Inspection Reports for
Aa Best Care Homes
857 HEARN AVE., SANTA ROSA, CA, 95407
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
60% occupied
Based on a February 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 24
Capacity: 40
Deficiencies: 0
Date: Feb 27, 2026
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff wrongfully evicted a resident.
Complaint Details
The complaint alleged that staff wrongfully evicted a resident. The investigation included interviews, record reviews, and police report verification. The allegation was unsubstantiated as there was no preponderance of evidence to prove the violation occurred.
Findings
The investigation found conflicting information regarding the resident's discharge and return to the facility. There was no written eviction letter, and the resident was briefly refused reentry but later allowed back. The allegation was determined to be unsubstantiated due to insufficient evidence.
Report Facts
Facility Capacity: 40
Resident Census: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marisol Cuadra | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Charito Santos | Administrative Assistant | Met with the investigator and involved in the investigation |
| Bethany Moellers | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Census: 24
Capacity: 40
Deficiencies: 0
Date: Dec 8, 2025
Visit Reason
The visit was an unannounced case management follow-up to an informal meeting held on 2025-10-29 addressing concerns about the facility's operation and management, specifically regarding the submission of a change of ownership application.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst provided guidance to the Co-Licensee on submitting the change of ownership application to the Centralized Application Bureau.
Inspection Report
Capacity: 40
Deficiencies: 0
Date: Oct 29, 2025
Visit Reason
An informal meeting was conducted at the Santa Rosa Regional Office as requested by the Co-Licensees to discuss further management options for this facility and another facility they operate.
Findings
No deficiencies were cited during the office meeting. The Co-Licensees agreed to submit a change of ownership application to the Department Centralized Application Bureau.
Inspection Report
Complaint Investigation
Census: 23
Capacity: 40
Deficiencies: 0
Date: Oct 24, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the facility had not provided a due refund as required.
Complaint Details
The complaint alleged the facility failed to provide a due refund to a resident who moved out on June 9, 2025. The investigation confirmed the refund was mailed on October 22, 2025, and the allegation was unsubstantiated.
Findings
The investigation found that the facility had mailed the requested refund check of $1420.07 to the resident prior to the visit. The allegation that the facility did not provide the refund was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Refund amount: 1420.07
Capacity: 40
Census: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marisol Cuadra | Licensing Program Analyst | Conducted the complaint investigation |
| Nicanor Aquino | Licensee | Facility licensee involved in investigation |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 40
Deficiencies: 1
Date: Sep 18, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff yelled at a resident in care.
Complaint Details
The complaint was substantiated. The allegation involved staff yelling at a resident without reason, confirmed by interviews and observations. Previous similar complaint was unsubstantiated. The Department will review for further action.
Findings
The allegation was substantiated based on interviews and observations that staff member S1 raised their voice at residents, causing distress. S1 admitted to not wearing hearing aids which contributed to speaking loudly. The facility was cited for failing to accord dignity to residents.
Deficiencies (1)
HSC 1569.269(a)(1) requires residents to be accorded dignity in personal relationships. Facility staff (S1) yelled at residents causing them to withdraw and become distressed, posing an immediate risk to client health and safety.
Report Facts
Capacity: 40
Census: 31
Deficiencies cited: 1
Plan of Correction Due Date: Sep 19, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicanor Aquino | Administrator | Met during investigation |
| Marisol Cuadra | Licensing Program Analyst | Conducted complaint investigation |
| Bethany Moellers | Supervisor | Supervisor overseeing investigation |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 40
Deficiencies: 0
Date: Sep 18, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff did not seek timely medical care for a resident with scabies.
Complaint Details
The complaint alleged that staff did not seek timely medical care for a resident with scabies. The allegation was unsubstantiated as the resident did not alert staff to symptoms and staff were not aware of the diagnosis until after the resident was hospitalized.
