (1)
CCR 87311 Telephones requires all facilities to have telephone service on the premises. The facility experienced multiple telephone outages during 2022, posing a potential risk to residents' health, safety, and personal rights. The deficiency was cleared after the phone system was demonstrated operational.
Report Facts
Facility Capacity: 225
Resident Census: 128
Individuals Interviewed: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation and unannounced visits |
| Georgianna Mendez | Executive Director | Facility representative who met with the Licensing Program Analyst during the visit |
| Michael Silverman | Executive Director | Interviewed during initial investigation visit |
| Tracii Brown | Health Care Director | Interviewed during initial investigation visit |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 225
Deficiencies: 0
Date: Mar 14, 2023
Visit Reason
The visit was an unannounced complaint investigation follow-up to investigate the allegation that the facility was not providing services pursuant to contract.
Complaint Details
The complaint alleged that the facility was not providing services pursuant to contract. The investigation included interviews with the resident and staff, review of records, and follow-up on payment issues. The allegation was found unsubstantiated.
Findings
The investigation found that although there were issues with payment of facility fees and discontinuation of optional services, all other services included in the basic service rate were still being provided as per the resident's admission agreement. The allegation was deemed unsubstantiated due to lack of sufficient evidence.
Report Facts
Past due fees amount: 26094.96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation and follow-up visit |
| Georgianna Mendez | Administrator | Facility administrator interviewed during investigation |
| Mike Silverman | Administrator | Named as facility administrator in report header |
| Sheila Santos | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 225
Deficiencies: 0
Date: Jan 27, 2023
Visit Reason
The visit was an unannounced complaint investigation to deliver an amended complaint investigation report for a prior visit conducted on 2023-01-18 related to a complaint with control number 22-AS-20211221095941.
Complaint Details
The visit was related to a complaint investigation referenced by control number 22-AS-20211221095941. The amended report was delivered and signed by the facility administrator.
Findings
The Licensing Program Analyst delivered the amended complaint investigation report and conducted an exit interview. The visit type was corrected from an office visit to a complaint visit due to a computer error.
Inspection Report
Census: 123
Capacity: 225
Deficiencies: 0
Date: Jan 18, 2023
Visit Reason
The Licensing Program Analyst conducted a case management visit to inspect the recently updated Sage wing of the facility.
Findings
The Sage wing includes new construction with various unit types and shared amenities. At the time of the visit, only one unit was occupied by one resident. No deficiencies were cited during the visit.
Inspection Report
Complaint Investigation
Census: 123
Capacity: 225
Deficiencies: 2
Date: Jan 18, 2023
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following allegations of staff mishandling a resident's medication, failure to follow physician's orders, and inadequate record keeping for a resident.
Complaint Details
The complaint investigation was substantiated based on evidence that staff mishandled medication, did not follow physician orders, and had inadequate record keeping for a resident. The resident was left to self-administer medication without assistance for 16 months after a physician ordered otherwise.
Findings
The investigation substantiated the allegations that a resident was left to self-administer medication without supervision for 16 months after a physician ordered assistance. The facility failed to transition the resident to medication management in a timely manner and lacked the original signed Admission Agreement in the resident's file.
Deficiencies (2)
CCR 87464(f) requires basic services to include ongoing assistance with activities of daily living including medication. Resident R1 was left out of Medication Management for 16 months after being assessed to require assistance with self-administration.
CCR 87465(a)(4) requires the licensee to assist residents with self-administered medications as needed. The facility delayed implementing the resident’s transition into Medication Management.
Report Facts
Census: 123
Total Capacity: 225
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation and inspection visit |
| Georgianna Mendez | Administrator | Facility administrator who met with the evaluator during the visit |
| Mike Silverman | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Capacity: 225
Deficiencies: 0
Date: Sep 23, 2022
Visit Reason
The visit was an unannounced delivery of an amended complaint investigation report related to a previously referenced complaint.
Complaint Details
The visit was related to complaint control number 22-AS-20220513105549. The amended complaint investigation report was delivered and signed by the facility administrator.
Findings
The Licensing Program Analyst delivered the amended complaint investigation report and conducted an exit interview. No additional findings or deficiencies are detailed in this report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mike Silverman | Administrator | Facility administrator who received the amended complaint investigation report. |
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the unannounced visit and delivered the amended complaint investigation report. |
Inspection Report
Capacity: 225
Deficiencies: 0
Date: Aug 31, 2022
Visit Reason
An unannounced case management visit was conducted to deliver an amended report for a complaint under control number 22-AS-20220513105549.
Findings
The amendment redacted a confidential name, but all other indications and investigation findings were left as originally delivered. A copy of the report and amended LIC9099-C were reviewed and left with the facility representative.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Mike Silverman | Administrator | Facility representative met during the visit. |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 225
Deficiencies: 0
Date: Aug 2, 2022
Visit Reason
The visit was conducted as a case management follow-up on a mandatory incident report alleging verbal and physical abuse by a staff member towards a resident on 07/30/2022.
