Inspection Reports for
The Avant
4075 El Camino Way, Palo Alto, CA 94306, United States, CA, 94306
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Occupancy
Latest occupancy rate
76% occupied
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 191
Capacity: 250
Deficiencies: 0
Date: Jan 8, 2026
Visit Reason
The visit was an unannounced case management follow-up on an incident reported by the facility involving suspected dependent adult/elder abuse concerning resident #1.
Complaint Details
The complaint involved a report received on December 19, 2025, about resident #1 alleging that a male staff member 'man handled' them on December 14, 2025. The police investigated and closed the case with no evidence of abuse. The facility removed the staff member from caring for the resident and offered nursing care instead.
Findings
The investigation found no evidence of elder abuse after interviews with the administrator, assistant administrator, staff, and police involvement. Resident #1 preferred female caregivers but was given options when female caregivers were unavailable. No deficiencies were cited.
Report Facts
Capacity: 250
Census: 191
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Administrator | Met with Licensing Program Analyst during the visit and provided information about the incident and facility practices |
| Murial Han | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
| Cara Smith | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 178
Capacity: 250
Deficiencies: 0
Date: Dec 9, 2025
Visit Reason
The inspection was an unannounced case management visit conducted in response to an incident report received on 2025-12-05 regarding missing jewelry from a resident's safe.
Complaint Details
The visit was complaint-related due to a reported incident of missing jewelry from a resident's safe. The suspect was unknown, and the investigation included staff interviews and police involvement. The complaint was not substantiated with any findings.
Findings
The facility reported the missing jewelry to the Department and local police, who conducted a preliminary investigation. Staff interviews revealed no immediate findings. The facility conducted in-service training on theft and loss in response to the incident. No citations were issued.
Report Facts
Capacity: 250
Census: 178
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the unannounced case management visit |
| Jenny Huynh | Assistant Executive Director | Met with Licensing Program Analyst during the inspection |
Inspection Report
Complaint Investigation
Census: 186
Capacity: 250
Deficiencies: 0
Date: Nov 25, 2025
Visit Reason
An unannounced case management - incident report visit was conducted following an incident report received on 11/20/2025 regarding a resident who had a fall resulting in a laceration and hospital treatment.
Complaint Details
The visit was triggered by an incident report of a resident fall on 11/18/2025 resulting in a laceration and hospital treatment. The resident did not suffer broken bones or other injuries. The resident's care plan and physician's report were reviewed. No further falls have occurred since the incident. No citations were issued.
Findings
The resident sustained a laceration on the left eyebrow after a fall without staff assistance, was treated at the hospital, and returned without further injury. The resident's care plan includes high supervision and assistance to the restroom. No citations were issued during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Executive Director | Met with during the inspection and discussed resident care plan and incident. |
| Jaime Vado | Licensing Program Analyst | Conducted the unannounced case management - incident report visit. |
| Cara Smith | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Census: 185
Capacity: 250
Deficiencies: 0
Date: Oct 22, 2025
Visit Reason
The visit was an unannounced case management inspection to inquire about the employment status of staff #1.
Findings
No deficiencies were cited during this inspection. The licensing program analyst met with the health and wellness director and spoke with the executive director by phone regarding staff employment status.
Report Facts
Capacity: 250
Census: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Executive Director | Spoke by phone regarding employment status of staff #1 |
| Trish Oliver | Health and Wellness Director | Met with licensing program analyst during inspection |
Inspection Report
Census: 185
Capacity: 250
Deficiencies: 0
Date: Oct 22, 2025
Visit Reason
The visit was a case management inspection conducted to inquire about the employment status of a specific staff member (staff #1).
Findings
No deficiencies were cited during this unannounced case management visit. The licensing program analyst met with the health and wellness director and spoke with the executive director by phone regarding staff employment status.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Executive Director | Named in relation to inquiry about employment status of staff #1. |
| Trish Oliver | Met with during the inspection visit. | |
| Audrey Jeung | Licensing Program Analyst | Conducted the inspection and inquiry. |
Inspection Report
Complaint Investigation
Census: 184
Capacity: 250
Deficiencies: 0
Date: Jul 31, 2025
Visit Reason
The inspection visit was conducted as a Case Management – Incident inspection regarding a reported Theft and Loss incident involving four missing art pieces from a resident's room.
Complaint Details
The complaint involved a reported theft and loss of four art pieces valued at $160, allegedly taken by a staff member during a room flooring replacement. The complaint was not substantiated due to lack of evidence.
Findings
The investigation found no missing art pieces in the resident's room or storage, and no evidence of staff involvement. The police were contacted but advised filing online due to lack of evidence. An in-service training was conducted with staff on residents' rights and property protection. No deficiencies were cited during the visit.
Report Facts
Number of missing art pieces: 4
Art pieces value: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Executive Director | Met with Licensing Program Analyst and involved in investigation and exit interview |
| Kiran Jain | Licensing Program Analyst | Conducted the inspection visit and investigation |
Inspection Report
Complaint Investigation
Census: 184
Capacity: 250
Deficiencies: 0
Date: Jul 31, 2025
Visit Reason
The inspection visit was conducted as a Case Management – Incident inspection regarding a reported Theft and Loss incident that occurred on 07/17/2025 involving missing art pieces belonging to resident R1.
Complaint Details
The visit was complaint-related due to a reported Theft and Loss incident involving missing art pieces valued at $160. The complaint was investigated, but no evidence was found to substantiate theft by staff. The resident and DPOA were satisfied with the investigation.