Findings
The investigation found no evidence that facility staff were aware of the resident's scabies diagnosis in time to seek medical assistance sooner. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility Capacity: 40
Resident Census: 31
Inspection Report
Annual Inspection
Census: 21
Capacity: 40
Deficiencies: 6
Date: Jul 24, 2025
Visit Reason
The inspection was a required unannounced annual inspection to assess compliance with licensing regulations and facility standards.
Findings
The facility had multiple maintenance and safety issues including exposed electrical cables, mold, and insect presence. Water temperature exceeded allowable limits. Staff files lacked current CPR and First Aid certifications, and resident care plans were not updated. The facility had outstanding annual fees and had not conducted emergency drills in the past quarter.
Deficiencies (6)
CCR 87303(a) Maintenance and Operation: Electrical face plates in the dining room exposed cables, ceiling holes exposed cables, mold was present in bathroom ceilings and mirrors, walls and floors needed repair or painting, debris was found in the backyard, insects were inside resident bedrooms, and window screens needed repair or replacement.
CCR 87303(e)(2) Maintenance and Operation: Hot water temperature in resident bathrooms measured at 121.8 and 121.6 degrees F, exceeding the allowable range of 105-120 degrees F.
HSC 1569.618(c)(3) Other Provisions: Staff members (S1, S2, S3 & S4) did not have current First Aid or CPR certification on file.
CCR 87463(a) Reappraisals: Nine out of nine residents did not have current appraisal/needs and services plans on file.
HSC 1569.695(a)(2) Other Provisions: The facility had not conducted fire and emergency drills within the last quarter, with the last drill in July 2024.
HSC 87156(b)(1)(F) Licensing Fees: The licensee had not paid the annual licensing fee, with outstanding fees totaling $1,238 as of the inspection date.
Report Facts
Outstanding annual fees: 1238
Hot water temperature: 121.8
Hot water temperature: 121.6
Census: 21
Total capacity: 40
Inspection Report
Complaint Investigation
Census: 20
Capacity: 40
Deficiencies: 0
Date: Jun 13, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff was financially abusing a client while in care.
Complaint Details
The complaint alleged staff financially abused a client by convincing them to give money to repay possibly non-existent debts. Interviews and records review showed the staff member was not forcing payments and the resident gave small amounts voluntarily. The allegation was unsubstantiated.
Findings
The investigation found that although the resident believed they owed money and was giving money to a staff member, there was no preponderance of evidence to prove financial abuse occurred. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 40
Census: 20
Inspection Report
Census: 24
Capacity: 40
Deficiencies: 0
Date: May 19, 2025
Visit Reason
The visit was an unannounced case management investigation to follow up on an informal meeting held on 2025-04-04 regarding concerns about facility operation, medication management, and ongoing bed bug issues.
Findings
No deficiencies were cited during the visit. The Co-Licensee had not submitted a required corporate structure change application but provided documentation of bed bug clearance from an exterminator. Medication management incidents were previously addressed under a prior complaint.
Inspection Report
Census: 24
Capacity: 40
Deficiencies: 0
Date: Apr 18, 2025
Visit Reason
The visit was an unannounced case management investigation to follow up on a self-reported death involving a resident who was not receiving hospice services at the time of passing.
Findings
The investigation found no deficiencies or unusual circumstances leading to the resident's unexpected death. The facility reported a probable heart attack as the cause, and the licensing analyst requested the death certificate for further review.
Inspection Report
Complaint Investigation
Census: 24
Capacity: 40
Deficiencies: 1
Date: Apr 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an anonymous allegation that facility staff were not keeping residents free from infestation of bugs.
Complaint Details
The complaint was substantiated based on evidence including observations of bug infestation, smeared blood, and resident bites. The licensee agreed to contract a pest control vendor to treat all resident rooms. An immediate civil penalty of $250 was issued for repeated violation within the last 12 months.
Findings
The investigation substantiated the complaint, finding that a resident had a bug infestation posing an immediate health and safety risk. The facility failed to ensure safe, healthful, and comfortable accommodations as required by regulation.
