31 Reports
Inspection Report — Feb 19, 2026
Complaint Investigation
Date: Feb 19, 2026
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to multiple allegations regarding staff actions affecting a resident, including damage to a personal item, failure to ensure attendance at a medical appointment, failure to ensure receipt of prescribed medication, and failure to pick up the resident from an appointment in a timely manner.
Complaint Details
The complaint investigation was substantiated for the allegation that staff damaged a resident's personal item (a duvet cover) by fading its color during washing, with a credit issued for replacement. The other allegations about medical appointment attendance, medication receipt, and transportation delays were unsubstantiated due to lack of sufficient evidence.
Findings
The allegation that staff damaged a resident's personal item was substantiated but considered a technical violation with no citations issued. The other allegations related to medical appointment attendance, medication administration, and timely transportation were unsubstantiated due to insufficient evidence. No deficiencies were cited.
Report Facts
Credit amount: 207.43
Medication delay days: 9
Medication delay days: 17
Lyft ride wait time: 75
Number of missed calls: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lourdes Bustamante | Administrator | Facility administrator involved in investigation and transportation resolution |
| Jessica Saks | Associate Executive Director | Met with Licensing Program Analyst during investigation |
| Allison Marty | Executive Director | Met with Licensing Program Analyst during investigation |
| Kristin Heffernan | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report — Oct 30, 2025
Complaint Investigation
Date: Oct 30, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that, due to lack of supervision, a resident injured another resident while in care.
Complaint Details
The complaint alleged that due to lack of supervision, Resident #1 injured Resident #2 by throwing an object causing a C1 fracture. Interviews and record reviews showed no evidence of lack of supervision or malicious intent. The allegation was unsubstantiated.
Findings
The investigation found that Resident #1 threw an object at Resident #2 causing injury, but there was insufficient evidence to support the allegation of lack of supervision. Both residents did not require supervision in common areas, and the facility responded effectively to the incident. The allegation was deemed unsubstantiated.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation |
| Jessica Saks | Director of Nursing | Met with Licensing Program Analyst upon arrival |
| Lourdes Bustamante | Administrator | Discussed allegation during investigation |
| Allison Marty | Executive Director | Arrived shortly after investigation began |
Inspection Report — Sep 3, 2025
Complaint Investigation
Date: Sep 3, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff did not clean a resident's room, were not following a resident's care plan, and were not changing a resident's clothing.
Complaint Details
The complaint was unsubstantiated. Allegations included staff not cleaning a resident's room, not following the resident's care plan, and not changing the resident's clothing. Evidence did not support these claims.
Findings
The investigation found insufficient evidence to substantiate the allegations. Observations, interviews, and record reviews confirmed that the resident's room was clean, the resident received stand-by assistance with dressing as documented, and frequent safety checks were conducted. No deficiencies were cited.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation |
| Allison Marty | Executive Director | Met with Licensing Program Analyst during investigation |
| Kristin Heffernan | Supervisor | Supervisor overseeing the investigation |
Inspection Report — Aug 19, 2025
Annual Inspection
Date: Aug 19, 2025
Visit Reason
The inspection was an unannounced Case Management - Annual Continuation visit to evaluate the facility's compliance with licensing requirements and health and safety regulations.
Findings
The facility was found to be in compliance with Title 22 Regulations, with no citations issued. Observations included adequate facility layout, sufficient food supply, well-equipped resident rooms and bathrooms, functional emergency systems, and clear outdoor areas. Interviews with residents and staff were conducted.
Report Facts
Resident rooms toured: 37
Resident rooms in Memory Care Unit: 4
Additional resident rooms toured: 33
Residents interviewed: 5
Staff interviewed: 6
Fire extinguisher service date: Apr 22, 2025
Hot water temperature range: 109.2-116.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Saks | Director of Nursing | Met with Licensing Program Analyst during inspection |
| Allison Marty | Executive Director | Met with Licensing Program Analyst during inspection |
| Miguel Castenada | Director of Plant Operations | Participated in physical plant tour during inspection |
| Angela Barutyan | Licensing Program Analyst | Conducted the inspection visit |
| Kristin Heffernan | Licensing Program Manager | Named in report header |
| Edgar Antonyan | Los Angeles County Public Health Environmental Health Specialist | Participated in physical plant tour during inspection |
Inspection Report — Aug 5, 2025
Annual Inspection
Date: Aug 5, 2025
Visit Reason
The inspection was an unannounced Case Management - Annual Continuation visit to review the facility's compliance with licensing requirements, including infection control, emergency disaster planning, and staff and resident record reviews.