Findings
The investigation found that four art pieces were missing from R1's closet, with no evidence found during a staff search of the room. The police were contacted but due to lack of evidence, the incident was filed online. No deficiencies were cited during the visit.
Report Facts
Number of missing art pieces: 4
Value of missing art pieces: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Executive Director | Met with Licensing Program Analyst during inspection and provided information about the incident |
| Kiran Jain | Licensing Program Analyst | Conducted the Case Management – Incident inspection visit |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 184
Capacity: 250
Deficiencies: 0
Date: Jul 21, 2025
Visit Reason
The visit was an unannounced Case Management – Incident inspection regarding an incident that occurred on 2025-07-02 between two residents involving inappropriate contact.
Findings
The investigation found that Resident #1 placed their hand on Resident #2's chest inside clothing without direct skin contact. No physical injuries were observed. The facility took appropriate actions including notifying police, physicians, and updating medication and service plans. Staff training was conducted and no deficiencies were cited during the visit.
Report Facts
Police case number: Police case number was provided but not specified in the report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Executive Director | Met with Licensing Program Analyst during the visit and provided information about the incident. |
| Kiran Jain | Licensing Program Analyst | Conducted the unannounced Case Management – Incident visit. |
| April Cowan | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 184
Capacity: 250
Deficiencies: 0
Date: Jul 21, 2025
Visit Reason
The inspection visit was conducted as a Case Management – Incident visit regarding an incident on 2025-07-02 where Resident #1 placed their hand on Resident #2's left chest.
Complaint Details
The visit was complaint-related due to an incident between two residents involving inappropriate contact. The incident was reported to police and the Ombudsman, who determined no further reporting was needed due to lack of physical injury. The facility monitored the residents closely and implemented intervention and safety measures.
Findings
The investigation found that the contact was indirect with no physical injuries observed. The facility took appropriate actions including notifying police, physicians, updating medication and service plans, and implementing an intervention plan. Staff training was conducted and no deficiencies were cited during the visit.
Report Facts
Police case number: Police case number was provided but not specified in the report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Executive Director | Met with Licensing Program Analyst during the visit and provided information about the incident and facility actions. |
| Kiran Jain | Licensing Program Analyst | Conducted the unannounced Case Management – Incident visit. |
Inspection Report
Complaint Investigation
Census: 182
Capacity: 250
Deficiencies: 0
Date: May 28, 2025
Visit Reason
The inspection visit was conducted unannounced on May 28, 2025, regarding a reported staff-to-resident physical abuse incident that occurred on May 17, 2025.
Complaint Details
The visit was complaint-related due to a reported staff-to-resident physical abuse incident. The incident was substantiated by the facility's actions including suspension and termination of the caregiver. Resident R1 was monitored and found to have no injuries. The responsible party was notified and had no concerns.
Findings
The investigation found that caregiver S1 inappropriately slapped and tapped Resident R1 during a combative episode, but no injuries were noted after assessment. S1 was suspended and subsequently terminated. No deficiencies were cited during the visit.
Report Facts
Capacity: 250
Census: 182
Incident date: May 17, 2025
Termination date: May 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Executive Director | Met with Licensing Program Analyst and provided information about the incident |
| Kiran Jain | Licensing Program Analyst | Conducted the inspection visit and investigation |
| April Cowan | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 182
Capacity: 250
Deficiencies: 0
Date: May 28, 2025
Visit Reason
The inspection visit was conducted unannounced on May 28, 2025, regarding a reported staff-to-resident physical abuse incident that occurred on May 17, 2025.
Complaint Details
The visit was complaint-related due to a reported staff-to-resident physical abuse incident on 05/17/2025. The allegation was investigated, and no injuries were found. The staff member involved was suspended and terminated. The resident's responsible party was notified and had no concerns. Police were contacted but no in-person response occurred.
Findings
The investigation found that caregiver S1 inappropriately slapped and tapped resident R1 during a combative episode, but no injuries were noted upon assessment. S1 was suspended and subsequently terminated. Resident R1 was observed to be calm and reported no pain or memory of the incident. No deficiencies were cited during the visit.
Report Facts
Incident date: May 17, 2025
Report date: May 28, 2025
Census: 182
Total capacity: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Executive Director | Met with Licensing Program Analyst and provided information about the incident and facility actions |
| Kiran Jain | Licensing Program Analyst | Conducted the inspection visit and investigation |
Inspection Report
Annual Inspection
Census: 179
Capacity: 250
Deficiencies: 0
Date: May 21, 2025
Visit Reason
The inspection was an unannounced Required 1-Year Annual inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, well-maintained, and compliant with all applicable regulations. Emergency systems, medication storage, and recreational areas were inspected and found satisfactory. No deficiencies were cited during the visit.
Report Facts
Residents in care: 179
Facility capacity: 250
Rooms inspected: 10
Emergency drill date: May 15, 2025
Fire extinguisher last service date: Dec 24, 2024
Smoke detector last inspection date: Mar 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Executive Director | Met with Licensing Program Analyst during inspection and named in exit interview |
| Kiran Jain | Licensing Program Analyst | Conducted the inspection |
| April Cowan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 179
Capacity: 250
Deficiencies: 0
Date: May 21, 2025
Visit Reason
The inspection was an unannounced Required 1-Year Annual inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, well-maintained, and compliant with all applicable regulations. No deficiencies were cited during the visit. Resident rooms, common areas, kitchen, medication storage, and safety equipment were all inspected and found to be in good condition.
