Citations (last 7 years)
Citations (over 7 years)
5 citations/year
Citations are regulatory findings recorded during state inspections.
25% worse than California average
California average: 4 citations/year
Citations per year
12
9
6
3
0
Occupancy
Latest occupancy rate
82% occupied
Based on a February 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 172
Capacity: 210
Citations: 0
Date: Feb 26, 2026
Visit Reason
The inspection was a required 1-year unannounced visit to evaluate the facility's compliance with licensing requirements.
Findings
The inspection found the facility to be in full compliance with no deficiencies cited. The physical plant, safety equipment, food storage, and care environment met all regulatory standards.
Report Facts
Staff files reviewed: 6
Resident files reviewed: 5
Fire extinguisher last checked: Oct 27, 2025
Non-perishable food supply: 7
Perishable food supply: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kelly Phillips | Health Services Director | Facility representative who met with the Licensing Program Analyst during the inspection |
Inspection Report
Annual Inspection
Census: 178
Capacity: 210
Citations: 2
Date: Feb 25, 2026
Visit Reason
The inspection was conducted as the Annual 1-year required unannounced inspection of the facility.
Findings
The facility was generally well maintained with proper lighting, safety features, and medication labeling. However, a deficiency was found where a resident's medication was ordered by a physician but the physical medication was not present in the centrally stored medication room.
Citations (2)
Facility had a physician's order for R1's medication but did not have the physical medication, posing an immediate health, safety, or personal rights risk.
Medications which are centrally stored were not all stored in their originally received containers; no medications shall be transferred between containers as required by CCR 87465(h)(5).
Report Facts
Capacity: 210
Census: 178
Resident files reviewed: 5
Staff files reviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Kelly Phillips | Health Services Director | Met with Licensing Program Analyst during inspection |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 210
Citations: 0
Date: Feb 18, 2026
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff did not take steps to prevent the spread of a communicable disease, did not safeguard resident personal belongings, and did not ensure that a resident was attending medical appointments.
Complaint Details
The complaint was unsubstantiated. Allegations included failure to prevent spread of communicable disease, failure to safeguard personal belongings, and failure to ensure attendance at medical appointments. The facility followed infection control policies, made reasonable efforts to safeguard belongings, and staff reported that missed appointments were due to resident refusal.
Findings
The investigation found that the facility followed infection control policies regarding a resident with COVID-19, safeguarded resident belongings by securing and labeling items and reimbursing for missing items, and that missed medical appointments were due to resident refusal. There was insufficient evidence to substantiate the allegations, resulting in an unsubstantiated finding.
Report Facts
Capacity: 210
Census: 167
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kelly Phillips | Health Services Director | Met with investigator during the visit |
| Chris Schuster | Executive Director/Administrator | Met with investigator during the visit |
Inspection Report
Census: 172
Capacity: 210
Citations: 0
Date: Jan 29, 2026
Visit Reason
The visit was conducted as a follow-up on a self-reported incident involving a resident who was reported to have taken their own life.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst interviewed staff, reviewed records, and requested additional documentation related to the incident.
Report Facts
Capacity: 210
Census: 172
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the inspection visit and follow-up on the incident |
| Chris Schuster | Administrator | Provided information regarding the incident |
| Kelly Phillips | Health Services Director | Met with the Licensing Program Analyst and provided information about the incident |
Inspection Report
Census: 162
Capacity: 210
Citations: 0
Date: Dec 23, 2025
Visit Reason
The visit occurred to deliver an amended report originally delivered on 10/19/2025 and to conduct a case management-related evaluation.
Findings
No deficiencies were cited during the visit. The licensee surrendered the original copy of the report, and an exit interview was conducted with the facility representative.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Delivered the amended report and conducted the visit. |
| Chris Schuster | Executive Director/Administrator | Facility representative who greeted the Licensing Program Analyst and participated in the exit interview. |
| Brenda Chan | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 162
Capacity: 210
Citations: 1
Date: Dec 23, 2025
Visit Reason
The inspection visit occurred to follow up on a complaint received by the Department on 2025-07-11 regarding the facility's failure to create a fall prevention plan for a resident considered a fall risk.
Complaint Details
The visit was triggered by complaint #14-AS-20250711142309 received on 2025-07-11. The deficiency cited was substantiated and previously cited on 2025-10-13. A Plan of Correction had been submitted and the deficiency was cleared during this visit.
Findings
The facility admitted a resident considered a fall risk but did not create a fall prevention plan to meet the resident's needs. A Type B citation was issued for this deficiency, which had been previously cited on 2025-10-13. The deficiency was cleared during this visit after a Plan of Correction was provided.
