Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
42% occupied
Based on a March 2026 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 50
Capacity: 120
Deficiencies: 1
Date: Mar 13, 2026
Visit Reason
An unannounced case management visit was conducted in relation to complaint control 14-AS-20260227122349 to investigate the complaint.
Complaint Details
Complaint control 14-AS-20260227122349 triggered the visit. Deficiency was substantiated as the facility failed to provide personnel training records during the complaint investigation.
Findings
The facility was unable to provide requested personnel training records during the complaint investigation, resulting in a cited deficiency related to staff training documentation.
Deficiencies (1)
Licensees shall maintain in the personnel records verification of required staff training and orientation. Facility was unable to provide training records for requested staff members, posing a potential health and safety risk.
Report Facts
Personnel records reviewed: 7
Plan of Correction Due Date: Mar 20, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Dasmarinas | Resident Services Director | Met with Licensing Program Analyst during the visit and discussed findings |
| Komal Curley | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| April Cowan | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 120
Deficiencies: 1
Date: Mar 13, 2026
Visit Reason
An unannounced case management visit was conducted in relation to complaint control 14-AS-20260227122349 to investigate the complaint.
Complaint Details
The visit was complaint-related under complaint control 14-AS-20260227122349. The deficiency was substantiated as the facility failed to provide personnel training records during the investigation.
Findings
The facility was unable to provide requested personnel training records during the complaint investigation, resulting in a cited deficiency related to staff training documentation as per California Code of Regulations, Title 22 and Health and Safety Code.
Deficiencies (1)
Licensees shall maintain in the personnel records verification of required staff training and orientation. Facility failed to provide training records for requested staff members, posing a potential health and safety risk to residents.
Report Facts
Personnel records reviewed: 7
Plan of Correction Due Date: Mar 20, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Dasmarinas | Resident Services Director | Met with Licensing Program Analyst during the visit and discussed the purpose of the visit and findings. |
| Komal Curley | Licensing Program Analyst | Conducted the unannounced case management visit and documented findings. |
| April Cowan | Licensing Program Manager | Named in the report as Licensing Program Manager overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 120
Deficiencies: 2
Date: Mar 13, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2026-02-27 regarding staff training deficiencies and medication mishandling at Serra Highlands Senior Living Facility.
Complaint Details
The complaint investigation was substantiated for the allegation that staff were not properly trained, specifically regarding medication administration training deficiencies. The allegation that staff mishandled residents' medications was unsubstantiated.
Findings
The investigation substantiated that two med-tech staff members did not complete their required 16 hours of initial medication training prior to administering medications, and the facility lacked documentation of annual on-the-job medication training for med-techs. Another allegation of medication mishandling was unsubstantiated based on medication administration records and staff interviews.
Deficiencies (2)
Staff members S1 and S2 did not have their initial 16 hours of medication training documented prior to administering medication to residents, posing an immediate health and safety risk.
Facility was unable to provide documentation showing med-techs received their annual on-the-job medication training.
Report Facts
Capacity: 120
Census: 50
Deficiencies cited: 2
Initial training hours required: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Curley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Anne Dasmarinas | Resident Services Director | Interviewed during investigation and involved in review of training records |
| Shayan Gheisar | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 120
Deficiencies: 2
Date: Mar 13, 2026
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff were not properly trained and that staff mishandled residents' medications.
Complaint Details
The complaint investigation was substantiated for the allegation of improper staff training due to lack of documented medication training for med-techs. The allegation of medication mishandling was unsubstantiated after review of medication administration records and staff interviews.
Findings
The allegation that staff were not properly trained was substantiated due to med-techs not completing required initial and annual medication training. The allegation that staff mishandled residents' medications was unsubstantiated based on medication administration records and staff interviews.
Deficiencies (2)
HSC 1569.69(a)(1) requires employees assisting residents with self-administration of medication to complete 16 hours of initial training. Two med-techs did not complete this training prior to administering medications, posing an immediate health and safety risk.
CCR 87411(c)(3)(D) requires all RCFE staff assisting residents with personal activities to receive initial and annual training including medication policies. The facility could not provide documentation of annual on-the-job training for med-techs.