Report Facts
Residents in care: 179
Licensed capacity: 250
Resident rooms inspected: 10
Staff personnel records reviewed: 6
Resident records reviewed: 5
Emergency drills frequency: 1
Most recent emergency drill date: May 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Kiran Jain | Licensing Program Analyst | Conducted the inspection |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 184
Capacity: 250
Deficiencies: 0
Date: May 6, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 09/27/2022 regarding staff hitting residents, improper transfer assistance causing injuries, and failure to mitigate a cockroach infestation at the facility.
Complaint Details
The complaint included allegations that staff hit residents, residents sustained injuries due to improper transfer assistance, and staff failed to mitigate a cockroach infestation. The investigation found no preponderance of evidence to prove the alleged violations occurred, resulting in an unsubstantiated status.
Findings
After interviews with residents, staff, and review of records including pest control invoices and resident files, there was insufficient evidence to substantiate the allegations. No deficiencies were cited under California Code of Regulations Title 22.
Report Facts
Capacity: 250
Census: 184
Pest control invoices: 7
Inservice Sign In Sheets: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the complaint investigation visits and authored the report |
| Li Li | Administrator | Facility administrator met during the investigation and reviewed the report |
| Sarah Yip | Supervisor | Supervisor overseeing the licensing evaluation |
| S6 | HR Director | Interviewed regarding staff conduct and reports of resident abuse |
Inspection Report
Complaint Investigation
Census: 185
Capacity: 250
Deficiencies: 0
Date: Apr 23, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not provide adequate supervision, resulting in a resident wandering into an unsafe area.
Complaint Details
The complaint alleged inadequate staff supervision leading to a resident wandering into an unsafe area, specifically the basement garage. The allegation was unsubstantiated after investigation, interviews, and record reviews.
Findings
The investigation found that a resident had accessed the basement garage and wandered to the Memory Care Unit without harm. The elevators and garage were found to be safe and regularly maintained. The resident was assessed and found to have no injuries or distress. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 250
Census: 185
Elevator maintenance frequency: 4
Date of last elevator maintenance: Jan 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kiran Jain | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Diana Smith | Business Office Director | Greeted the Licensing Program Analyst and participated in exit interview |
| Jenny Huynh | Assistant Executive Director | Met with the Licensing Program Analyst during the visit |
| Li Li | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 185
Capacity: 250
Deficiencies: 0
Date: Apr 23, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not provide adequate supervision, resulting in a resident wandering into an unsafe area, specifically the locked garage.
Complaint Details
The complaint alleged inadequate supervision leading to a resident wandering into an unsafe area. The resident, recovering from brain surgery and with memory issues, was found in the basement garage and later in the Memory Care Unit. Interviews and records showed no injuries or distress, and safety measures were in place. The allegation was unsubstantiated.
Findings
The investigation found that a resident had accessed the basement garage and wandered into the Meadow Wing Memory Care Unit without harm. The elevators and garage were deemed safe with regular maintenance and alarms. The resident was assessed with no injuries or distress. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 250
Census: 185
Elevator maintenance frequency: 4
Date of last elevator maintenance: Jan 8, 2025
Date complaint received: Mar 14, 2025
Date of incident: Mar 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kiran Jain | Licensing Program Analyst | Conducted the complaint investigation |
| April Cowan | Licensing Program Manager | Oversaw the complaint investigation |
| Diana Smith | Business Office Director | Met with Licensing Program Analyst and participated in exit interview |
| Jenny Huynh | Assistant Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 186
Capacity: 250
Deficiencies: 1
Date: Mar 27, 2025
Visit Reason
The inspection was an unannounced Case Management – Incident visit regarding a medication error incident on 2025-03-19 where a resident (R1) was mistakenly given a PRN medication 'Labetalol' without meeting the required parameters.
Complaint Details
The visit was complaint-related due to a medication error incident where a resident was given a PRN medication incorrectly. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility staff did not ensure the prescribed PRN medication was given according to the physician's directions, resulting in an immediate health and safety risk to the resident. The medication was administered as a routine medication despite blood pressure readings not meeting the threshold for administration. The facility conducted follow-up actions including notifying the PCP, performing assessments, and holding a care conference with the resident's family.
Deficiencies (1)
Facility staff did not ensure R1 was given the prescribed PRN medication according to the physician's directions, posing an immediate health, safety, or personal rights risk to persons in care.
Report Facts
Deficiencies cited: 1
Capacity: 250
Census: 186
Plan of Correction Due Date: Mar 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Oliver | Health and Wellness Director | Named in medication error finding and involved in incident response |
| Diana Smith | Business Office Director | Named in medication error finding and involved in incident response and plan of correction |
| Kiran Jain | Licensing Program Analyst | Conducted the inspection and authored the report |
| April Cowan | Licensing Program Manager | Oversaw the licensing program and named in the report |
| S1 | Medication Technician | Administered the medication in error |
| S2 | LVN Community Nurse | Performed bedside assessment and coordinated with PCP |
| ED | Executive Director | Interviewed regarding the medication error and facility response |
Inspection Report
Complaint Investigation
Census: 186
Capacity: 250
Deficiencies: 1
Date: Mar 27, 2025
Visit Reason
The inspection visit was an unannounced Case Management - Incident visit regarding a medication error incident on 03/19/2025 where a resident (R1) was given a PRN medication by mistake.
Complaint Details
The visit was triggered by a complaint or incident involving a medication error where resident R1 was given 'Labetalol' as a routine medication instead of as needed, contrary to physician orders. The medication error was substantiated based on observations, interviews, and record reviews.