Deficiencies (1)
HSC 1569.269(a)(5) Residents of RCFE must be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. The facility failed to meet this requirement as a resident had a bug infestation posing an immediate health and safety risk.
Report Facts
Capacity: 40
Census: 24
Civil penalty amount: 250
Plan of Correction Due Date: Due date is 04/11/2025 as stated in the report
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marisol Cuadra | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Bethany Moellers | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 40
Deficiencies: 1
Date: Apr 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that facility staff were not providing medication as prescribed to a client.
Complaint Details
The complaint was substantiated. The allegation that facility staff were not providing medication as prescribed was confirmed based on records review, interviews, and pharmacy confirmation. The resident had refused psychiatric visits, resulting in medications not being filled.
Findings
The investigation substantiated that a resident (R1) had not received prescribed psychiatric medications since December 17, 2024, due to the previous psychiatrist retiring and the resident refusing to see a new psychiatrist. This posed an immediate risk to the health and safety of residents in care.
Deficiencies (1)
CCR 87465(c)(2) requires medication to be given according to physician's directions. This was not met as R1 had not been assisted with psychiatric medications since 12/17/24, posing an immediate health and safety risk.
Report Facts
Capacity: 40
Census: 24
Inspection Report
Complaint Investigation
Census: 24
Capacity: 40
Deficiencies: 0
Date: Apr 10, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff did not provide adequate supervision resulting in a resident wandering away and that staff were not safeguarding residents' monies.
Complaint Details
The complaint investigation was triggered by allegations received on 03/03/2025. The allegations included inadequate supervision leading to a resident wandering away and failure to safeguard residents' monies. Both allegations were unsubstantiated after investigation.
Findings
Both allegations were found to be unsubstantiated due to lack of preponderance of evidence. The resident wandering away was confirmed but attributed to cognitive decline with no evidence of elder abuse. The allegation regarding safeguarding of monies could not be determined due to unclear circumstances around a cashed check.
Report Facts
Capacity: 40
Census: 24
Check amount: 450
Inspection Report
Census: 40
Capacity: 40
Deficiencies: 0
Date: Apr 4, 2025
Visit Reason
The informal meeting was conducted to address concerns regarding further operation and management of this facility and the Licensee's other facility, including medication management, hospice care responsibilities, and recurrent bed bugs issues.
Findings
No deficiencies were cited during the office meeting. The co-licensees were informed about submitting a change in corporate structure application and addressing ongoing bed bug issues by May 4, 2025.
Inspection Report
Follow-Up
Census: 24
Capacity: 40
Deficiencies: 0
Date: Mar 11, 2025
Visit Reason
The visit was an unannounced subsequent case management follow-up to continue review of a death certificate related to a resident who passed away unexpectedly on 2025-02-01.
Findings
No deficiencies were cited during the visit. The Department will review the information obtained to determine if further actions are needed.
Inspection Report
Follow-Up
Census: 24
Capacity: 40
Deficiencies: 1
Date: Feb 13, 2025
Visit Reason
Unannounced case management visit to follow up on Administrator certification and deficiencies related to certification renewal compliance.
Findings
The licensee failed to maintain a qualified and currently certified administrator as required. The certification unit withdrew the application due to lack of follow-up and communication, resulting in a citation and a civil penalty of $250.
Deficiencies (1)
CCR 87405(a) requires all facilities to have a qualified and currently certified administrator. The licensee failed to comply by not maintaining a certified administrator and failing to follow up with the Department Certification Unit.
Report Facts
Civil penalty amount: 250
Inspection Report
Complaint Investigation
Census: 24
Capacity: 40
Deficiencies: 1
Date: Feb 13, 2025
Visit Reason
An unannounced complaint investigation was conducted following an allegation that staff did not keep residents free from bed bugs.
Complaint Details
The complaint was substantiated. The allegation that staff did not keep residents free from bed bugs was confirmed based on records and interviews. An immediate civil penalty of $250 was issued for repeated violation within the last 12 months.