Citations (1)
Facility admitted a resident considered a fall risk but did not have a fall prevention plan in place to meet the resident's needs.
Report Facts
Capacity: 210
Census: 162
Deficiency citation date: Oct 13, 2025
Complaint received date: Jul 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the inspection and investigation |
| Chris Schuster | Executive Director/Administrator | Facility administrator met with the Licensing Program Analyst during the visit |
| Brenda Chan | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 162
Capacity: 210
Citations: 1
Date: Dec 18, 2025
Visit Reason
An unannounced visit was conducted on 12/18/2025 in response to a complaint received by the Department on 10/14/2025 regarding medication management at the facility.
Complaint Details
The visit was triggered by a complaint received on 10/14/2025 concerning medication management for resident R1. The complaint was substantiated by findings of failure to have physician orders and proper medication logging.
Findings
The investigation found that the licensee did not have a physician's order for medications provided by R1's responsible party, failed to log the medications, and did not contact the physician. This resulted in R1 not being provided safe, healthful, and comfortable accommodations. A Type B citation was issued for this deficiency.
Citations (1)
Licensee did not ensure R1 was provided care, supervision, and services that met their individual needs by failing to contact R1's primary care physician upon receipt of medications and failing to log medications.
Report Facts
Capacity: 210
Census: 162
Deficiency count: 1
Plan of Correction Due Date: Dec 31, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Chris Schuster | Administrator | Facility administrator who met with the Licensing Program Analyst during the visit |
| Brenda Chan | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 157
Capacity: 210
Citations: 0
Date: Oct 13, 2025
Visit Reason
The visit was a Case Management visit conducted in regards to a Change in Management request at the facility.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst requested updated documentation related to the new administrator and other compliance items.
Report Facts
Capacity: 210
Census: 157
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the Case Management visit and requested updated documents |
| Kelly Phillips | Health Services Director | Facility representative who greeted the Licensing Program Analyst and participated in the visit |
Inspection Report
Complaint Investigation
Census: 157
Capacity: 210
Citations: 2
Date: Oct 13, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations of lack of supervision resulting in resident falls and injuries, and failure of staff to report incidents involving residents as necessary.
Complaint Details
The complaint was substantiated based on evidence that lack of supervision led to multiple falls and injuries of resident R1, and staff failed to report incidents as required. The preponderance of evidence standard was met.
Findings
The investigation substantiated that a resident (R1) fell multiple times resulting in serious injuries without an adequate fall prevention plan or documented safety checks. Additionally, staff failed to submit required written incident reports for 9 out of 10 falls within the mandated 7-day timeframe. An immediate civil penalty was issued.
Citations (2)
Failure to ensure residents are regularly observed for changes and provided appropriate assistance after falls, posing an immediate health, safety, or personal rights risk.
Failure to submit written incident reports to the licensing agency and responsible persons within seven days of fall occurrences.
Report Facts
Civil penalty amount: 500
Number of falls by resident R1: 10
Number of falls without timely incident report: 9
Plan of Correction due date: Oct 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Chris Schuster | Executive Director/Administrator | Facility representative met during the investigation. |
| Brenda Chan | Supervisor | Supervisor overseeing the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 210
Citations: 0
Date: Jul 1, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the licensee was not ensuring that a resident had hot water while in care.
Complaint Details
The complaint alleging lack of hot water for a resident was investigated and found to be unsubstantiated due to lack of corroborating evidence.
Findings
The Licensing Program Analyst toured the facility, interviewed staff and outside parties, and tested water temperatures in multiple resident bedrooms. The water temperature was found to be within the appropriate range, and contradictory information was provided by the reporting party. The allegation was found to be unsubstantiated and no deficiencies were cited.
Report Facts
Complaint Control Number: 14
Complaint Control Number Suffix: 20250602135433
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Fili Igafo | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 153
Capacity: 210
Citations: 0
Date: Mar 26, 2025
Visit Reason
The inspection visit occurred as an unannounced continuation of the Annual Required 1-Year Inspection to evaluate compliance with licensing requirements.
Findings
The Licensing Program Analyst toured the facility and found all exits and doorways free from obstruction, resident bedrooms clean and comfortable, food supplies sufficient and properly stored, and residents engaged in activities. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fili Igafo | Executive Director | Met with during the inspection and noted for positive relationship with residents. |
| Dominic Tobola | Licensing Program Analyst | Conducted the inspection visit. |
| Andrea Medlin | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 164
Capacity: 210
Citations: 0
Date: Feb 25, 2025
Visit Reason
An unannounced Annual Required – 1 year inspection was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, safe, and well-maintained with no deficiencies cited. Resident care plans, staff training, and medication records were all in order, and positive staff-resident interactions were observed.
