Inspection Reports for
Cloisters of the Valley, LLC

The complaint was substantiated. Staff failed to provide a written incident report within seven days and did not dispense medications as prescribed, including administering a discontinued medication and incorrect administration of PRN medication.

The investigation substantiated both allegations based on interviews and record reviews. Staff failed to provide a timely written incident report and administered a discontinued medication as well as incorrectly administered an as-needed pain medication.

The complaint was substantiated. The allegation involved neglect resulting in delayed medical care to Resident 1. Evidence showed no medical care was provided from January 26 to January 29, 2025, leading to hospitalization. An immediate civil penalty of $500 was charged.

The investigation substantiated the allegation that medical care was delayed for one resident with symptoms of illness, resulting in hospitalization for Influenza A and acute hypoxic respiratory failure. The facility failed to communicate and provide appropriate medical care between January 26 and January 29, 2025.

The complaint alleged medications were not given as prescribed due to a lost key and jammed lock on the medication cart, resulting in multiple residents missing medications for two days. The allegation was substantiated.

The investigation found that the medication cart lock was jammed, preventing medication administration for 27 residents on 12/04/25 and 12/05/25, posing an immediate health and safety risk. The allegation was substantiated based on interviews and record review.

The visit was complaint-related and substantiated by the observation of an unlocked medication room accessible to residents.

A violation was observed where the medication room was unlocked and accessible to residents, posing an immediate health and safety risk. A deficiency was cited for failure to keep centrally stored medicines locked and inaccessible to unauthorized persons.

The complaint alleged staff neglect causing a resident to sustain a fracture. The allegation was substantiated based on interviews and record reviews. Other allegations about food service, incontinence care, grooming, mobility, and activity participation were investigated and found unsubstantiated.

The investigation substantiated that staff neglect caused resident R1 to sustain a fracture due to being left unsupervised on the toilet. Other allegations regarding inadequate food service, incontinence care, grooming, mobility assistance, and participation in activities were unsubstantiated.

The complaint alleged staff did not issue a refund to a resident's responsible party. The allegation was substantiated based on interviews and record review. The responsible party was not the Power of Attorney, and the facility initially did not refund them. The facility changed its policy in August 2025 to refund responsible parties even if not the POA.

The investigation substantiated the allegation that the facility did not refund the responsible party of Resident #1 despite the resident's belongings being removed. The facility policy was changed in August 2025 to refund responsible parties even if they are not the Power of Attorney. The refund check was approved and awaiting signatures at the time of the visit.

The complaint investigation was substantiated for the allegation that staff did not ensure the facility had hot water. Other allegations including physical and verbal abuse, failure to follow physician instructions, privacy violations, safeguarding personal belongings, and billing for services not provided were unsubstantiated.

The investigation substantiated the allegation that the facility lacked hot water for multiple consecutive days, affecting all 68 residents. Other allegations including abuse, privacy violations, and improper billing were unsubstantiated based on interviews and record reviews.

The complaint investigation was substantiated regarding staff failure to address slipping hazards leading to a resident fall and fracture, and failure to seek timely medical care despite ongoing pain complaints. The allegation about failure to maintain a comfortable temperature was unsubstantiated.

The investigation substantiated that staff negligence in addressing the slipping hazard caused a resident's fall and fracture. It was also substantiated that staff delayed seeking timely medical care despite ongoing pain complaints. Another complaint regarding facility temperature was unsubstantiated.

The Assisted Living Waiver Addendum to the Residency Agreement was not signed by Resident 1 or the Responsible Party, violating California Code of Regulations, Title 22.

The complaint alleged that staff did not notify the responsible party of a resident's change in care. The allegation was substantiated after investigation. A secondary complaint regarding the resident’s payment obligation was not within the jurisdiction and was not investigated further.

The investigation confirmed that staff transferred Resident 1 from a private room to a shared room without providing the required 30-day written notice to the resident's representative, violating the resident's personal rights. The allegation was substantiated based on interviews, record reviews, and facility visits.

The complaint was substantiated. The incident involved misappropriation of resident property by staff, resulting in a deficiency citation and a jointly developed Plan of Correction.

The investigation found that a staff member used a resident's automobile beyond the scope of consent, causing temporary loss of control of property and distress to the resident. One deficiency was cited related to protection of resident property.

The visit was triggered by a complaint incident report about two residents eloping from the facility. The complaint was substantiated with findings of staff incompetence and failure to observe residents properly.

The investigation found that staff were not trained to competently respond to the gate alarm, resulting in a delayed recognition that two residents had exited the premises. One resident suffered serious bodily injury and the other non-serious injury during the elopement.

The complaint investigation was substantiated for the allegation that the licensee did not treat a resident with dignity. The allegation of illegal eviction was unsubstantiated based on interviews and records.

The allegation that the licensee did not treat a resident with dignity was substantiated based on interviews and records. The allegation of unlawful eviction was unsubstantiated after investigation and records review.

The complaint was substantiated. The investigation confirmed that staff did not provide the required observation for Resident #1, leading to the resident leaving the facility unsupervised. Staff actions included termination and discipline following the incident.

The investigation found that staff failed to provide the required visual observation of Resident #1 as specified in their Care Plan, resulting in the resident leaving the facility unsupervised. The licensee terminated one staff member and disciplined another, and a deficiency was cited for failure to ensure regular resident observation.

The complaint investigation was substantiated regarding medication administration errors and lack of dignity in resident care. The allegation that staff did not follow a resident's dietary order was unsubstantiated.

The investigation substantiated that the licensee did not assist four residents with self-administered medications as needed, resulting in missed doses and potential health risks. Additionally, staff member S1 did not treat Resident #1 with dignity, as evidenced by multiple staff and resident interviews. A separate allegation regarding failure to follow a resident's dietary order was unsubstantiated.

The complaint investigation was substantiated for allegations that the licensee did not provide personal care to Resident #1 and restricted visitation rights beyond authorized COVID-19 waivers. The allegation that the licensee failed to report a resident's change in condition and did not provide required activities to residents with dementia was unsubstantiated.

The investigation substantiated that the licensee failed to provide adequate personal care to Resident #1 (R1) and restricted residents' visitation rights beyond what was authorized by COVID-19 waivers. Another complaint regarding failure to report a resident's change in condition and inadequate activities for residents with dementia was unsubstantiated.

The visit found that one staff member (S1) was hired and worked without the required criminal record clearance, posing an immediate health and safety risk. A civil penalty of $500 was issued for this violation.

The complaint investigation was substantiated. Allegations included unlawful eviction and failure to administer medications as prescribed. Evidence showed the resident was verbally told to move due to cessation of financial assistance and medication was not administered for about two months.

The investigation substantiated the allegations that the facility pursued an unlawful eviction by increasing the monthly rate after cessation of financial assistance and failed to administer prescribed medication to a resident for approximately two months.

The complaint was substantiated. The allegation was that the licensee listed an incorrect license number on their public website, which was confirmed by the Licensing Program Analyst during the investigation.

The investigation substantiated that the facility's website incorrectly displayed the license number as #372604267 instead of the correct 374604267. This violated California Code of Regulations, Title 22, Section 87206(a), requiring license numbers to be revealed in all public advertisements including the Internet.