Findings
The facility's infection control practices and emergency disaster plan were found adequate. However, four out of seven care staff files were missing valid first aid certification, which was cited as a deficiency posing a potential health and safety risk.
Citations (1)
Four out of seven care staff files were missing valid first aid certification from a qualified agency.
Report Facts
Staff files missing valid first aid certification: 4
Resident records reviewed: 10
Staff records reviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allison Marty | Executive Director | Met with Licensing Program Analysts during inspection |
| Lourdes Bustamante | Administrator | Named as facility administrator in report |
| Angela Barutyan | Licensing Program Analyst | Conducted inspection and signed report |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report — Jun 13, 2025
Annual Inspection
Date: Jun 13, 2025
Visit Reason
Licensing Program Analyst Emily Peraldi conducted an unannounced required annual visit to the facility to evaluate compliance with licensing requirements.
Findings
The Licensing Program Analyst reviewed medication and medication documentation for eleven residents and observed that medications were properly documented and assisted with as prescribed. Medications were securely stored. The inspection was not completed due to time constraints and will be resumed at a later date.
Report Facts
Residents reviewed for medication documentation: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Peraldi | Licensing Program Analyst | Conducted the inspection and medication review |
| Jessica Saks | Wellness Director | Assisted with medication and medication documentation review |
| Allison Marty | Executive Director | Met with Licensing Program Analyst during inspection |
| Lourdes Bustamante | Administrator/Director | Facility Administrator/Director |
Inspection Report — Jun 13, 2025
Complaint Investigation
Date: Jun 13, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2025-06-10 alleging that facility staff did not properly assist a resident with self-administration of medications and that reporting requirements were not being met.
Complaint Details
The complaint was substantiated. Allegations included improper assistance with medication self-administration and failure to meet reporting requirements. The medication error involved giving half the prescribed dose of Escitalopram. The facility self-reported the error and conducted staff training. The failure to report medication refusal was also substantiated.
Findings
The investigation substantiated that staff did not properly assist Resident #1 with medication administration as prescribed, resulting in a medication error. Additionally, the facility failed to report a medication refusal to the resident's responsible person as required.
Citations (2)
Staff did not properly assist Resident #1 with self-administered medications as prescribed, posing an immediate health and safety risk.
Facility failed to report Resident #1's medication refusal to the responsible person, posing a potential health, safety, or personal rights risk.
Report Facts
Medication dosage error: 5
Medication prescribed dosage: 10
Plan of Correction due date: 1
Plan of Correction due date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Saks | Wellness Director | Interviewed regarding medication error and reporting failures |
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation |
| Allison Marty | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report — Feb 3, 2025
Complaint Investigation
Date: Feb 3, 2025
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff were not ensuring infection control practices and did not notify appropriate agencies of an outbreak.
Complaint Details
The complaint alleged failure to follow infection control practices and failure to notify appropriate agencies of an outbreak. The allegations were deemed unsubstantiated due to insufficient evidence despite some validity of the claims.
Findings
The investigation found that the facility implemented multiple infection control measures including closing common areas, using PPE, and notifying families. Incident reports and notifications to the public health department were timely. There was insufficient evidence to substantiate the allegations, and no deficiencies were cited.