Report Facts
Residents receiving hospice services: 10
Sample file review: 10
Staff files spot check: 10
Administrator Certificate Number: 7003332740
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Program Analyst | Conducted the inspection and file reviews |
| Alan Fox | Regional Operations Specialist | Met with Licensing Program Analyst during inspection |
| Fili Igafo | Executive Director | Administrator Certificate pending renewal |
Inspection Report
Census: 81
Capacity: 210
Citations: 0
Date: Dec 27, 2024
Visit Reason
The visit was an unannounced case management follow-up to review several incidents reported by the facility involving resident safety and care.
Findings
The facility responded appropriately to incidents involving residents leaving the facility unsupervised and a resident injury during showering. No deficiencies were cited during the visit, and the facility is within the current hospice waiver capacity.
Report Facts
Capacity: 210
Census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Program Analyst | Conducted the case management visit and evaluation |
| Fili Igafo | Acting Administrator | Met with Licensing Program Analyst during the visit and discussed incidents and hospice waiver |
Inspection Report
Complaint Investigation
Capacity: 210
Citations: 4
Date: Nov 7, 2024
Visit Reason
The inspection visit was conducted unannounced on 11/07/2024 to close an investigation regarding a self-reported unusual incident involving a resident found deceased with a plastic bag over their head, related to suicidal ideations and care concerns.
Complaint Details
The visit was complaint-related, closing an investigation into a self-reported incident where resident R1 was found deceased with a plastic bag over their head. The complaint involved failure to provide adequate supervision and care despite known suicidal ideations. The complaint was substantiated with findings of deficient care and oversight.
Findings
The investigation found that the facility failed to update the resident's care plan and increase supervision despite awareness of suicidal statements and a hospital visit. The Health Service Director and Executive Director did not ensure one-on-one care or increased checks, contributing to the resident's death. An immediate civil penalty was assessed.
Citations (4)
Failure to provide care, supervision, and services that meet individual needs, resulting in severe injury/death by suicide.
Failure to observe residents for changes in condition and provide appropriate assistance, leading to severe injury/death.
Failure to update pre-admission appraisal and reappraisals to note significant changes in resident's condition, contributing to severe injury/death.
Administrator failed to have sufficient freedom and presence to adequately manage the facility, resulting in failure to ensure frequent checks and updated care plans.
Report Facts
Civil penalty amount: 500
Plan of Correction Due Date: Nov 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ella Frick | Administrator/Director | Facility administrator named in relation to oversight responsibilities. |
| Fili Igafo | Executive Director | Interviewed regarding resident care and supervision failures. |
| Dominic Tobola | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Andrea Medlin | Licensing Program Manager | Oversaw licensing program and signed report. |
| S1 | Health Service Director (Licensed Vocational Nurse) | Failed to update care plans and ensure increased supervision for resident R1. |
| S2 | Executive Director | Failed to ensure frequent checks and updated care plans for resident R1. |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 210
Citations: 1
Date: Aug 28, 2024
Visit Reason
The visit was an unannounced case management inspection to follow up on a facility self-reported incident involving a staff member intentionally obstructing a resident's bedroom door.
Complaint Details
The visit was complaint-related, following up on a self-reported incident where staff (S1) intentionally blocked resident R1's bedroom door. The deficiency was substantiated and corrective action included termination of staff S1.
Findings
The facility failed to ensure that residents' room doors were unobstructed, violating the personal rights of resident R1. Staff member S1 intentionally placed a table in front of R1's door to prevent wandering, which was confirmed by investigation and staff interviews.
Citations (1)
Personal Rights of Residents in All Facilities - failure to ensure residents' room doors were not locked or obstructed, specifically a table was placed in front of resident R1's bedroom door preventing exit.
Report Facts
Capacity: 210
Census: 141
Deficiencies cited: 1
Plan of Correction Due Date: Sep 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Program Analyst | Conducted the inspection and documented findings |
| Andrea Medlin | Licensing Program Manager | Supervisor overseeing the inspection |
| Fili Igafo | Executive Director | Facility representative who met with the Licensing Program Analyst and discussed corrective actions |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 210
Citations: 2
Date: Aug 9, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on March 5 and March 12, 2024, regarding inadequate supervision, delayed response to call buttons, and other resident care concerns at Ivy Park at Cathedral Hill.