Findings
The facility staff administered a PRN medication ('Labetalol') to resident R1 without meeting the physician's specified parameters, posing an immediate health and safety risk. The error was acknowledged by staff, reported to the resident's PCP, and communicated to the resident's family. A deficiency was cited for failure to ensure medication was given according to physician's directions.
Deficiencies (1)
Facility staff did not ensure R1 was given the prescribed PRN medication according to the physician's directions, posing an immediate health, safety, or personal rights risk.
Report Facts
Deficiencies cited: 1
Medication dosage: 50
Blood pressure reading: 146
Blood pressure reading: 90
Capacity: 250
Census: 186
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Oliver | Health and Wellness Director | Met with Licensing Program Analyst and provided information about the medication error |
| Diana Smith | Business Office Director | Met with Licensing Program Analyst and participated in exit interview and plan of correction |
| Kiran Jain | Licensing Program Analyst | Conducted the inspection visit and authored the report |
| Li Li | Administrator | Facility administrator named in report header |
| S1 | Medication Technician | Administered the medication in error and acknowledged the mistake |
| S2 | LVN Community Nurse | Performed bedside assessment and contacted PCP regarding medication error |
| Executive Director | Provided statements about the medication error and staff involved |
Inspection Report
Complaint Investigation
Census: 183
Capacity: 250
Deficiencies: 0
Date: Mar 11, 2025
Visit Reason
The inspection visit was conducted as a Case Management – Incident inspection regarding an incident where a resident presented with a sudden change of condition and had removed his suprapubic catheter.
Complaint Details
The visit was triggered by an incident involving a resident removing his suprapubic catheter. The Vice President of Clinical Services stated there was no need to file an exception request for the catheter after a call with CDSS.
Findings
The facility did not have an exception granted for the resident's suprapubic catheter, but no deficiencies were cited during the visit. The facility had documents ready to submit for an exception request if needed.
Report Facts
Facility census: 183
Facility capacity: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Executive Director | Met with Licensing Program Analyst during the inspection and involved in discussion about the catheter exception request |
| Kiran Jain | Licensing Program Analyst | Conducted the inspection visit |
| Mariam Perez | Vice President of Clinical Services | Discussed catheter exception request with CDSS and Licensing Program Analyst |
Inspection Report
Census: 183
Capacity: 250
Deficiencies: 0
Date: Mar 11, 2025
Visit Reason
The inspection visit was an unannounced Case Management - Incident inspection regarding an incident where a resident presented with a sudden change of condition and had removed his suprapubic catheter.
Findings
The facility did not have an exception granted for the resident's suprapubic catheter, but no deficiencies were cited during the visit. The facility was prepared to submit an exception request if needed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Executive Director | Greeted the Licensing Program Analyst and participated in the inspection visit. |
| Kiran Jain | Licensing Program Analyst | Conducted the inspection visit. |
| Mariam Perez | Vice President of Clinical Services | Participated in phone conversation regarding catheter exception request. |
Inspection Report
Complaint Investigation
Census: 185
Capacity: 250
Deficiencies: 0
Date: Mar 7, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 07/21/2022 regarding resident hygiene needs not being met and staff not changing a resident's diaper.
Complaint Details
The complaint was unsubstantiated after investigation. Allegations included resident's hygiene needs not being met and staff not changing resident's diaper. Interviews and observations did not support these claims.
Findings
Based on interviews with staff, the administrator, and review of records, there was insufficient evidence to substantiate the allegations. Staff reported regularly assisting the resident with oral care and diaper changes, and no deficiencies were cited.
Report Facts
Census: 185
Total Capacity: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the complaint investigation visit |
| Li Li | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 185
Capacity: 250
Deficiencies: 0
Date: Mar 7, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 07/21/2022 regarding resident hygiene and diaper changing practices at the facility.
Complaint Details
The complaint alleged that the resident's hygiene needs were not being met and that staff were not changing the resident's diaper. The investigation found no preponderance of evidence to prove the alleged violations occurred, and the complaint was unsubstantiated.
Findings
Based on interviews with staff and the administrator, as well as review of resident assessments and training logs, there was insufficient evidence to substantiate the allegations. Staff reported regularly assisting the resident with oral care and diaper changes, and no deficiencies were cited.
Report Facts
Capacity: 250
Census: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the complaint investigation visit |
| Li Li | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 186
Capacity: 250
Deficiencies: 0
Date: Mar 4, 2025
Visit Reason
The inspection visit was conducted as a Case Management – Incident inspection regarding a reported Theft and Loss incident that occurred on 2025-02-24 involving missing personal items of a deceased hospice resident.
Complaint Details
The complaint involved a theft and loss incident reported by a family member of a deceased resident. The family member reported missing items including a wallet, watch, Apple iPad, camera equipment, music box, and Faberge Pinecone Egg. The facility cooperated with the police investigation. No substantiation status was explicitly stated.
Findings
The facility reported a theft and loss incident involving multiple missing items valued at $14,275.00 from a resident's room. The police were contacted and a case was opened. No deficiencies were cited during the visit.
Report Facts
Value of missing items: 14275
Facility census: 186
Facility capacity: 250
Number of hospice staff visitors: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Executive Director | Met with Licensing Program Analyst and provided information regarding the theft and loss incident |
| Kiran Jain | Licensing Program Analyst | Conducted the inspection visit |
| April Cowan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 186
Capacity: 250
Deficiencies: 0
Date: Mar 4, 2025
Visit Reason
The inspection visit was conducted as a Case Management – Incident inspection regarding a reported Theft and Loss incident that occurred on 2025-02-24 involving missing personal items of a deceased hospice resident.