Report Facts
Resident symptom reports: 15
Resident symptom onset: 7
Resident symptom onset: 8
Resident symptom reports: 3
Resident symptom reports: 6
Stool samples collected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joyce Aquino | Administrator | Facility administrator mentioned in the report header |
| Jessica Saks | Director of Nursing | Met with Licensing Program Analyst during investigation |
| Allison Marty | Executive Director | Met with Licensing Program Analyst during investigation |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report — Jan 3, 2025
Complaint Investigation
Date: Jan 3, 2025
Visit Reason
The visit was conducted as a case management incident investigation following a report of fraudulent activity by a staff member toward a resident involving unauthorized personal checks.
Complaint Details
The complaint involved fraudulent activity by Staff #1 toward Resident #1 involving two personal checks totaling $8,000. The staff member was suspended and terminated. The facility cross-reported to Adult Protective Services, the Long-Term Care Ombudsman, and Law Enforcement. Adult Protective Services conducted a visit. The resident confirmed the facility acted appropriately.
Findings
The facility responded quickly and effectively to the incident, suspending and terminating the staff member involved, cross-reporting to appropriate agencies, and safeguarding resident property. No monies were taken from the resident's account as the bank prevented the fraudulent checks from processing. No citations were issued.
Report Facts
Amount involved in fraudulent checks: 8000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allison Marty | Executive Director | Met with Licensing Program Analyst during the visit |
| Jessica Saks | Director of Nursing | Interviewed during initial visit related to investigation |
| Angela Barutyan | Licensing Program Analyst | Conducted the unannounced case management incident visit |
| Kristin Heffernan | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report — Nov 26, 2024
Complaint Investigation
Date: Nov 26, 2024
Visit Reason
The visit was an unannounced case management incident inspection triggered by a reported incident of fraudulent activity by a staff member toward a resident involving unauthorized personal checks.
Complaint Details
The complaint involved fraudulent activity by Staff #1 toward Resident #1, with two personal checks totaling $8,000 made out from the resident's account. Staff #1 was terminated and the facility reported the incident to Adult Protective Services, the Long-Term Care Ombudsman, and Law Enforcement.
Findings
The Licensing Program Analyst conducted interviews, a physical plant tour, and document reviews related to the incident. Further investigation was determined necessary before issuing a final licensing report.
Report Facts
Amount of fraudulent checks: 8000
Number of staff interviewed: 2
Number of residents interviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Saks | Director of Nursing | Met with during the inspection and interviewed regarding the incident |
| Angela Barutyan | Licensing Program Analyst | Conducted the unannounced case management incident visit |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report — Aug 6, 2024
Annual Inspection
Date: Aug 6, 2024
Visit Reason
The visit was an unannounced Case Management - Annual Continuation inspection to review compliance with licensing requirements.
Findings
The inspection included record reviews, medication reviews, staff interviews, and a physical plant tour. No deficiencies were cited, and all reviewed areas were found to be in compliance.
Report Facts
Staff files reviewed: 10
Medications reviewed: 5
Staff interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Saks | Director of Nursing | Met with LPAs during the inspection |
| Angel Ascencio | Director of Compliance | Met with LPAs during the inspection |
| Angela Barutyan | Licensing Program Analyst | Conducted the inspection |
| Trevor Byrne Barutyan | Licensing Program Analyst | Conducted the inspection |
| Kristin Heffernan | Licensing Program Manager | Named in the report |
Inspection Report — Jul 11, 2024
Annual Inspection
Date: Jul 11, 2024
Visit Reason
The inspection was an unannounced required annual visit to evaluate compliance with Title 22 Regulations and ensure health and safety standards at the facility.
Findings
The facility was found to be in compliance with regulations, with no citations issued. Observations included adequate facility layout, safety features, amenities, infection control practices, and emergency preparedness. Resident records reviewed were compliant, and staff and resident interviews were conducted.