Complaint Details
The complaint investigation substantiated allegations that staff did not provide adequate supervision resulting in resident falls and did not respond to residents' call buttons in a timely manner. The allegation that a resident was left on the floor for an extended period and that staff did not observe changes in health or reassess care plans were unsubstantiated due to lack of evidence.
Findings
The investigation substantiated that staff did not provide adequate supervision resulting in resident falls and failed to respond timely to residents' call buttons, with documented delays up to 289 minutes and 16 residents waiting over 30 minutes for assistance. Other allegations regarding failure to observe changes in resident health and reassess care plans were unsubstantiated due to lack of evidence.
Citations (2)
16 out of 137 clients waited in some cases more than 289 minutes for care, which is an immediate health and safety risk to persons in care.
Multiple facility staff are not competent to provide the services necessary to meet resident needs.
Report Facts
Residents waiting more than 30 minutes for assistance: 16
Maximum delay in call button response time (minutes): 289
Census: 137
Total Capacity: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Dominic Tobola | Licensing Program Analyst | Assisted in conducting the complaint investigation. |
| Fili Igafo | Executive Director | Facility representative present during the investigation and exit interview. |
| Tam Nguyen | Maintenance Director | Met with investigators during the visit. |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 210
Citations: 1
Date: May 14, 2024
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following a complaint received on May 9, 2024, regarding staff not ensuring emergency services were contacted in a timely manner.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. Staff failed to contact emergency personnel in a timely manner as alleged.
Findings
The complaint allegation that staff did not contact emergency personnel in a timely manner was substantiated. It was found that staff failed to call 911 immediately for a resident who was found unresponsive, resulting in a delay of approximately two hours before emergency services were alerted.
Citations (1)
Failure to provide assistance in meeting necessary medical and dental needs, specifically staff did not call 911 immediately for a resident found unresponsive, delaying emergency response by approximately two hours.
Report Facts
Capacity: 210
Census: 147
Deficiency due date: May 15, 2024
Delay in emergency contact: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Fili Igafo | Executive Director | Facility representative who met with the investigator during the visit |
| Ella Frick | Administrator | Facility administrator named in the report header |
| Andrea Medlin | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 120
Capacity: 210
Citations: 0
Date: Apr 23, 2024
Visit Reason
The inspection was an unannounced Case Management-Health and Safety check conducted in response to an incident report received regarding the death of a resident.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst reviewed multiple resident-related documents and discussed the findings with the Regional Operations Specialist.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the inspection and requested resident documents. |
| Alan Fox | Regional Operations Specialist | Met with the Licensing Program Analyst and was involved in the inspection. |
Inspection Report
Annual Inspection
Census: 133
Capacity: 210
Citations: 0
Date: Feb 15, 2024
Visit Reason
The visit was conducted to continue the Annual 1-year required inspection as part of the facility's routine regulatory oversight.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst reviewed resident records, interviewed residents and staff, and found all records complete.
Report Facts
Resident records reviewed: 5
Residents interviewed: 3
Staff interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the inspection and reviewed records |
| Faimafili Igafo | Executive Director | Met with Licensing Program Analyst during the visit and reviewed the report |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 210
Citations: 0
Date: Jan 4, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted due to multiple allegations including failure to maintain records for new residents, pest infestation, confidentiality breaches, and failure to assess a resident for a higher level of care.
Complaint Details
The complaint investigation addressed allegations that staff did not ensure records for new residents, the facility had a pest infestation, staff did not keep residents' personal information confidential, and staff did not assess a resident for a higher level of care. All allegations were found to be unsubstantiated or unfounded.
Findings
The investigation found no preponderance of evidence to substantiate the allegations; resident records were complete and assessments up to date, the facility was clean and orderly, and no pest infestation concerns were noted. The complaints were determined to be unsubstantiated or unfounded.
Report Facts
Capacity: 210
Census: 123
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the complaint investigation |
| Cara Smith | Licensing Program Manager | Conducted the complaint investigation |
| Ella Frick | Executive Director | Facility representative met during investigation |
| Arturo Balancas | Senior Maintenance Director | Interviewed during investigation with no concerns noted |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 210
Citations: 2
Date: Dec 15, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2023-11-28 regarding staff not administering resident medication as prescribed and not responding to resident call buttons in a timely manner.
Complaint Details
The complaint was substantiated based on interviews, observations, and record reviews. The allegations included failure to administer medication as prescribed and failure to respond to call buttons in a timely manner. Evidence showed medication discrepancies and delayed staff responses ranging from 55 to 120 minutes.