Report Facts
Facility Capacity: 120
Resident Census: 50
Number of med-techs: 7
Initial training hours required: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Curley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Anne Dasmarinas | Resident Services Director | Interviewed during investigation and involved in reviewing training records |
| Shayan Gheisar | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 120
Deficiencies: 0
Date: Mar 5, 2026
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff do not provide adequate food service.
Complaint Details
The complaint alleged inadequate food service, specifically that a caregiver did not assist a resident who had not eaten breakfast. The investigation included interviews with the resident, staff, and review of the resident's service plan. The resident was found to be independent in meals and prefers to eat in his/her room. The allegation was unsubstantiated.
Findings
The investigation found that although the allegation may have happened or is valid, there was no preponderance of evidence to prove the alleged violation did or did not occur, resulting in the allegation being unsubstantiated.
Report Facts
Capacity: 120
Census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Curley | Licensing Program Analyst | Conducted the complaint investigation |
| Anne Dasmarinas | Resident Services Director | Met with the Licensing Program Analyst during the investigation |
| Shayan Gheisar | Administrator | Facility administrator named in the report |
Inspection Report
Census: 51
Capacity: 120
Deficiencies: 1
Date: Mar 5, 2026
Visit Reason
An unannounced case management visit was conducted following notification of an eviction status for a resident, to review compliance with eviction notice reporting requirements.
Findings
The facility was found deficient for failing to provide documentation that a 30-day eviction notice was submitted to the licensing agency, posing a potential health and safety risk to residents.
Deficiencies (1)
Failure to submit a written report of any eviction to the licensing agency within five days as required by CCR 87224(f).
Report Facts
Capacity: 120
Census: 51
Plan of Correction Due Date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Dasmarinas | Resident Services Director | Met with Licensing Program Analyst during inspection and discussed findings |
| Komal Curley | Licensing Program Analyst | Conducted the inspection and authored the report |
| Shayan Gheisar | Administrator/Director | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 120
Deficiencies: 0
Date: Mar 5, 2026
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff do not provide adequate food service.
Complaint Details
The complaint alleged inadequate food service, specifically that a caregiver did not assist Resident 1 to get up for breakfast. The allegation was unsubstantiated after investigation.
Findings
The investigation included interviews with staff and Resident 1 (R1), and a review of R1's service plan. It was found that R1 is independent for meals and prefers to eat in his/her room. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 120
Census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Curley | Licensing Program Analyst | Conducted the complaint investigation |
| Anne Dasmarinas | Resident Services Director | Met with the Licensing Program Analyst during the investigation |
| Shayan Gheisar | Administrator | Facility administrator named in the report |
| April Cowan | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 120
Deficiencies: 1
Date: Feb 18, 2026
Visit Reason
An unannounced complaint investigation visit was conducted to investigate multiple allegations including improper maintenance of residents' rooms, unmet bathing needs, improper feeding, unmet planned activities, and lack of privacy for residents.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not properly maintain residents' rooms, specifically Resident 1's room having a urine odor. Other allegations including unmet bathing needs, improper feeding, unmet planned activities, and lack of privacy were unsubstantiated.
Findings
The investigation substantiated the allegation that staff did not properly maintain residents' rooms, specifically noting a urine odor in Resident 1's room. Other allegations regarding bathing needs, feeding, planned activities, and privacy were found to be unsubstantiated based on interviews, observations, and document reviews.
Deficiencies (1)
Facility failed to maintain resident rooms clean, safe, sanitary, and in good repair, evidenced by urine odor in Resident 1's room posing a potential health and safety risk.
Report Facts
Capacity: 120
Census: 60
Deficiency count: 1
Plan of Correction Due Date: Feb 25, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Curley | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Shannon Metcalfe | Community Support Nurse | Met with Licensing Program Analyst during the investigation and reviewed findings |
| Shayan Gheisar | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 120
Deficiencies: 1
Date: Feb 18, 2026
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations including improper maintenance of residents' rooms, unmet bathing needs, improper feeding, lack of planned activities, and failure to afford residents privacy.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not properly maintain residents' rooms. Other allegations including unmet bathing needs, improper feeding, lack of planned activities, and failure to afford residents privacy were unsubstantiated.
Findings
The investigation substantiated the allegation that staff did not properly maintain residents' rooms, specifically noting a urine odor in Resident 1's room. Other allegations regarding bathing, feeding, activities, and privacy were found to be unsubstantiated based on interviews, observations, and document reviews.