Report Facts
Resident rooms toured: 30
Resident records reviewed: 10
Residents interviewed: 5
Water temperature range: 107.6
Water temperature range: 119.3
Fire extinguisher service date: Apr 9, 2024
Emergency disaster drill date: May 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Met with Licensing Program Analysts during inspection and participated in facility tour |
| Angel Ascencio | Director of Compliance | Participated in facility tour with Licensing Program Analysts |
| Jessica Saks | Director of Nursing | Participated in facility tour with Licensing Program Analysts |
| Mark Lagasca | Maintenance Technician | Participated in facility tour with Licensing Program Analysts |
| Angela Barutyan | Licensing Program Analyst | Conducted inspection and signed report |
| Kelly Dulek | Licensing Program Analyst | Conducted inspection |
| Trevor Byrne | Licensing Program Analyst | Conducted inspection |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report — Mar 8, 2024
Complaint Investigation
Date: Mar 8, 2024
Visit Reason
The visit was an unannounced Case Management Deficiency inspection conducted in conjunction with an initial 10-day complaint investigation to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.
Complaint Details
The visit was conducted as part of an initial 10-day complaint investigation (CC #29-AS-20240305121059). The deficiencies cited were not related to the original complaint but were observed during the investigation.
Findings
The facility failed to have personnel records for two staff members readily available for Licensing review, which is a violation of Title 22, California Code of Regulations, and poses a potential risk to residents in care. Citations were issued and a plan of correction was agreed upon.
Citations (1)
Personnel records for two staff members (S1, S2) were not readily available for Licensing review as required by CCR 87412(g)(1).
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Mar 15, 2024
Personnel files missing: 2
Total personnel files: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Met with Licensing Program Analyst during inspection and acknowledged issues with personnel files |
| Valeria Conway | Licensing Program Analyst | Conducted the unannounced Case Management Deficiency visit |
| Desaree Perera | Supervisor | Supervisor overseeing the inspection |
Inspection Report — Dec 27, 2023
Complaint Investigation
Date: Dec 27, 2023
Visit Reason
The visit was an unannounced Case Management – Incident inspection to follow up on a self-reported incident and suspected abuse involving a staff member reportedly pinching a resident to wake them up.
Complaint Details
The visit was triggered by a complaint of suspected abuse where Staff #1 was reported to have pinched Resident #1's nipples to wake them. The complaint was substantiated based on interviews, witness statements, and photographic evidence of bruising.
Findings
The investigation found that Staff #1 reportedly pinched Resident #1's nipples to awaken them, causing bilateral bruising consistent with pinching. Staff #1 was suspended pending investigation, and remaining staff were retrained on resident personal rights and proper care.
Citations (1)
Failure to ensure residents are free from punishment, humiliation, intimidation, abuse, or other actions interfering with daily living functions such as eating, sleeping, or elimination, evidenced by Staff #1 pinching Resident #1's nipples to awaken them.
Report Facts
Plan of Correction Due Date: Jan 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Met during inspection and involved in reporting the incident |
| Kelly Dulek | Licensing Program Analyst | Conducted the inspection |
| Kristin Heffernan | Supervisor | Supervisor overseeing the inspection |
Inspection Report — Dec 27, 2023
Follow-Up
Date: Dec 27, 2023
Visit Reason
The visit was an unannounced Case Management – Incident follow-up to a self-reported incident and suspected abuse involving a staff member reportedly pinching a resident to awaken them.
Findings
The investigation confirmed that Staff #1 pinched Resident #1's nipples to awaken them, causing bilateral bruising consistent with pinching. The facility cited a deficiency for violating personal rights by subjecting the resident to punishment and abuse.
Citations (1)
Based on interview, review of witness statements and bruising observed on Resident #1, Staff #1 reportedly pinched Resident #1's nipples to awaken them, posing an immediate health, safety, and personal rights risk.
Report Facts
Plan of Correction Due Date: Jan 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Met with Licensing Program Analyst during the visit and involved in incident reporting |
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced Case Management – Incident visit and authored the report |
| Kristin Heffernan | Licensing Program Manager | Supervisor named in the report |
Inspection Report — Oct 12, 2023
Follow-Up
Date: Oct 12, 2023
Visit Reason
The inspection was conducted as a follow-up on a self-reported incident from 10/11/2023, where the facility reported that the main water line had burst and the facility water was shut off.