Findings
The investigation substantiated that staff failed to administer a resident's medication as prescribed due to a discrepancy between the physician's order, the medication administration record, and the pharmacy prescription bottle. Additionally, staff did not respond to resident call buttons in a timely manner, with documented delays ranging from 55 to 120 minutes.
Citations (2)
Failure to assist residents with self-administered medications as prescribed, including failure to clarify discrepancies between physician's orders and pharmacy prescriptions.
Failure to provide basic services including timely response to resident call buttons.
Report Facts
Civil penalty amount: 1000
Delay in response time (minutes): 67
Delay in response time (minutes): 55
Delay in response time (minutes): 120
Delay in response time (minutes): 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ella Frick | Executive Director | Met with Licensing Program Analyst during the investigation and discussed report findings. |
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report. |
| Cara Smith | Supervisor | Named as supervisor overseeing the investigation. |
Inspection Report
Annual Inspection
Census: 128
Capacity: 210
Citations: 3
Date: Sep 23, 2023
Visit Reason
The visit was an unannounced annual required inspection to ensure compliance with Title 22 regulations and facility licensing requirements.
Findings
The facility was generally clean and well-maintained with proper emergency supplies and locked medications. However, deficiencies were cited related to expired elevator inspections, missing updated medical assessments (LIC 602) in resident files, and incomplete resident appraisals. Plans of correction were requested with due dates.
Citations (3)
Elevators were not inspected annually as required, posing a potential health, safety or personal rights risk.
8 out of 10 resident files did not have an updated LIC 602 medical assessment on file.
4 out of 10 resident files did not have a resident appraisal on file.
Report Facts
Resident files reviewed: 10
Staff files reviewed: 5
Elevators observed: 2
Residents without updated LIC 602: 8
Residents without appraisal: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ella Frick | Administrator | Spoke with Licensing Program Analysts regarding licensing fees and facility operations |
| Michelle Herman | Marketing Director | Met with Licensing Program Analysts and accompanied them during the inspection |
| Christina Valerio | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 210
Citations: 2
Date: Jul 5, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to address allegations including the facility not meeting a resident's dietary needs and not responding to a resident's emergency call cord.
Complaint Details
The complaint was substantiated. The resident (R1) was served a diet not prescribed by the physician and staff failed to respond to an emergency call cord in a timely manner, resulting in R1 assisting a roommate (R2) who had fallen. The laundry services allegation was unsubstantiated.
Findings
The investigation substantiated that a resident was served a diet not prescribed by the physician, including raw vegetables despite a mechanical soft diet order, and that staff failed to respond timely to an emergency call cord, resulting in a resident assisting another after a fall. Another allegation regarding laundry services was unsubstantiated.
Citations (2)
It took facility staff 205 minutes and 46 seconds to reset a resident's call cord, posing an immediate health risk.
Resident was served raw vegetables and other foods not prescribed by physician's order for mechanical soft diet, posing a potential health risk.
Report Facts
Call cord reset time: 205.77
Call cord reset time: 210.7
Facility capacity: 210
Resident census: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Cara Smith | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Jeff Sumabat | Administrator | Facility administrator involved in the investigation. |
| Ella Frick | Administrator | Met with Licensing Program Analyst during the unannounced visit. |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 210
Citations: 2
Date: May 3, 2023
Visit Reason
The visit was a case management visit conducted to deliver findings related to an abuse allegation reported by the facility involving staff and a resident.
Complaint Details
The visit was complaint-related due to an abuse allegation involving staff blocking a resident and punching the resident's abdominal area. The complaint was substantiated as the facility failed to ensure timely reporting and required staff training.
Findings
The facility failed to ensure the safety of a resident due to delayed reporting of an abuse incident by staff and failure to ensure required staff training on abuse and neglect. Deficiencies were cited under California Code of Regulations, Title 22.
Citations (2)
Staff witnessed an abuse allegation but did not report it to the facility director until 8 days later, resulting in the alleged abuser being assigned to care for the resident one more time before administrative leave.
Staff training records did not indicate that the staff received required training on abuse and neglect, posing a potential risk to residents.
Report Facts
Capacity: 210
Census: 97
Plan of Correction Due Date: May 4, 2023
Plan of Correction Due Date: May 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joy Quilet | Memory Care Director | Met with during the visit and discussed findings |
| Murial Han | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Cara Smith | Licensing Program Manager | Named as Licensing Program Manager overseeing the case |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 210
Citations: 0
Date: Apr 25, 2023
Visit Reason
An unannounced case management visit was conducted to follow up on an incident reported by the facility involving an alleged abuse incident.