Deficiencies (1)
Facility failed to maintain resident rooms clean and odor-free, specifically Resident 1's room had a urine odor posing a potential health and safety risk.
Report Facts
Capacity: 120
Census: 60
Deficiency count: 1
Plan of Correction Due Date: Feb 25, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Curley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Shannon Metcalfe | Community Support Nurse | Met with Licensing Program Analyst during investigation and discussed findings |
| Shayan Gheisar | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 120
Deficiencies: 1
Date: Jan 27, 2026
Visit Reason
An unannounced case management visit was conducted in relation to an incident on 2026-01-08 where Resident 1 left the facility unassisted and was missing for several hours.
Complaint Details
The visit was complaint-related due to an incident where Resident 1 left the facility unassisted on 2026-01-08 and was missing until found by a good samaritan. Staff were unaware of the resident's inability to leave unsupervised.
Findings
The investigation found that Resident 1, who was unable to leave the facility unassisted, left unaccompanied and was not located for several hours, posing an immediate health and safety risk. Staff were unaware of Resident 1's supervision needs, and a deficiency was cited accordingly.
Deficiencies (1)
Failure to provide care and supervision as required, evidenced by Resident 1 leaving the facility unassisted despite being unable to do so.
Report Facts
Capacity: 120
Census: 56
Plan of Correction Due Date: Jan 28, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Curley | Licensing Program Analyst | Conducted the inspection and investigation |
| Ruth Ocon | Regional Sales | Met with during inspection and involved in incident response |
| Shayan Gheisar | Administrator/Director | Facility administrator named in report header |
| April Cowan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 120
Deficiencies: 1
Date: Jan 27, 2026
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2026-01-09 regarding staff use of profanity towards a resident and other allegations including staff response to call buttons and room temperature.
Complaint Details
The complaint investigation was substantiated for the allegation that Staff 1 used profanity towards Resident 1, with evidence including resident and staff interviews. Other allegations about staff not responding timely to call buttons, not assisting residents, and not providing comfortable room temperature were unsubstantiated.
Findings
The allegation that staff used profanity towards a resident was substantiated based on interviews and evidence. Other allegations regarding staff response to call buttons and room temperature were found to be unsubstantiated due to lack of sufficient evidence.
Deficiencies (1)
Failure to accord dignity in personal relationships with staff as evidenced by staff cursing at a resident, posing a potential health and safety risk.
Report Facts
Capacity: 120
Census: 56
Plan of Correction Due Date: Feb 3, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Curley | Licensing Program Analyst | Conducted the complaint investigation visit |
| Shayan Gheisar | Administrator | Facility administrator named in the report |
| Ruth Ocon | Regional Sales | Met with Licensing Program Analyst during investigation |
| April Cowan | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 120
Deficiencies: 1
Date: Jan 27, 2026
Visit Reason
An unannounced case management visit was conducted in relation to an incident on 2026-01-08 where Resident 1 left the facility unassisted and was missing for several hours.
Complaint Details
The visit was triggered by a complaint/incident involving Resident 1 leaving the facility unassisted on 2026-01-08 and being missing for several hours until found by a good samaritan.
Findings
The investigation found that Resident 1, who was unable to leave unassisted, left the facility unsupervised and was missing for several hours before being found. Staff were unaware of Resident 1's supervision needs, posing an immediate health and safety risk. A deficiency was cited related to care and supervision.
Deficiencies (1)
Failure to provide care and supervision as Resident 1 left the facility unassisted despite being unable to do so, posing an immediate health and safety risk.
Report Facts
Capacity: 120
Census: 56
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Curley | Licensing Program Analyst | Conducted the inspection and investigation |
| Ruth Ocon | Regional Sales | Met with during inspection and involved in incident response |
| April Cowan | Licensing Program Manager | Named in report as Licensing Program Manager |
| Shayan Gheisar | Administrator/Director | Facility Administrator/Director |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 120
Deficiencies: 1
Date: Jan 27, 2026
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2026-01-09 regarding staff use of profanity towards a resident, failure to respond to call buttons timely, failure to assist residents, and not providing comfortable room temperatures.