Findings
The Licensing Program Analyst observed gallons of water throughout the facility and resident rooms, as well as catered food. The facility had a sufficient amount of bottled water for resident and staff use, and no immediate health and safety concerns were observed during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Saks | Director of Nursing | Met with the Licensing Program Analyst during the inspection and toured the facility. |
| Jim Biggs | Executive Director | Met with the Licensing Program Analyst during the inspection. |
Inspection Report — Oct 12, 2023
Date: Oct 12, 2023
Visit Reason
The inspection was an unannounced Case Management visit to follow up on a self-reported incident from 10/11/2023, where the facility reported that the main water line had burst and the facility water was shut off.
Findings
The Licensing Program Analyst observed gallons of water throughout the facility and resident rooms, as well as catered food. The facility had a sufficient amount of bottled water for resident and staff use. No immediate health and safety concerns were observed during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Saks | Director of Nursing | Met with the Licensing Program Analyst during the inspection and toured the facility. |
| Joyce Aquino | Administrator | Named as the facility administrator. |
| Jim Biggs | Executive Director | Met with the Licensing Program Analyst during the inspection. |
Inspection Report — Sep 28, 2023
Complaint Investigation
Date: Sep 28, 2023
Visit Reason
The visit was an unannounced Case Management - Incident inspection to address a self-reported Unusual Incident/Injury Report (LIC 624) concerning an incident on 2023-09-17 involving Resident #1 and two staff members.
Complaint Details
The visit was complaint-related, triggered by a self-reported Unusual Incident/Injury Report concerning alleged abuse by staff member S1 against Resident #1. The complaint was substantiated by staff interviews and observations.
Findings
The inspection found that staff member S1 was observed forcefully gripping and sitting Resident #1, causing redness/bruises on the resident's arm. This was determined to be a violation of personal rights regulations, posing an immediate risk to residents. A deficiency was cited accordingly.
Citations (1)
Failure to comply with CCR 87468.1(a)(3) Personal Rights of Residents to be free from punishment, humiliation, intimidation, abuse, or other actions interfering with daily living functions, evidenced by staff S1 forcefully gripping and sitting Resident #1.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Facility administrator interviewed during the visit |
| Esther Cortez | Licensing Program Analyst | Conducted the inspection visit |
| Kasandra Lopez | Supervisor | Supervisor overseeing the inspection |
Inspection Report — Sep 8, 2023
Complaint Investigation
Date: Sep 8, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff were not allowing a resident to leave the facility.
Complaint Details
The complaint alleged that staff were not allowing Resident #1 to leave the facility. The allegation was unsubstantiated after investigation, with no preponderance of evidence to prove the violation occurred.
Findings
The investigation found that Resident #1 was allowed to leave the facility unassisted per physician report, and staff did not restrict residents from leaving. Interviews and record reviews confirmed the resident had left the facility on multiple occasions. There was insufficient evidence to substantiate the allegation, and it was deemed unsubstantiated.
Report Facts
Complaint control number: 29-AS-20230901154555
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joyce Aquino | Administrator | Facility administrator interviewed during the investigation |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report — Aug 22, 2023
Complaint Investigation
Date: Aug 22, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff mishandled residents' medication and did not administer medication as prescribed.
Complaint Details
The complaint involved allegations that staff mishandled residents’ medication and did not administer medication as prescribed. The allegations were deemed unsubstantiated after investigation. The complaint did not provide names of residents or reporting parties, limiting interviews.
Findings
The investigation found the allegations to be unsubstantiated based on interviews and record reviews. A similar incident had been self-reported and resolved earlier in the year. No evidence supported the current allegations at the time of the investigation.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Met with Licensing Program Analyst during investigation and provided information |
| Sandra Urena | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Kasandra Lopez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report — Aug 9, 2023
Date: Aug 9, 2023
Visit Reason
An unannounced case management visit was conducted due to a fire incident in the facility kitchen on 08/08/2023.
Findings
The fire was localized to the kitchen area causing damage to ceiling panels and food, with water damage from sprinklers. There was no structural damage and kitchen equipment remained operational. The kitchen was closed pending clearance from the Department of Public Health. Residents were evacuated safely and provided meals from local restaurants during the kitchen shutdown.