Complaint Details
The visit was complaint-related due to an abuse allegation where staff #1 witnessed staff #2 blocking a resident and punching the resident's abdominal area with small pink dumbbells. The incident occurred on 4/4/2023 but was reported to the facility director on 4/12/2023. The facility took immediate actions including placing the alleged abuser on administrative leave, notifying the responsible party, CCL, and the Ombudsman, and starting daily monitoring and in-services.
Findings
The facility reported an abuse allegation involving staff and a resident. The alleged abuser was placed on administrative leave pending investigation, and no deficiencies were cited as the investigation was not yet complete.
Report Facts
Date of incident: Apr 4, 2023
Date incident reported to facility director: Apr 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Sumabat | Administrator | Met with Licensing Program Analyst during the visit |
| Joy Quilet | Memory Care Director | Met with Licensing Program Analyst during the visit |
| Murial Han | Licensing Program Analyst | Conducted the unannounced case management visit |
| Cara Smith | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 67
Capacity: 210
Citations: 0
Date: Apr 25, 2023
Visit Reason
An unannounced case management visit was conducted to follow up on an incident reported by the facility involving an alleged abuse incident.
Complaint Details
The visit was complaint-related due to an abuse allegation reported by the facility. The incident involved staff blocking a resident and physically striking the resident. The facility took immediate actions including notification to responsible parties and monitoring, but the investigation was ongoing.
Findings
The facility reported an abuse allegation involving staff and a resident. The alleged abuser was placed on administrative leave pending investigation, and no deficiencies were cited as the investigation was not yet complete.
Report Facts
Capacity: 210
Census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Sumabat | Administrator | Met during the visit and discussed the report |
| Joy Quilet | Memory Care Director | Met during the visit and discussed the report |
| Murial Han | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 210
Citations: 0
Date: Apr 24, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 07/01/2022 regarding resident care, staff conduct, medication management, and facility services at Coventry Place.
Complaint Details
The complaint included allegations such as unexplained resident injuries, failure to follow care plans, inadequate showering and feeding assistance, lack of food menus, inadequate laundry service, delayed response to call buttons, failure to provide timely resident records, inappropriate staff communication, medication mismanagement, insufficient staff training, and failure to safeguard resident personal items. All were investigated and found unsubstantiated.
Findings
After thorough investigation including interviews with staff, responsible parties, and review of documents, all allegations were deemed unsubstantiated due to lack of preponderance of evidence supporting the claims.
Report Facts
Facility capacity: 210
Resident census: 67
Complaint receipt date: Jul 1, 2022
Inspection visit time: 12.25
Inspection completion time: 14.08
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Cara Smith | Licensing Program Manager | Reviewed and managed the complaint investigation report |
| Gianni Amari | Business Office Director | Met with Licensing Program Analyst during the inspection visit |
| Jill C. Libhart | Administrator | Facility administrator mentioned in the report |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 210
Citations: 1
Date: Feb 21, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by allegations that staff were mismanaging residents' medications and not properly trained.
Complaint Details
The complaint was substantiated regarding medication mismanagement due to failure to follow up on medication refills from 10/11/2022 to 10/16/2022, causing delayed medication delivery and administration. The allegation that staff were not properly trained was unsubstantiated.
Findings
The investigation substantiated that the facility staff failed to properly follow through with medication refills for resident #1, resulting in delayed administration of two prescribed medications. However, the allegation that staff were not properly trained was unsubstantiated as staff were able to articulate proper procedures, though they failed to follow up timely.
Citations (1)
Facility staff failed to follow through with resident #1's pharmacy and physician on two prescribed medications, resulting in delayed medication administration posing a potential health risk.
Report Facts
Capacity: 210
Census: 119
Medication delay days: 8
Medication delay days: 2
In-service training date: Oct 27, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Cara Smith | Licensing Program Manager | Oversaw the complaint investigation |
| Melon Rivera | Administrator | Facility administrator during the investigation |
| Carol Dowell | Administrator | Administrator met with during the inspection visit |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 210
Citations: 3
Date: Nov 2, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations including insufficient staffing to meet residents' needs, the facility being unkempt, and failure of facility staff to provide a safe and comfortable environment for residents.
Complaint Details
The complaint investigation was substantiated based on evidence including staff interviews, observations of unclean rooms and unsanitary conditions, and review of staff assignment sheets showing multiple open shifts and uncovered shifts in the memory care unit.
Findings
The investigation substantiated the allegations, finding multiple open staff shifts, insufficient staffing especially in the memory care unit, and poor cleanliness including uncleaned resident rooms and unsanitary conditions. The facility was found to be unkempt, unsanitized, and uncomfortable for residents.