Findings
The investigation substantiated the allegation that the facility failed to maintain safe, healthful, and comfortable accommodations, resulting in a resident having a bed bug infestation. The facility had not treated resident rooms regularly, with the last treatment recorded in May 2024.
Deficiencies (1)
CCR 1569.269(a)(5) was cited for failure to ensure residents were accorded safe, healthful, and comfortable accommodations. A resident had a bed bug infestation posing an immediate health and safety risk.
Report Facts
Civil penalty amount: 250
Capacity: 40
Census: 24
Inspection Report
Complaint Investigation
Census: 24
Capacity: 40
Deficiencies: 0
Date: Feb 4, 2025
Visit Reason
The visit was an unannounced Case Management investigation triggered by an incident report concerning a resident who was found with a wound and subsequently hospitalized and passed away.
Complaint Details
The investigation concerned an incident where resident R1 was found with a wound on their ankle, was hospitalized due to inability to walk or put pressure on their leg, and later passed away. The facility reported the incident and all required parties were notified. The resident's responsible party indicated a lung issue as probable cause of death. The facility was asked to provide the death certificate once received.
Findings
The Licensing Program Analyst conducted interviews and document reviews related to the incident. No deficiencies were cited during this visit.
Report Facts
Census: 24
Total Capacity: 40
Inspection Report
Census: 23
Capacity: 40
Deficiencies: 1
Date: Dec 6, 2024
Visit Reason
The visit was an unannounced case management follow-up to address issues regarding the Administrator certification at the facility.
Findings
The licensee did not have a currently certified administrator, which poses an immediate health, safety, or personal rights risk to persons in care. The certification unit withdrew the application due to failure to comply with renewal requirements and lack of communication.
Deficiencies (1)
CCR 87405(a) requires all facilities to have a qualified and currently certified administrator. The licensee did not have a certified administrator, posing an immediate health, safety, or personal rights risk to persons in care.
Report Facts
Capacity: 40
Census: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicanor Aquino | Licensee/Administrator | Named in deficiency for not having a certified administrator |
Inspection Report
Census: 25
Capacity: 40
Deficiencies: 0
Date: Aug 29, 2024
Visit Reason
The Licensing Program Analyst conducted an unannounced case management visit to follow up on Administrator certification issues and documentation submission for the facility.
Findings
No deficiencies were cited during the visit. The facility had previously been cited for not providing supporting evidence of required documentation submission, and the Department is reviewing information to determine further actions.
Inspection Report
Complaint Investigation
Census: 25
Capacity: 40
Deficiencies: 1
Date: Aug 29, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that staff did not meet a resident's hygiene and grooming needs and did not provide adequate laundry services.
Complaint Details
The complaint investigation was substantiated for failure to meet hygiene and grooming needs, with supporting evidence including written statements and photographs. The laundry services allegation was unsubstantiated due to insufficient evidence.
Findings
The allegation that staff failed to meet the resident's hygiene and grooming needs was substantiated, with evidence showing the resident arrived at another facility with extreme matted and lice-infested hair. The allegation regarding inadequate laundry services was unsubstantiated due to lack of evidence.
Deficiencies (1)
HSC 1569.269(a)(5): The facility did not ensure the resident was accorded safe, healthful, and comfortable accommodations, resulting in extreme matted and lice-infested hair posing an immediate health and safety risk.
Report Facts
Capacity: 40
Census: 25
Immediate Civil Penalty: 250
Inspection Report
Annual Inspection
Census: 26
Capacity: 40
Deficiencies: 4
Date: Jul 23, 2024
Visit Reason
The inspection was an unannounced required annual inspection to evaluate compliance with licensing regulations and facility operations.
Findings
The facility had several technical violations including missing chairs in resident rooms, water temperatures exceeding allowable limits, and maintenance issues such as paint bubbles and missing window screens. Staff training requirements were not met, and the administrator's certification had expired. An incident involving two residents was also reviewed.