Complaint Details
The complaint investigation was substantiated for the allegation that Staff 1 used profanity towards Resident 1. Other allegations regarding staff response to call buttons, assistance to residents, and room temperature were unsubstantiated.
Findings
The allegation that staff used profanity towards a resident was substantiated based on interviews and evidence. The allegations regarding untimely response to call buttons, failure to assist residents, and uncomfortable room temperatures were unsubstantiated due to insufficient evidence. The facility was cited for a deficiency related to personal rights of residents.
Deficiencies (1)
Failure to accord dignity in personal relationships with staff as evidenced by staff cursing at a resident, posing a potential health and safety risk.
Report Facts
Capacity: 120
Census: 56
Plan of Correction Due Date: Feb 3, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Curley | Licensing Program Analyst | Conducted the complaint investigation |
| Shayan Gheisar | Administrator | Facility administrator named in report |
| Ruth Ocon | Regional Sales | Met with Licensing Program Analyst during investigation |
| Staff 1 | Alleged to have used profanity towards resident | |
| Staff 2 | Alleged to have turned off call button and not assist resident | |
| April Cowan | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 120
Deficiencies: 1
Date: Jan 16, 2026
Visit Reason
An unannounced case management visit was conducted in relation to an incident involving a medication error that occurred on 12/18/25.
Complaint Details
The visit was complaint-related due to a medication error involving Resident 1. The error was substantiated as the facility failed to provide medication as prescribed.
Findings
The facility failed to provide Resident 1's medication as prescribed by the physician when a med-tech administered a 50mg capsule of Pregabalin instead of the prescribed 75mg capsule. The med-tech responsible is no longer employed at the facility.
Deficiencies (1)
Failure to assist residents with self-administered medications as needed, resulting in Resident 1 receiving incorrect medication dosage.
Report Facts
Capacity: 120
Census: 62
Plan of Correction Due Date: Jan 17, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Valencia | Special Operations Director | Met with Licensing Program Analyst during the visit and reviewed the report |
| Komal Curley | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| April Cowan | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 120
Deficiencies: 1
Date: Jun 17, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2025-05-14 regarding staff not ensuring residents' records are up to date, food service provision, medical appointment attendance, staff training, restroom toiletry supplies, and retention of a resident requiring a higher level of care.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not ensure resident's medical records were up to date, specifically that Resident 1 had not seen a primary care physician since 2021. Other allegations were unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation substantiated that a resident (R1) had not received an annual routine physician visit since 9/2021, violating California Code of Regulations. Other allegations including food service provision, medical appointment attendance, staff training, restroom supplies, and retention of a resident requiring higher care were found unsubstantiated based on interviews, record reviews, and observations.
Deficiencies (1)
Failure to ensure all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.
Report Facts
Capacity: 120
Census: 70
Deficiency count: 1
Plan of Correction Due Date: Jun 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shayan Gheisar | Administrator | Met with Licensing Program Analyst during investigation and provided information regarding resident care and records |
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| April Cowan | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Plan of Correction
Census: 68
Capacity: 120
Deficiencies: 0
Date: Apr 24, 2025
Visit Reason
The visit was conducted as a Plan of Correction (POC) follow-up to address citations given to the facility on 2025-04-17.
Findings
As of the visit date, all previously cited deficiencies have been cleared. The report was reviewed and a copy provided to the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jonamar Pascua | Resident Services Director | Met with Licensing Program Analyst during the Plan of Correction visit. |
| Grace Donato | Licensing Program Analyst | Conducted the Plan of Correction visit. |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 65
Capacity: 120
Deficiencies: 2
Date: Apr 17, 2025
Visit Reason
An unannounced annual inspection visit was conducted to evaluate compliance with licensing requirements, including a tour of the facility, record reviews, and environmental checks.
Findings
The facility was generally well maintained with adequate supplies and safety equipment, but two Type A deficiencies were identified: hot water temperatures were below the required 125°F in most tested rooms, and four staff members lacked criminal background clearances.
Deficiencies (2)
Hot water was tested in random rooms and 7 out of 9 showed a temperature between 99-103 deg F, failing to meet the requirement for taps delivering water at 125 deg F or above.
Four staff members do not have criminal record clearances as required prior to working in the facility.