Citations (3)
Facility personnel were not sufficient in numbers and competent to provide necessary services to meet resident needs, evidenced by multiple open shifts and no housekeeping staff assigned to the memory care unit on 9/7/2022.
The facility was not clean, safe, sanitary, and in good repair at all times, with several rooms in the memory care unit not cleaned, posing potential health risks.
The facility failed to have sufficient personnel at all times to ensure residents were accorded safe, healthful, and comfortable conditions, posing a potential health risk.
Report Facts
Capacity: 210
Census: 144
Deficiencies cited: 3
Plan of Correction Due Dates: POC due dates include 11/04/2022, 11/14/2022, and 11/15/2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Sumabat | Administrator | Named as facility administrator involved in the investigation |
| Melon Rivera | Administrator | Met with Licensing Program Analyst during the investigation |
| Murial Han | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
Inspection Report
Census: 150
Capacity: 210
Citations: 3
Date: Aug 10, 2022
Visit Reason
An unannounced Health and Welfare check was conducted to observe if the facility is following COVID-19 management procedures.
Findings
The inspection found that two residents who tested positive for COVID-19 were participating in activities with non-affected residents without face coverings, and staff were unaware of their positive status. Additionally, the facility failed to report positive COVID-19 cases to the licensing agency within 24 hours as required.
Citations (3)
Two residents who tested positive for COVID-19 were observed participating in activities with non-affected residents, posing immediate health and safety risks.
The administrator failed to communicate residents' change of health condition to facility staff, posing immediate health and safety risks.
The facility failed and delayed reporting positive COVID-19 cases to the licensing agency within 24 hours.
Report Facts
Capacity: 210
Census: 150
Plan of Correction Due Date: 8
Plan of Correction Due Date: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the unannounced Health and Welfare check and authored the report |
| Jackie Jin | Licensing Program Manager | Supervisor overseeing the inspection |
| Jeff Sumabat | Acting Administrator | Met with Licensing Program Analyst during the inspection and involved in findings related to communication failures |
| Jill C. Libhart | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 210
Citations: 1
Date: Aug 10, 2022
Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-04-07 regarding staff not properly reporting an incident involving a resident and staff causing injuries to a resident while in care.
Complaint Details
The complaint investigation was substantiated for failure to properly report a resident's change of health condition to the responsible party. The allegation that staff caused injuries to a resident during transfer was unsubstantiated.
Findings
The investigation substantiated the allegation that staff did not properly report a resident's change of health condition to the responsible party, posing a potential health risk. The facility conducted an in-service on Incident Reporting Protocols as part of the plan of correction. The allegation that staff caused injuries to a resident during transfer was unsubstantiated based on interviews and observations.
Citations (1)
Failure to inform resident's responsible party of change in health condition, posing a potential health risk.
Report Facts
Capacity: 210
Census: 150
Deficiency count: 1
Plan of Correction Due Date: Aug 22, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jackie Jin | Licensing Program Manager | Oversaw the complaint investigation |
| Mark Nitsche | Administrator | Facility administrator named in relation to findings |
| Jeff Sumabat | Acting Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 210
Citations: 1
Date: Apr 12, 2022
Visit Reason
An unannounced case management visit was conducted to deliver findings related to complaint #14-AS-20211214115249 regarding the facility's failure to provide alternate accommodations for residents to take hot showers during a repair.
Complaint Details
The visit was complaint-related, investigating complaint #14-AS-20211214115249. The complaint was substantiated as the facility failed to provide alternate accommodations during hot water pump repair.
Findings
The facility failed to ensure residents were provided with comfortable and healthful accommodations during the repair of the hot water pump, as 7 out of 7 residents reported not being offered an alternate location for hot showers.
Citations (1)
The facility failed to provide an alternate accommodation(s) for the residents to take a hot shower while the circulator pump was in repair which posed potential health and safety risks to residents in care.
Report Facts
Residents interviewed: 7
Deficiency count: 1
Plan of Correction Due Date: Due date is 04/26/2022 as stated in the report
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nitsche | Administrator | Met with Licensing Program Analysts during the visit |
| Murial Han | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Julio Montes | Licensing Program Manager | Supervisor and Licensing Program Manager named in the report |
Inspection Report
Complaint Investigation
Capacity: 210
Citations: 1
Date: Apr 12, 2022
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 2021-12-14 alleging that the facility was in disrepair, specifically that it did not have hot water for a period and failed to provide alternate shower locations or proper communication to residents during the repair.
Complaint Details
Complaint investigation was unsubstantiated. The allegation that the facility was in disrepair due to lack of hot water and failure to provide alternate shower locations or proper communication was investigated. The facility responded promptly and communicated with residents, but did not offer alternate shower locations. The overall allegation was unsubstantiated.