Report Facts
Residents impacted by electricity disruption: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Director of Resident Care Services | Met with Licensing Program Analyst during the visit and provided information about the fire incident and facility response. |
| Christine Yee | Licensing Program Analyst | Conducted the unannounced case management visit and kitchen tour. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report — Jul 18, 2023
Annual Inspection
Date: Jul 18, 2023
Visit Reason
Licensing Program Analysts conducted an Annual Continuation inspection to evaluate compliance with state regulations following the initial annual inspection conducted on 06/12/2023.
Findings
The inspection found deficiencies related to medication management, including discrepancies in medication pill counts and unsecured medications, as well as food safety issues such as uncovered food items, expired food, unclean kitchen areas, and improper storage of cleaning substances and disinfectant wipes.
Citations (6)
3 out of 5 resident medication pill counts did not concur with documentation, posing an immediate health, safety, or personal rights risk.
Medications were accessible in an unlocked office, posing an immediate health, safety, or personal rights risk.
3 out of 5 centrally stored medication and destruction records were not up to date, posing a potential health, safety, or personal rights risk.
Pies, bread, and vegetables were not properly covered, posing a potential health, safety, or personal rights risk.
Disinfectant wipes were observed in the kitchen area, posing a potential health, safety, or personal rights risk.
Kitchen area was observed unclean and not sanitary, posing a potential health, safety, or personal rights risk.
Report Facts
Resident files reviewed: 10
Staff files reviewed: 10
Staff interviewed: 5
Residents medication reviewed: 5
Medication pill count discrepancies: 3
Medication administration errors: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Facility administrator named in medication audit and plan of correction |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection |
| Angel Ascencio | Licensing Program Analyst | Licensing evaluator conducting the inspection |
| Ashley Morgan | Licensing Program Analyst | Licensing evaluator conducting the inspection |
Inspection Report — Jul 7, 2023
Complaint Investigation
Date: Jul 7, 2023
Visit Reason
The visit was a Case Management - Incident investigation triggered by an incident reported on 07/05/2023 involving a Memory Care resident and staff members, concerning potential resident abuse.
Complaint Details
The visit was complaint-related, investigating an incident reported by the Director of Resident Care Services involving alleged abuse. The complaint was substantiated by written statements from staff confirming the incident.
Findings
The investigation found that staff member S1 waved a soiled adult brief in the resident's face, humiliating the resident, which violated the resident's personal rights. Staff members involved were temporarily suspended pending internal investigation. One citation was issued related to this deficiency.
Citations (1)
S1 humiliated Resident #1 by waving a soiled adult brief in the resident's face, violating personal rights.
Report Facts
Citation count: 1
Plan of Correction Due Date: Jul 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator / Director of Resident Care Services | Reported the incident and met with Licensing Program Analyst during the visit. |
| Angel Ascencio | Licensing Program Analyst | Conducted the Case Management - Incident visit and authored the report. |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the licensing evaluation. |
Inspection Report — Jun 12, 2023
Annual Inspection
Date: Jun 12, 2023
Visit Reason
The inspection was a required unannounced annual visit to evaluate the facility's compliance with Title 22 regulations.
Findings
The facility was toured inside and out, including resident rooms and common areas, with observations of compliance in most areas. However, deficiencies were cited related to water temperature exceeding safe limits in several resident rooms and accessible cleaning supplies posing a safety risk.
Citations (2)
Water temperature in 5 rooms in the Memory Care unit and 7 resident rooms in Buildings A, B, and C was observed to be between 121 - 130 degrees Fahrenheit, exceeding the maximum allowed temperature.
Windex and other cleaning supplies were accessible to persons in care, violating storage safety requirements.
Report Facts
Rooms with water temperature 121-130°F: 12
Resident water temperature measured low: 1
Vehicles for transportation: 3
Parking spots available: 275
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Director of Resident Care Services | Met with Licensing Program Analysts during inspection and involved in locking away hazardous items after deficiency cited |
| Ray Rosales | Maintenance Director | Participated in facility tour to ensure compliance |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection |
| Angel Ascencio | Licensing Program Analyst | Conducted the inspection and authored the report |
Inspection Report — Apr 25, 2023
Date: Apr 25, 2023
Visit Reason
An unannounced Case Management visit was conducted to discuss COVID-19 policies and procedures, review infection control areas of concern, and assist with outbreak line list for March/April.