Complaint Details
The visit was complaint-related due to a reported Theft and Loss incident involving missing personal property of a deceased resident. The incident was substantiated by the facility's report and police involvement.
Findings
The facility reported a theft and loss incident involving missing items valued at $14,275.00 from a deceased resident's apartment. The police were contacted and a case was opened. The Licensing Program Analyst reviewed relevant policies, records, and agreements. No deficiencies were cited during the visit.
Report Facts
Value of missing items: 14275
Census: 186
Total capacity: 250
Number of hospice staff visitors: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Executive Director | Met with Licensing Program Analyst and provided information about the incident |
| Kiran Jain | Licensing Program Analyst | Conducted the inspection visit |
| April Cowan | Supervisor | Named as supervisor on the report |
Inspection Report
Census: 186
Capacity: 250
Deficiencies: 0
Date: Feb 7, 2025
Visit Reason
The purpose of the visit was to obtain copies of resident records during an unannounced Case Management visit.
Findings
No deficiencies were cited at this time as per California Code of Regulations Title 22.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit and obtained copies of resident records. |
| Li Li | Executive Director | Met with Licensing Program Analyst during the visit and reviewed the report. |
Inspection Report
Census: 186
Capacity: 250
Deficiencies: 0
Date: Feb 7, 2025
Visit Reason
The purpose of the visit was to obtain copies of resident records during an unannounced Case Management visit.
Findings
No deficiencies were cited at this time as per California Code of Regulations Title 22.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit and obtained copies of resident records. |
| Li Li | Executive Director | Met with Licensing Program Analyst during the visit and reviewed the report. |
Inspection Report
Complaint Investigation
Census: 184
Capacity: 250
Deficiencies: 0
Date: Jan 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff were holding a resident against their will at the facility.
Complaint Details
The complaint alleged that staff were holding Resident R2 against their will and that R2's care nurse had placed R2 in the facility without proper consultation with R2's primary care physician. The investigation found no evidence to support this allegation, and it was determined to be unfounded.
Findings
After reviewing records and conducting multiple interviews with residents, staff, family members, fiduciaries, care managers, physicians, and attorneys, it was determined that the allegation was unfounded. The resident was not being held against their will, was free to move around the facility, and no deficiencies were cited.
Report Facts
Capacity: 250
Census: 184
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Executive Director | Met with Licensing Program Analyst during the investigation and provided information about the facility and resident census |
| Kiran Jain | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 184
Capacity: 250
Deficiencies: 0
Date: Jan 15, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff were holding a resident against their will.
Complaint Details
The complaint alleged that staff were holding Resident R2 against their will and that R2's care nurse placed R2 in the facility without proper consultation with R2's primary care physician. The investigation found no evidence to support this claim, and the allegation was determined to be unfounded.
Findings
After interviews and record reviews, it was determined that the allegation was unfounded. The resident was not being held against their will, was free to move around the facility, and no deficiencies were cited.
Report Facts
Capacity: 250
Census: 184
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Executive Director | Met with Licensing Program Analyst during the investigation and provided statements regarding the resident and facility operations. |
| Kiran Jain | Licensing Program Analyst | Conducted the complaint investigation visit. |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| GCM | Geriatric Care Manager | Care nurse involved in resident placement, identified as employed by a private company and not the facility. |
Inspection Report
Complaint Investigation
Census: 187
Capacity: 250
Deficiencies: 1
Date: Nov 14, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-07-18 regarding multiple allegations including inadequate accommodations, lack of privacy, room disrepair, lack of planned activities, and insufficient staffing.
Complaint Details
The complaint investigation was substantiated for insufficient staffing, specifically that resident R1 was left in bed multiple times past 1 PM due to staff being overscheduled and insufficient in number. Other allegations were unsubstantiated.
Findings
The investigation substantiated the allegation of insufficient staffing as resident R1 was left in bed multiple times past 1 PM, posing an immediate health risk. Other allegations related to accommodations, privacy, and activities were unsubstantiated. The facility was undergoing renovations and had ongoing communication with the resident's responsible party regarding apartment changes and credits.
Deficiencies (1)
Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Resident R1 was left in bed multiple times past 1 PM, which poses an immediate health risk to residents in care.
Report Facts
Capacity: 250
Census: 187
Monthly rental credit: 2500
Plan of Correction Due Date: Nov 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the complaint investigation visit |
| Li Li | Administrator | Facility administrator involved in investigation and communications |
| Sarah Yip | Supervisor | Supervisor overseeing the licensing evaluation |
| S1 | Director of Environmental Services | Interviewed regarding sliding glass door and facility renovations |
Inspection Report
Complaint Investigation
Census: 187
Capacity: 250
Deficiencies: 1
Date: Nov 14, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 07/18/2023 regarding resident accommodations, privacy, room disrepair, lack of planned activities, and insufficient staffing.
Complaint Details
The complaint investigation was initiated based on allegations received on 07/18/2023. The allegations included staff not providing comfortable accommodations, lack of privacy, room disrepair, lack of planned activities, and insufficient staffing. The allegation of insufficient staffing was substantiated based on interviews and observations, while other allegations were unsubstantiated. The report notes that the occupational therapist and resident reported staff leaving R1 in bed late in the day, and the facility agreed to submit a plan of correction.
Findings
The investigation substantiated the allegation of insufficient staffing as resident R1 was left in bed multiple times past 1 PM, posing an immediate health risk. Other allegations regarding accommodations, privacy, room disrepair, and activities were unsubstantiated due to lack of preponderance of evidence. The facility was undergoing renovations and had scheduled activities for residents.