Deficiencies (4)
CCR 87303(a) Maintenance and Operation: Bathroom #2 windowsill has paint bubbles needing cleaning; bathroom #1 sink needs cleaning; window screens missing in rooms 10, 11, 13, and 17; face plate in room #10 needs replacement posing immediate risk.
CCR 87405(d) Administrator Qualifications and Duties: Licensee did not obtain a valid administrator certification after informal meeting on 6/28/23, posing immediate risk to persons in care.
HSC 1569.625(b)(2) Other Provisions: Four out of four staff have not completed required additional 20 hours annual training, posing potential health and safety risk.
HSC 1569.695(c) Other Provisions: Facility did not conduct emergency disaster drills at least quarterly for each shift, posing potential health and safety risk.
Report Facts
Resident files reviewed: 5
Staff files reviewed: 4
Water temperature readings: 124.3
Water temperature readings: 126.7
Water temperature readings: 106.1
Water temperature readings: 126.3
Administrator certificate expiration date: Oct 7, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicanor Aquino | Licensee/Administrator | Named in relation to expired administrator certification and licensee duties |
| Marisol Cuadra | Licensing Evaluator | Conducted the inspection and authored the report |
| Bethany Moellers | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Monitoring
Census: 28
Capacity: 40
Deficiencies: 0
Date: Jun 6, 2024
Visit Reason
The visit was an unannounced case management inspection to follow up on three self-incident reports filed by the facility regarding resident behavioral and health incidents.
Findings
The facility reported incidents involving two residents with suicidal thoughts and substance abuse issues. The facility took appropriate measures including hospital transports, notifying responsible parties, issuing eviction notices, and ensuring close monitoring and supervision of affected residents. No deficiencies were cited during the visit.
Report Facts
Eviction notice duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angelita Aquino | Licensee | Met with Licensing Program Analyst during inspection and involved in incident follow-up. |
| Charito Santos | Administrative Assistant | Provided information about eviction letters and resident incidents during inspection. |
| Marisol Cuadra | Licensing Evaluator | Conducted the inspection visit and signed the report. |
| Bethany Moellers | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 40
Deficiencies: 1
Date: May 21, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that the facility was not meeting residents' care needs, including reports of residents being unclean and infested with bed bugs and lice.
Complaint Details
The complaint investigation was substantiated. Allegations included residents being unclean, with black dirty fingernails, open wounds from bug bites, and infestations of bed bugs, mites, and lice. Multiple agency reports and a police welfare visit confirmed these issues. The facility had not treated affected rooms timely, posing health and safety risks.
Findings
The investigation substantiated the allegations that residents were not accorded safe, healthful, and comfortable accommodations, resulting in injuries and health risks due to bed bug infestations and inadequate treatment of residents' rooms. The facility had not treated some rooms since October and September 2023, despite internal logs indicating regular treatments.
Deficiencies (1)
CCR 1569.269(a)(5) Residents of RCFE shall be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. The facility failed to ensure this, resulting in injuries and immediate health and safety risks to residents R1 and R2.
Report Facts
Capacity: 40
Census: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marisol Cuadra | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Bethany Moellers | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 26
Capacity: 40
Deficiencies: 0
Date: Mar 7, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-01-11 regarding staff mistreatment of residents and facility disrepair.
Complaint Details
The complaint investigation addressed three allegations: a staff member slapped a resident, a staff member yelled at a resident, and the facility was in disrepair. After interviews, records review, and facility tour, all allegations were determined unsubstantiated due to insufficient evidence.
Findings
All allegations including staff slapping a resident, staff yelling at a resident, and facility disrepair were found to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited during the inspection.
Report Facts
Facility Capacity: 40
Resident Census: 26
Inspection Report
Complaint Investigation
Census: 26
Capacity: 40
Deficiencies: 0
Date: Mar 7, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 2023-12-21 regarding staff treatment of residents, facility cleanliness, bed linen hygiene, personal rights, and medication administration.