Findings
Two residents were observed in isolation due to COVID-19, with no staff testing positive. The facility's COVID-19 policies and procedures were reviewed, and no citations were issued during the visit.
Report Facts
Residents in isolation: 2
COVID positive residents: 2
Isolation end date: Apr 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Met with Licensing Program Analyst and participated in the visit |
| Angel Ascencio | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Chelsea De Lara | Public Health Nurse | Participated in the meeting regarding COVID-19 policies |
| Camellia Babaie | Physician Specialist | Participated in the meeting regarding COVID-19 policies |
| Jessica Saks | Variel Representative participating in the meeting |
Inspection Report — Sep 12, 2022
Complaint Investigation
Date: Sep 12, 2022
Visit Reason
The inspection was an unannounced Case Management-Deficiencies visit conducted due to deficiencies observed during the investigation of complaint control #29-AS-20220826125755.
Complaint Details
The visit was triggered by complaint control #29-AS-20220826125755. The complaint involved concerns about Resident #2's care needs not being communicated or discovered until admission. The complaint was substantiated as deficiencies were cited.
Findings
The facility did not accurately reflect Resident #2's extensive care needs in the medical assessment and care plan, which poses a potential health and safety risk. Specifically, R2 requires more assistance than documented, and there were inconsistencies regarding R2's ability to feed themselves.
Citations (2)
The pre-admission appraisal was not updated as frequently as necessary to note significant changes and keep the appraisal accurate, resulting in R2's care needs not being accurately reflected.
The licensee did not obtain an updated medical assessment reflecting R2's capacity for activities of daily living care.
Report Facts
Plan of Correction Due Date: Sep 16, 2022
Plan of Correction Due Date: Sep 23, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and authored the report |
| Keith Payne | Administrator | Facility administrator involved in the inspection and agreed to corrective actions |
| Jeralyn Ann Pfannenstiel | Supervisor | Supervisor overseeing the inspection |
Inspection Report — Jun 29, 2022
Original Licensing
Date: Jun 29, 2022
Visit Reason
This is a pre-licensing visit for a new facility, Variel of Woodland Hills, to evaluate compliance and readiness for licensing including a dementia program and hospice waiver.
Findings
The facility was found to be in compliance with Title 22 regulations at the time of the visit. The physical plant, safety systems, amenities, infection control measures, and medication storage were all observed to meet regulatory requirements.
Report Facts
Maximum bedridden residents: 20
Units: 336
Water temperature range: 106-114
Parking spots: 275
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Payne | Executive Director | Met with Licensing Program Analysts during pre-licensing visit |
| Elsie Campos | Licensing Program Analyst | Conducted the pre-licensing visit and signed the report |
| Ashley Smith | Licensing Program Analyst | Participated in the pre-licensing visit |
| Emily Peraldi | Licensing Program Analyst | Participated in the pre-licensing visit |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report — Feb 17, 2022
Original Licensing
Date: Feb 17, 2022
Visit Reason
Initial licensing evaluation conducted via telephone call with the Community Care Licensing analyst to verify applicant and administrator understanding of Title 22 and facility operation requirements.
Findings
The applicant and administrator successfully completed the COMP II component, confirming understanding of licensing requirements including staff qualifications, training, medication management, and grievance procedures. No clients were in care at the time of the evaluation.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Payne | Administrator | Named as applicant and administrator participating in COMP II |
| Shannon Betker | Licensing Evaluator | Analyst conducting the COMP II evaluation |
| Jude De La Concepcion | Supervisor | Supervisor named in the report |
Report — July 15, 2026
July 15, 2026
Report — July 15, 2026
July 15, 2026
Report — June 3, 2026
June 3, 2026
Viewing
Loading inspection reports...