Deficiencies (1)
87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Resident R1 was left in bed multiple times past 1 PM, posing an immediate health risk.
Report Facts
Capacity: 250
Census: 187
Deficiencies cited: 1
Plan of Correction Due Date: 2024
Monthly credit: 2500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Li Li | Administrator | Facility administrator interviewed during investigation and involved in correspondence regarding resident R1 |
| Sarah Yip | Licensing Program Manager | Oversaw the licensing program and signed the report |
| S1 | Director of Environmental Services | Interviewed regarding sliding glass door and facility maintenance |
Inspection Report
Complaint Investigation
Census: 190
Capacity: 250
Deficiencies: 1
Date: Nov 12, 2024
Visit Reason
An unannounced case management visit was conducted to follow up on an incident where resident R1 eloped from the facility unsupervised on 2024-11-04 after attending a birthday concert.
Complaint Details
The visit was complaint-related due to an incident where resident R1 eloped unsupervised. The complaint was substantiated as the facility failed to provide required supervision and escort to R1, posing immediate health and safety risks.
Findings
The facility staff failed to ensure that resident R1, who has dementia and requires staff escort, did not leave the facility unassisted, posing an immediate health and safety risk. An immediate civil penalty of $500 was assessed for absence of supervision.
Deficiencies (1)
Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This was not met as evidenced by failure to prevent resident R1 from eloping the facility on 11/04/2024.
Report Facts
Civil penalty amount: 500
Residents present during event: 20
Activities assistant staff present: 2
Staff to resident ratio in Elite care: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Executive Director | Named in relation to the incident and findings regarding resident supervision |
| Kiran Jain | Licensing Program Analyst | Conducted the inspection and authored the report |
| April Cowan | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 190
Capacity: 250
Deficiencies: 1
Date: Nov 12, 2024
Visit Reason
The inspection was an unannounced case management visit to follow up on an incident where a resident (R1) eloped from the facility unsupervised on 2024-11-04 after attending a birthday concert.
Complaint Details
The visit was complaint-related due to an incident where resident R1 eloped from the facility unsupervised. The complaint was substantiated as the facility failed to ensure R1 did not leave unassisted, posing immediate risk.
Findings
The facility staff failed to prevent R1, who has dementia and is non-ambulatory due to mental condition, from leaving the facility unassisted, posing an immediate health, safety, or personal rights risk. An immediate civil penalty of $500 was assessed for the absence of supervision.
Deficiencies (1)
Facility staff failed to prevent resident (R1) from eloping the facility on 11/04/2024. R1 has dementia, is non-ambulatory due to mental condition, deemed not able to leave the facility unassisted, and was able to leave facility unassisted by the scheduled staff, posing an immediate health, safety or personal rights risk.
Report Facts
Immediate civil penalty: 500
Residents present during event: 20
Activities assistant staff present: 2
Staff to resident ratio in Elite care: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kiran Jain | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Li Li | Executive Director | Met with Licensing Program Analyst and discussed incident and findings |
| April Cowan | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Annual Inspection
Census: 104
Capacity: 250
Deficiencies: 0
Date: Jun 13, 2024
Visit Reason
An unannounced Case Management - Annual Continuation Visit was conducted to review compliance with regulations and assess facility conditions.
Findings
The Licensing Program Analyst reviewed medication and destruction records, resident and staff records, and toured resident living units, bathrooms, and outside areas. No deficiencies were cited during this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the inspection and reviewed records and facility conditions. |
| Li Li | Administrator | Met with the Licensing Program Analyst during the inspection. |
Inspection Report
Annual Inspection
Census: 104
Capacity: 250
Deficiencies: 0
Date: Jun 13, 2024
Visit Reason
An unannounced Case Management - Annual Continuation Visit was conducted to review facility compliance with regulations.
Findings
The Licensing Program Analyst reviewed medication and destruction records, resident and staff records, and toured resident living units, bathrooms, and outside areas. No deficiencies were cited during this inspection.
Report Facts
Residents reviewed: 7
Staff records reviewed: 7
Resident living units toured: 7
Bathrooms toured: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the inspection and reviewed records |
| Li Li | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Census: 104
Capacity: 250
Deficiencies: 0
Date: Jun 11, 2024
Visit Reason
An unannounced Required - 1 Year visit was conducted as part of the annual inspection process.
Findings
No deficiencies were cited at this time as per California Code of Regulations Title 22. The inspection included interviews with residents and staff, review of the first aid kit, fire drill records, smoke detector testing, and kitchen food supply observations.
Report Facts
Residents interviewed: 5
Staff interviewed: 5
Fire drill date: May 31, 2024
Smoke detector testing months: 5
Perishable food supply days: 2
Non-perishable food supply days: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the inspection and authored the report |
| Li Li | Administrator | Met with the Licensing Program Analyst during the inspection |
Inspection Report
Annual Inspection
Census: 104
Capacity: 250
Deficiencies: 0
Date: Jun 11, 2024
Visit Reason
The inspection visit was an unannounced Required - 1 Year annual inspection to evaluate facility compliance.
Findings
No deficiencies were cited during this inspection. The first aid kit was complete, fire drills were up to date, smoke detectors were tested monthly, and food supplies were adequate.