Complaint Details
The complaint involved allegations of verbal and physical abuse by a staff member towards a resident. The staff member was suspended pending investigation. No deficiencies were found during the visit.
Findings
No deficiencies were cited based on observations during the case management visit. The staff member accused was suspended pending investigation and was not present during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mike Silverman | CEO | Met with Licensing Program Analyst during the visit and interviewed regarding the incident. |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 225
Deficiencies: 0
Date: Jun 6, 2022
Visit Reason
The visit was an unannounced follow-up on an incident report submitted regarding alleged rough handling of a resident by an agency caregiver.
Complaint Details
The complaint involved an allegation that an agency caregiver handled a resident roughly and restricted the resident's ambulation due to time constraints. The investigation was conducted by the licensing authority.
Findings
The administrator reported the incident and took steps including interviewing staff and notifying the Long Term Care Ombudsman and staffing company. Efforts are ongoing to hire permanent staff and prioritize reliable agency staff.
Report Facts
Agency staff per shift: 3.5
New caregivers onboarded: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mike Silverman | Administrator | Facility administrator who reported the incident and was present during the visit |
| Tracii Brown | Director of Health Care | Met with licensing evaluator during the visit |
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the unannounced visit and evaluation |
Inspection Report
Complaint Investigation
Capacity: 225
Deficiencies: 0
Date: May 19, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to follow up on allegations received on 2022-05-13 regarding harassment, theft by the administrator, and illegal eviction of a resident.
Complaint Details
The complaint included allegations that the administrator was harassing and threatening a resident, stole from a resident, and illegally evicted a resident. The illegal eviction allegation was found unfounded, and the harassment and theft allegations were unsubstantiated.
Findings
The investigation found the allegation of illegal eviction to be unfounded and the allegations of harassment and theft by the administrator to be unsubstantiated due to lack of evidence. Interviews and documentation supported these conclusions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation and inspection. |
| Mike Silverman | Chief Executive Officer | Facility administrator involved in the investigation and interview. |
| Alisa Ortiz | Supervisor | Supervisor overseeing the complaint investigation. |
Inspection Report
Census: 143
Capacity: 225
Deficiencies: 0
Date: May 12, 2022
Visit Reason
The inspection visit was conducted to amend findings delivered on March 16, 2022, related to Complaint Control #22-AS-20220314153540.
Findings
The Licensing Program Analyst met with the Executive Director to discuss the amended report. An exit interview was conducted and copies of the report and amended findings were provided.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mike Silverman | Executive Director | Met with Licensing Program Analyst during inspection and exit interview. |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 225
Deficiencies: 0
Date: May 12, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff do not bathe residents regularly.
Complaint Details
The complaint alleged that staff do not bathe residents regularly. The allegation was investigated and found to be unfounded.
Findings
The investigation included interviews with ten interviewees and review of relevant documentation. All interviewees denied the allegation, indicating residents receive their baths regularly. The allegation was deemed unfounded.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mike Silverman | Executive Director | Met during investigation and report review. |
| Tiffany Kennebraw | Nursing Supervisor | Met during investigation. |
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation. |
Inspection Report
Capacity: 225
Deficiencies: 0
Date: May 10, 2022
Visit Reason
The visit was an unannounced case management follow-up on a Special Incident Report received regarding potential financial misappropriation involving a resident's checks.
Findings
An investigation revealed that a caregiver cashed checks written by a resident for personal expenses and sent money abroad. The caregiver was reported to their agency and reportedly terminated. The resident's family is seeking reimbursement for the misappropriated funds.
Report Facts
OCSD case number: 22014682
Misappropriated check amount: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mike Silverman | Chief Executive Officer | Facility representative providing information about the incident |
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the unannounced case management visit |
| Edward James | Caregiver admitted to misappropriating resident funds |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 225
Deficiencies: 0
Date: Mar 16, 2022
Visit Reason
The visit was conducted as an unannounced complaint investigation following a complaint received on 2020-11-25 alleging the facility failed to safeguard a resident's property.
Complaint Details
The complaint allegation was unsubstantiated, meaning there was insufficient evidence to prove the alleged violation did or did not occur.
Findings
The complaint allegation that the facility failed to safeguard resident's property was found to be unsubstantiated after interviews, document reviews, and observations. There was no preponderance of evidence to prove the alleged violation occurred.
Report Facts
Capacity: 225
Census: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosie Quiroz | Licensing Evaluator | Conducted the complaint investigation and delivered findings |
| Tracii Brown | Director of HealthCare | Met with evaluator during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 225
Deficiencies: 0
Date: Mar 16, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not prevent residents from engaging in inappropriate interactions.