Report Facts
Staff without criminal background clearance: 4
Rooms tested for hot water temperature: 9
Residents present: 65
Facility capacity: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shayan Gheisar | Administrator | Met during inspection and mentioned in findings regarding expired certificate pending renewal. |
| Grace Donato | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Andrea Medlin | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Capacity: 120
Deficiencies: 0
Date: Apr 4, 2025
Visit Reason
The visit was an unannounced office inspection conducted by the California Department of Social Services Community Care Licensing Division for regulatory oversight of Serra Highlands Senior Living Facility.
Findings
The report provides general information about the facility evaluation process, types of deficiencies (Type A and Type B), plans of correction, civil penalties, and appeal rights. No specific deficiencies or findings are detailed in the provided pages.
Inspection Report
Complaint Investigation
Census: 69
Capacity: 120
Deficiencies: 2
Date: Mar 7, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2025-02-11 regarding resident care issues including inaccessible dresser and uncomfortable room temperature, as well as improper resident transfer and medical attention concerns.
Complaint Details
The complaint investigation was triggered by allegations including inaccessible dresser and uncomfortable temperature, which were substantiated, and allegations of improper resident transfer resulting in injury, failure to seek timely medical attention, and failure to transport resident to medical appointment, which were unsubstantiated.
Findings
The investigation substantiated that a resident's dresser was inaccessible due to its placement against the bed and that the facility did not maintain a comfortable temperature in some areas due to non-functioning heating units, with space heaters provided as a temporary measure. Another set of allegations regarding improper resident transfer and delayed medical attention were found unsubstantiated due to lack of preponderance of evidence.
Deficiencies (2)
Residents did not have access to individual storage space as Resident 1's dresser was against the bed and could not be fully opened.
Facility did not maintain a comfortable temperature as heating units were not functioning in some areas, with space heaters provided as an alternative.
Report Facts
Capacity: 120
Census: 69
Plan of Correction Due Date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Shayan Gheisar | Administrator | Facility administrator met during investigation and involved in findings discussion |
| April Cowan | Licensing Program Manager | Reviewed the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 120
Deficiencies: 1
Date: Feb 24, 2025
Visit Reason
An unannounced complaint investigation visit was conducted due to allegations including residents eloping due to lack of supervision, inadequate administrator presence, broken resident toilet, unmet nutritional needs, insufficient staffing levels and training, and failure to notify residents and families of corporate changes.
Complaint Details
The complaint investigation was substantiated for the allegation that three residents eloped due to lack of supervision. Other allegations were unsubstantiated. An immediate civil penalty of $500 was assessed for absence of supervision.
Findings
The allegation that three residents eloped due to lack of supervision was substantiated with evidence of one resident leaving unassisted once. An immediate civil penalty of $500 was issued for absence of supervision. Other allegations including administrator presence, broken toilet, nutritional needs, staffing levels and training, and notification of corporate changes were found to be unsubstantiated based on interviews, observations, and document reviews.
Deficiencies (1)
Failure to provide adequate care and supervision resulting in a resident leaving the facility unassisted, posing an immediate health and safety risk.
Report Facts
Civil penalty amount: 500
Number of residents present: 70
Total licensed capacity: 120
Number of caregivers: 6
Average response time: 7
Number of independent residents: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shayan Gheisar | Administrator | Met with Licensing Program Analyst during investigation and involved in findings |
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation visit |
| April Cowan | Licensing Program Manager | Oversaw complaint investigation report |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 120
Deficiencies: 0
Date: Dec 4, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility faucets used by residents for personal care do not deliver hot water.
Complaint Details
The complaint alleged that facility faucets used by residents for personal care did not deliver hot water, specifically failing to provide bathing shower water temperature above 86 degrees. The allegation was unsubstantiated after investigation.
Findings
The investigation found that water temperatures measured in resident rooms ranged between 105-107.2 degrees Fahrenheit, contradicting the allegation. The complaint was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Water temperature range: 105
Water temperature range: 107.2
Census: 68
Total capacity: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shayan Gheisar | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation visit |
| Natice Coles | Business Office Manager | Met with Licensing Program Analyst during complaint investigation |
Inspection Report
Annual Inspection
Census: 62
Capacity: 120
Deficiencies: 0
Date: May 15, 2024
Visit Reason
An unannounced continuation visit was conducted for an annual inspection that was initially conducted on 2024-04-23.