Findings
The investigation found that the facility did experience a hot water outage from 12/2/21 to 12/14/21 due to a malfunctioned circulator hot water pump. The facility acted promptly to address the issue, but the repair was delayed due to a part shipment from another state. Residents were offered hot showers in unaffected apartments and received updates via a broadcast system. However, residents were not offered an alternate location for hot showers during the repair. The allegation was ultimately unsubstantiated due to insufficient evidence of violations.
Citations (1)
Residents were not offered an alternate location for hot showers during the repair.
Report Facts
Total licensed capacity: 210
Number of residents interviewed: 7
Number of apartments without hot water: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nitsche | Administrator | Met with Licensing Program Analyst during investigation and provided information about the hot water issue |
| Murial Han | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Julio Montes | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 210
Citations: 2
Date: Apr 14, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including failure to provide medical care, failure to notify authorized representatives of incidents, facility disrepair, inadequate staff training, and failure to assist residents with hygiene needs.
Complaint Details
The complaint investigation was initiated based on allegations received on 01/16/2020. The investigation included interviews and record reviews. Some allegations were found to be unfounded or unsubstantiated, while others were substantiated. The substantiated allegations involved unexplained injury to a resident and failure to assist with eating. Deficiencies were cited accordingly.
Findings
The investigation found some allegations to be unfounded or unsubstantiated, such as failure to provide medical care and timely notification, facility disrepair, and cleanliness issues. However, two allegations were substantiated: a resident sustained an unexplained injury while in care, and staff failed to adequately assist a resident with eating, posing a potential health and safety risk.
Citations (2)
Former client sustained a lump and hematoma on upper chest from unexplained blunt force trauma observed on 12/29/19, indicating failure to ensure client's right to safety.
Staff failed to adequately assist client with eating, as food remained in her mouth after meals, posing a potential health and safety risk.
Report Facts
Capacity: 210
Census: 127
Deficiencies cited: 2
Plan of Correction Due Date: Apr 28, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nitsche | Administrator | Met with during investigation and named in report |
| Audrey Jeung | Licensing Program Analyst | Investigator who conducted the complaint investigation |
| Julio Montes | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 160
Capacity: 210
Citations: 0
Date: Mar 26, 2021
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations received on 2021-02-17 regarding psychiatric care, medication training and errors, and facility disrepair.
Complaint Details
The complaint included allegations that facility staff did not seek psychiatric help for a resident, medical technicians were not properly trained to assist residents with medication, medication errors were not reported to licensing, and the facility was in disrepair. After investigation, all allegations were found unsubstantiated.
Findings
All allegations were investigated through interviews and record reviews, and found to be unsubstantiated due to lack of evidence or confirmation from involved parties.
Report Facts
Facility capacity: 210
Census: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nitsche | Facility Director | Interviewed regarding complaint allegations and findings |
| Mohamed Filouane | Licensing Program Analyst | Conducted complaint investigation and interviews |
| Murial Han | Licensing Program Analyst | Assisted in complaint investigation |
| Julio Montes | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 160
Capacity: 210
Citations: 0
Date: Mar 22, 2021
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations received on 2020-06-22 regarding staffing adequacy, staff training, first aid kit supplies, access to drinking water, and access to telephone for residents.
Complaint Details
The complaint included allegations that the facility did not have adequate staff to meet residents' hygiene needs, staff were not properly trained, the first aid kit was not fully supplied, residents did not have access to drinking water, and residents did not have access to a telephone. All allegations were deemed unsubstantiated after investigation.
Findings
All allegations were investigated and found to be unsubstantiated based on staff interviews, training logs, virtual observations, and submitted evidence. The facility was found to have adequate staffing, properly trained staff, a fully supplied first aid kit, access to drinking water, and working telephones accessible to residents.
Report Facts
Capacity: 210
Census: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nitsche | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Bertha Raygoza | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Capacity: 210
Citations: 0
Date: Nov 19, 2020
Visit Reason
The inspection was conducted as a Case Management inspection in response to an Unusual Incident reported by the facility.
Findings
The Licensing Program Analysts interviewed a resident and the Executive Director, and requested multiple documents related to the incident including medical records, staff training records, investigation summary, staffing schedules, and contact information. The Executive Director agreed to submit the requested documents within 24 hours.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nitsche | Executive Director | Met with during inspection and named in relation to the incident investigation. |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Murial Han | Licensing Program Analyst | Conducted the inspection and named as Licensing Program Analyst. |
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