Report Facts
Residents interviewed: 5
Staff interviewed: 5
Fire drill date: May 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Administrator | Facility Administrator met during the inspection |
| David Marrufo | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Census: 180
Capacity: 250
Deficiencies: 0
Date: May 23, 2024
Visit Reason
The visit was an unannounced Case Management inspection to address an incident self-reported by the facility involving a private duty caregiver driving an independent living resident to a bank and the subsequent withdrawal of $6,500 by the resident.
Findings
The investigation found that the private care giver admitted to driving the resident to the bank and receiving $200 as a gift, while $6,300 remains missing and unaccounted for. No deficiencies were cited at this time according to California Code of Regulations Title 22.
Report Facts
Amount withdrawn: 6500
Amount received as gift: 200
Amount missing: 6300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Administrator | Met with Licensing Program Analyst and interviewed regarding incident |
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit |
Inspection Report
Complaint Investigation
Census: 180
Capacity: 250
Deficiencies: 0
Date: May 23, 2024
Visit Reason
The visit was conducted to address an incident self-reported by the facility involving a private duty caregiver driving an independent living resident to a bank and the subsequent withdrawal of $6,500 by the resident.
Complaint Details
The visit was complaint-related, triggered by an incident reported on 02/20/2024 concerning a private caregiver driving a resident to a bank and the missing $6,300 according to the resident's Financial Power of Attorney.
Findings
During the visit, the Licensing Program Analyst interviewed the administrator and residents. The private caregiver admitted to driving the resident to the bank and receiving $200 as a gift, while $6,300 remains missing and unaccounted for. No deficiencies were cited at this time.
Report Facts
Amount withdrawn: 6500
Amount received as gift: 200
Amount missing: 6300
Number of residents interviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Administrator | Interviewed during the visit and provided information about the incident |
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit |
Inspection Report
Complaint Investigation
Census: 172
Capacity: 250
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2022-01-07 alleging that the facility does not follow COVID-19 guidelines.
Complaint Details
The complaint alleged that the facility does not follow COVID-19 guidelines. The investigation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation included interviews and record reviews, and it was determined that there was insufficient evidence to prove whether the facility did or did not follow COVID-19 guidelines. Therefore, the allegation was unsubstantiated.
Report Facts
Complaint Control Number: 26-AS-20220107110340
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Li Li | Executive Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 172
Capacity: 250
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by a report received on 2022-01-07 alleging that the facility does not follow COVID-19 guidelines.
Complaint Details
The complaint alleged that the facility did not follow COVID-19 guidelines. The investigation found insufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Findings
The investigation included interviews and record reviews but was unable to prove whether the facility did not follow COVID-19 guidelines. The allegation was determined to be unsubstantiated and no deficiencies were cited during the visit.
Report Facts
Facility capacity: 250
Census: 172
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Li Li | Executive Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Census: 172
Capacity: 250
Deficiencies: 0
Date: Jan 18, 2024
Visit Reason
The visit was conducted to follow up on an Incident Report and Suspected Adult/Elderly Abuse Form submitted by the facility regarding a witnessed resident fall and concerns about staff reporting accuracy.
Findings
The investigation included interviews with staff and a family member, observation of the resident, and review of the incident. No deficiencies were cited as the staff were found not to have neglected the resident and no withholding of information was substantiated.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit and interviews related to the incident. |
| Li Li | Administrator | Facility administrator met during the visit and reviewed the report. |
Inspection Report
Follow-Up
Census: 172
Capacity: 250
Deficiencies: 0
Date: Jan 18, 2024
Visit Reason
The visit was conducted to follow up on an Incident Report and Suspected Adult/Elderly Abuse Form submitted by the facility regarding a resident's fall and concerns about staff reporting accuracy.
Complaint Details
The visit was complaint-related, following up on an incident report of a resident fall and alleged inaccurate reporting by staff. The complaint was not substantiated as staff and family member interviews did not support neglect or withholding information.
Findings
The investigation included interviews with staff and a family member, observation of the resident, and review of the incident. No deficiencies were cited as the staff were found not to have neglected the resident and no withholding of information was substantiated.
Report Facts
Facility capacity: 250
Resident census: 172
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Administrator | Facility administrator met during the visit |
| David Marrufo | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Census: 174
Capacity: 250
Deficiencies: 0
Date: Jul 26, 2023
Visit Reason
The visit was an unannounced Case Management visit to inquire about an incident self-reported by the facility regarding a resident's bicycle stolen on 05/29/2023.
Findings
The facility provided camera footage showing two individuals breaking through the garage gate to steal the bicycle. The facility filed a police report and installed alarms on the gate door. No deficiencies were cited as per California Code of Regulations Title 22.
Report Facts
Incident date: May 29, 2023
Report date: Jun 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit and evaluation |
| Li Li | Administrator | Facility administrator interviewed during the visit |
Inspection Report
Census: 174
Capacity: 250
Deficiencies: 0
Date: Jul 26, 2023
Visit Reason
The visit was an unannounced Case Management visit to inquire about an incident self-reported by the facility regarding a stolen resident's bicycle on 05/29/2023.
Findings
The facility provided camera footage showing the theft, filed a police report, installed alarms on the gate door, and conducted staff training on theft and loss policy. No deficiencies were cited during the visit.
Report Facts
Incident date: May 29, 2023
Incident report date: Jun 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Administrator | Met during visit and provided information about the incident and corrective actions |
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit |
Inspection Report
Census: 187
Capacity: 250
Deficiencies: 0
Date: May 15, 2023
Visit Reason
The visit was an unannounced Case Management visit conducted in response to an incident involving resident R1 leaving the facility without supervision on 03/22/2023, reported via an Unusual Injury/Incident Report on 03/24/2023.