Complaint Details
The complaint alleged that staff did not prevent residents from engaging in inappropriate interactions. The allegation was investigated and deemed unfounded, meaning it was false or without reasonable basis.
Findings
The investigation included interviews, facility walkthroughs, and document reviews. The allegation was found to be unfounded based on interviews and evidence, and the complaint was dismissed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracii Brown | Director of Health Care | Met with Licensing Program Analyst during complaint investigation and exit interview. |
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 225
Deficiencies: 0
Date: Mar 16, 2022
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations that facility staff refused to provide a resident with clean towels.
Complaint Details
The complaint alleging that facility staff refused to provide a resident with clean towels was investigated and found to be unfounded.
Findings
The investigation found that seven of seven interviewees confirmed sufficient towels were provided during housekeeping and upon request. The allegation was deemed unfounded as all eight interviewees indicated they received their towels.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracii Brown | Director of Health Care | Met with during the investigation and discussed the complaint findings. |
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation visit. |
Inspection Report
Census: 146
Capacity: 225
Deficiencies: 0
Date: Mar 11, 2022
Visit Reason
The visit was an unannounced case management inspection to confirm an Order for Immediate Exclusion regarding a staff member.
Findings
The facility confirmed that the excluded staff member, Jhon Garcia, was physically removed, no longer employed, and his access badge was recovered. The facility's HR department notified the licensing analyst of the disassociation before the visit concluded.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mike Silverman | Chief Executive Officer | Met with licensing analysts during the visit and confirmed staff exclusion. |
| Autumn Conquest | Director of Human Resources | Met with licensing analysts and notified them of staff disassociation. |
| Jhon Garcia | Staff member subject to Order for Immediate Exclusion. |
Inspection Report
Annual Inspection
Census: 143
Capacity: 225
Deficiencies: 0
Date: Mar 3, 2022
Visit Reason
Licensing Program Analysts conducted an unannounced required annual inspection of the facility to assess compliance with regulatory standards.
Findings
The facility was found to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations. The environment was safe, clean, and well-maintained with operational safety alarms and adequate emergency supplies.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracii Brown | Director of Healthcare | Met with Licensing Program Analysts during the inspection and exit interview. |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 225
Deficiencies: 0
Date: Dec 9, 2021
Visit Reason
The visit was conducted to investigate a complaint alleging insufficient staffing to meet the residents' needs at Heritage Pointe facility.
Complaint Details
The complaint alleging insufficient staffing to meet residents' needs was investigated and deemed unsubstantiated due to lack of preponderance of evidence.
Findings
The complaint allegation of insufficient staffing was found to be unsubstantiated after interviews, observations, and document reviews. Staffing levels observed and documented met the residents' needs.
Report Facts
Capacity: 225
Census: 151
Staffing: 9
Staff to resident ratio: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mike Silverman | Executive Director | Met with Licensing Program Analyst during investigation |
| Tracii Brown | Director of Health Care | Met with Licensing Program Analyst during investigation |
| Rosie Quiroz | Licensing Program Analyst | Conducted complaint investigation |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 225
Deficiencies: 1
Date: Dec 9, 2021
Visit Reason
The visit was conducted as a case management inspection to conclude findings related to Complaint Control #22-AS-20210614115537 regarding resident call light response times.
Complaint Details
The visit was complaint-related, concluding findings for Complaint Control #22-AS-20210614115537. The deficiency was substantiated based on observations, interviews, and record review.
Findings
The inspection found that resident call light alarms were not answered in a timely manner, specifically an alarm in Room 6A was not addressed for 9 minutes. Staff did not have beepers on their person to be alerted promptly, posing a potential health, safety, and personal rights risk to residents.
Deficiencies (1)
CCR 87468(a) Personal Rights: Resident call light alarms were not answered in a timely manner, with a specific incident where an alarm in Room 6A was not addressed for 9 minutes. Staff lacked beepers to receive timely notifications of alarms.
Report Facts
Census: 151
Total Capacity: 225
Response time: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mike Silverman | Executive Director | Present during inspection and involved in addressing alarm response |
| Tracii Brown | Director of Health Care | Interviewed regarding alarm system and call light response |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 225
Deficiencies: 0
Date: Dec 9, 2021
Visit Reason
Unannounced complaint investigation visit conducted to address allegations that resident files were not kept confidential and that food was too high in sodium.
Complaint Details
The complaint investigation was unannounced and addressed two allegations: lack of confidentiality of resident files and high sodium content in food. Both allegations were found to be unfounded.
Findings
The investigation found that resident files were kept confidential as access required an entry card and the file room was secured. Interviews with residents indicated that the food was good, kosher, and not salty. Therefore, the allegations were deemed unfounded.
Report Facts
Census: 151
Total Capacity: 225
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mike Silverman | Administrator | Met with Licensing Program Analyst during the complaint investigation |
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tracii Brown | Director of Health Care | Received report at exit meeting |
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