Findings
During the visit, a review of six resident files and seven staff files was conducted, along with staff and resident interviews. No deficiencies were cited.
Report Facts
Resident files reviewed: 6
Staff files reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shayan Gheisar | Administrator | Met with the Licensing Program Analyst during the inspection |
| Murial Han | Licensing Program Analyst | Conducted the unannounced continuation visit |
| Cara Smith | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 61
Capacity: 120
Deficiencies: 0
Date: Apr 23, 2024
Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was toured and found to have no accessible bodies of water or fire safety hazards, with unobstructed passageways, sufficient lighting, and comfortable temperature. Medications and sharps were properly secured, rooms were spacious and furnished, and some areas were undergoing construction. No deficiencies were cited during this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shayan Gheisar | Administrator | Met with Licensing Program Analyst during inspection. |
| Murial Han | Licensing Program Analyst | Conducted the unannounced annual inspection. |
| Cara Smith | Licensing Program Manager | Reviewed and discussed the report. |
Inspection Report
Census: 61
Capacity: 120
Deficiencies: 0
Date: Apr 9, 2024
Visit Reason
An unannounced Case Management visit was conducted to investigate a death that occurred in January 2024.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst reviewed documents and interviewed one staff member.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the Case Management visit and interviewed staff. |
| Shayan Gheisar | Executive Director | Met with Licensing Program Analyst and reviewed the report. |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 120
Deficiencies: 0
Date: Mar 27, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-01-08 regarding infection control practices and facility odor.
Complaint Details
The complaint alleged that the licensee was not ensuring infection control practices were maintained and that the facility was malodorous. The investigation concluded these allegations were unsubstantiated.
Findings
The investigation found the allegations to be unsubstantiated due to insufficient evidence. Observations and interviews indicated that infection control practices and odor issues could not be conclusively proven as violations.
Report Facts
Capacity: 120
Census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Licensing Program Analyst | Conducted the complaint investigation |
| Cara Smith | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Shayan Gheisar | Administrator | Facility administrator who participated by phone |
Inspection Report
Census: 60
Capacity: 120
Deficiencies: 0
Date: Mar 19, 2024
Visit Reason
The inspection visit was conducted as a Case Management in regards to a death that occurred on January 20, 2024.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst reviewed staff files, training records, and interviewed staff members.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the case management visit and reviewed staff files and training records. |
| Shayan Gheisar | Executive Director | Met with Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 120
Deficiencies: 0
Date: Feb 7, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received regarding staff behavior, food quality and quantity, and cleanliness and safety of the environment.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included inappropriate communication by staff, inadequate food quality and quantity, and unsafe or unclean environment. The Licensing Program Analyst did not find sufficient evidence to prove these allegations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Observations and interviews indicated that food services met standards, residents were not spoken to inappropriately, and the environment was maintained safely despite ongoing renovations.
Report Facts
Capacity: 120
Census: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shayan Gheisar | Administrator | Met with Licensing Program Analyst during investigation |
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation visit |
| April Cowan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Original Licensing
Census: 58
Capacity: 120
Deficiencies: 3
Date: Mar 17, 2023
Visit Reason
An unannounced pre-licensing visit was conducted to evaluate the facility's compliance with regulations and readiness for licensure.
Findings
The facility was found to be clean, in good repair, and in compliance with Title 22 regulations. No citations were issued, and licensure is recommended. Minor issues were noted such as soap dispensers not dispensing properly and insufficient linen supply, but corrective actions were planned.
Deficiencies (3)
Soap dispenser in communal bathrooms did not dispense soap properly.
Communal bathrooms need trash cans with fitted lids and hand-washing signs.
Facility does not have a sufficient amount of linen for residents; residents supply their own linen per contract.
Report Facts
Resident rooms on first floor: 44
Resident rooms on second floor: 51
Water temperature in communal bathrooms: 107
Water temperature in resident rooms: 106
PPE supply duration: 30
Fire prevention system inspection date: Jan 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Charitra | Licensing Program Analyst | Conducted the pre-licensing visit and authored the report |
| Shayan Gheisar | Co-Administrator | Met with Licensing Program Analyst during the visit |
| Amanda North | Administrator | Facility Administrator mentioned in the report |
| Cara Smith | Licensing Program Manager | Named as Licensing Program Manager overseeing the report |
Inspection Report
Original Licensing
Census: 68
Capacity: 120
Deficiencies: 0
Date: Feb 21, 2023
Visit Reason
The visit was conducted as a Component II completion for original licensing of the Serra Highlands Senior Living Facility, verifying the applicant/administrator's understanding of community care facility licensing laws and readiness for licensing.