Findings
No deficiencies were cited at this time. The facility had conducted safety checks on resident R1 every 2 hours and escorted R1 to meals as required. An Advisory Note was issued regarding the incident.
Report Facts
Incident date: Mar 22, 2023
Incident report date: Mar 24, 2023
In-Service Training date: Apr 5, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the Case Management visit and investigation |
| Li Li | Administrator | Facility administrator met during the visit and reviewed the report |
Inspection Report
Census: 187
Capacity: 250
Deficiencies: 0
Date: May 15, 2023
Visit Reason
The visit was an unannounced Case Management visit in response to an incident involving resident R1 leaving the facility without supervision on 2023-03-22, reported via an Unusual Injury/Incident Report on 2023-03-24.
Findings
The Licensing Program Analyst reviewed resident and staff records, confirming that R1 has dementia and requires supervision. Staff conduct safety checks every 2 hours and escort R1 to meals. An Advisory Note was issued, but no deficiencies were cited at this time according to California Code of Regulations Title 22.
Report Facts
Safety check times: 3
Incident date: Mar 22, 2023
Report date: Mar 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit and investigation |
| Li Li | Administrator | Facility administrator met during the visit and reviewed the report |
Inspection Report
Annual Inspection
Census: 165
Capacity: 250
Deficiencies: 0
Date: Sep 19, 2022
Visit Reason
An unannounced Required 1 Year visit was conducted to evaluate the facility's compliance with regulations.
Findings
The facility was toured inside and outside, with observations including visitor screening, availability of soap and paper towels, hand washing posters, adequate food supplies, and a 30-day supply of PPEs. No deficiencies were cited at this time.
Report Facts
Capacity: 250
Census: 165
Food supply: 2
Food supply: 7
PPE supply: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the inspection visit |
| Li Li | Administrator | Facility administrator met during inspection |
Inspection Report
Annual Inspection
Census: 165
Capacity: 250
Deficiencies: 0
Date: Sep 19, 2022
Visit Reason
An unannounced Required 1 Year visit was conducted to evaluate the facility's compliance with regulations.
Findings
The facility was toured inside and outside, with observations including visitor screening, availability of soap and paper towels, hand washing posters, adequate food supplies, and PPE supplies. No deficiencies were cited during this inspection.
Report Facts
Capacity: 250
Census: 165
Food supply duration: 2
Food supply duration: 7
PPE supply duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Li Li | Administrator | Met during the inspection and reviewed the report |
| David Marrufo | Licensing Program Analyst | Conducted the inspection visit |
| Sarah Yip | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 250
Deficiencies: 0
Date: Apr 7, 2022
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility did not have hot water for residents in care.
Complaint Details
The complaint was unsubstantiated based on interviews, records review, and observations. The allegation that the facility lacked hot water was not proven.
Findings
The investigation found that plumbing issues with water temperature were identified and addressed promptly by the facility. Observations and interviews showed mixed resident experiences with hot water, but overall there was insufficient evidence to substantiate the allegation. No deficiencies were cited.
Report Facts
Number of residents interviewed: 6
Number of staff interviewed: 2
Water temperature range: 105
Water temperature range: 115
Number of tankless water heaters observed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marybeth Donovan | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Li Li | Executive Director | Facility administrator met during investigation and exit interview |
| Charito Amoranto | Assistant Executive Director | Facility staff met during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 250
Deficiencies: 0
Date: Apr 7, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility did not have hot water for residents in care.
Complaint Details
The complaint alleged that the facility did not have hot water for residents in care. The investigation found some residents experienced hot water temperature issues, but the facility addressed plumbing problems promptly. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The Licensing Program Analyst investigated the complaint by interviewing staff and residents, reviewing records, and observing the facility. Although some residents reported issues with hot water temperature, the facility had taken corrective actions including installing a storage and mixing tank. The allegation was determined to be unsubstantiated with no deficiencies cited.
Report Facts
Residents interviewed: 6
Staff interviewed: 2
Water heaters observed: 6
Water temperature range: 105
Water temperature range: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marybeth Donovan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Li Li | Executive Director | Facility administrator interviewed during the investigation |
| Charito Amoranto | Assistant Executive Director | Facility staff interviewed during the investigation |
Inspection Report
Original Licensing
Census: 138
Capacity: 250
Deficiencies: 0
Date: Jun 29, 2021
Visit Reason
Licensing Program Analyst David Marrufo conducted an unannounced prelicensing visit to evaluate the facility for licensing approval.
Findings
The facility was toured and inspected, including resident living units, emergency systems, kitchen, and medication logs. No deficiencies were found and all records were complete.
Report Facts
Fire extinguishers: 8
Resident living units: 12
Staff records reviewed: 8
Resident records reviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the unannounced prelicensing visit and inspection |
| Li Li | Administrator | Facility administrator met with Licensing Program Analyst during visit |
Inspection Report
Original Licensing
Census: 138
Capacity: 250
Deficiencies: 0
Date: Jun 29, 2021
Visit Reason
An unannounced prelicensing visit was conducted to evaluate the facility for initial licensing approval.
Findings
The facility was toured and inspected, including resident living units, dining area, kitchen, medication logs, personnel records, and emergency systems. No deficiencies were found during the prelicensing inspection.
Report Facts
Fire extinguishers: 8
Resident living units: 12
Resident records reviewed: 8
Staff personnel records reviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the prelicensing visit and inspection |
| Li Li | Administrator | Facility administrator met during the visit |
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