Findings
The Component II completion was successful, confirming the applicant/administrator's knowledge of facility operation, admission policies, staffing requirements, restrictive health conditions, emergency preparedness, complaints and reporting, and pre-licensing readiness.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda North | Applicant's Representative/Administrator | Participated in Component II completion and verified understanding of licensing requirements. |
| Julia Kim | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Thai Doan | Licensing Program Analyst | Named as Licensing Program Analyst on the report. |
Inspection Report
Plan of Correction
Census: 61
Capacity: 120
Deficiencies: 2
Date: Apr 21, 2022
Visit Reason
An unannounced plan of correction (POC) visit was conducted to verify and confirm that the facility is in compliance with citations issued on 2022-04-08. The facility had failed to submit a plan of correction by the due date of 2022-04-15.
Findings
The facility was cited for two Type B violations related to advertisement and license number disclosure, and transferability of license. The facility was advertising under a different name without a valid license and failed to notify residents or their representatives in writing about the transfer of the property or business.
Deficiencies (2)
Failure to reveal each facility license number in all public advertisements, including Internet or correspondence, as required by CCR 87206(a). Facility was advertising as Serra Highlands Senior Living without a valid RCFE license.
Failure to notify the licensing agency and all residents or their representatives in writing at least 30 days prior to the transfer of the property or business, as required by CCR 87109(b).
Report Facts
Capacity: 120
Census: 61
Deficiencies cited: 2
Plan of Correction Due Date: Apr 28, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced plan of correction visit and authored the report |
| Amanda North | Interim Executive Director | Met with Licensing Program Analyst during the visit |
| Julio Montes | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Plan of Correction
Census: 61
Capacity: 120
Deficiencies: 2
Date: Apr 21, 2022
Visit Reason
An unannounced plan of correction (POC) visit was conducted to verify and confirm that the facility is in compliance with citations issued on 2022-04-08. The facility had failed to provide a plan of correction by the due date of 2022-04-15.
Findings
The facility was cited for two Type B violations related to failure to display the license number in advertisements and failure to notify residents or their representatives in writing at least 30 days prior to transfer of the property or business. The facility failed to correct these deficiencies by the POC due date.
Deficiencies (2)
Failure to reveal each facility license number in all public advertisements, including Internet or correspondence, as required by Health and Safety Code Sections 1569.68 and 1569.681.
Failure to notify the licensing agency and all residents or their representatives in writing at least 30 days prior to the transfer of the property or business, as required by Health and Safety Code Section 1569.191.
Report Facts
Capacity: 120
Census: 61
Plan of Correction Due Date: Apr 28, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda North | Interim Executive Director | Met with Licensing Program Analyst during the inspection and discussed findings |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced plan of correction visit and authored the report |
| Julio Montes | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 120
Deficiencies: 2
Date: Apr 8, 2022
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility advertising itself as a licensed RCFE without having an approved license.
Complaint Details
The visit was complaint-related, triggered by observations that the facility was advertising as a licensed RCFE without having an approved license. The complaint was substantiated by the deficiencies cited.
Findings
The facility was found to be advertising as Serra Highlands Senior Living without a valid RCFE license and failed to notify residents or their representatives in writing about the transfer of the property or business as required by regulation. These deficiencies pose potential health, safety, or personal rights risks to clients in care.
Deficiencies (2)
Advertising the facility as licensed without a valid RCFE license, violating Health and Safety Code Sections 1569.68 and 1569.681.
Failure to notify residents or their representatives in writing at least 30 days prior to the transfer of the property or business, violating Health and Safety Code Section 1569.191.
Report Facts
Census: 62
Total Capacity: 120
Plan of Correction Due Date: Apr 15, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda North | Interim Executive Director | Met with during inspection and discussed findings |
| Komal Charitra | Licensing Program Analyst | Conducted inspection and cited deficiencies |
| Julio Montes | Licensing Program Manager | Supervisor overseeing the inspection |
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