Complaint Details
The complaint investigation addressed allegations including staff failing to treat residents with dignity and privacy, facility not being clean or sanitary, staff not ensuring clean bed linens, personal rights violations, and medications not being given per doctor's orders. All allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Findings
All complaint allegations were found to be unsubstantiated after investigation, interviews, observations, and record reviews. No evidence was found to support violations related to dignity and privacy, facility cleanliness, bed linen care, personal rights, or medication administration.
Report Facts
Capacity: 40
Census: 26
Medications checked: 5
Medications prescribed: 10
Medications given: 6
Inspection Report
Complaint Investigation
Census: 25
Capacity: 40
Deficiencies: 0
Date: Feb 27, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation received on 2023-12-14 regarding residents smoking inside the facility.
Complaint Details
The complaint alleged residents were smoking inside the facility and near entrances causing smoke to enter resident rooms. The allegation was unsubstantiated after interviews and records review.
Findings
The investigation found no clear evidence that residents were smoking inside the facility or violating smoking policies. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility Capacity: 40
Resident Census: 25
Inspection Report
Census: 28
Capacity: 40
Deficiencies: 0
Date: Feb 8, 2024
Visit Reason
The visit was an unannounced case management follow-up to review a prior incident report (SOC341) and self-incident reports related to a resident making threats to staff and the facility.
Findings
No deficiencies were found during the visit. The facility is in the process of issuing a 30-day eviction notice to the resident who made threats. The Department will review documents received.
Report Facts
Case report number: 240360217
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicanor Aquino | Administrator | Facility administrator named in report header |
| Marisol Cuadra | Licensing Program Analyst | Conducted the case management visit |
| Charito Santos | Administrative Assistant | Met with Licensing Program Analyst during visit |
| Bethany Moellers | Supervisor | Supervisor named in report |
Inspection Report
Monitoring
Census: 28
Capacity: 40
Deficiencies: 1
Date: Dec 8, 2023
Visit Reason
The visit was an unannounced case management health check to ensure the facility is clean, safe, and in good repair.
Findings
The inspection found that the facility was generally clean and residents were engaged in activities. However, one resident's bedroom door was missing due to maintenance issues, posing an immediate health, safety, or personal rights risk.
Deficiencies (1)
CCR 87303(a): The facility was not clean, safe, sanitary, and in good repair as one resident's bedroom door was missing, posing an immediate health, safety, or personal rights risk.
Report Facts
Civil penalty amount: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicanor Aquino | Administrator | Named as facility administrator. |
| Marisol Cuadra | Licensing Evaluator | Conducted the inspection. |
| Charito Santos | Administrative Assistant | Met with Licensing Program Analyst during inspection. |
| Bethany Moellers | Supervisor | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 40
Deficiencies: 0
Date: Oct 27, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2023-10-16 regarding medical attention, staff behavior, theft of personal documents, unlawful eviction, and meal quality at the facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to provide medical attention, staff yelling at residents, theft of personal documents, unlawful eviction, and failure to offer nutritious meals. The investigation found no evidence to support these claims.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Medical attention was provided as required, staff did not yell at residents, no theft of personal documents was found, eviction procedures were within regulation, and nutritious meals were offered properly.
Report Facts
Capacity: 40
Census: 29
Inspection Report
Complaint Investigation
Census: 29
Capacity: 40
Deficiencies: 0
Date: Oct 27, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2023-10-09 regarding personal rights violations, record maintenance, pest control, water temperature, and medication administration.
Complaint Details
The complaint investigation was unsubstantiated based on records review, interviews, and observations. Allegations included personal rights violations, failure to maintain records, pest presence, improper water temperature, and medication errors. No evidence was found to prove these violations.
Findings
The investigation found no evidence to support the allegations. The facility was found to have no pest issues at the time, water temperatures were within regulation, medication was administered as prescribed, and resident rights were respected. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 40
Census: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Charito Santos | Administrative Assistant | Met with Licensing Program Analyst during investigation |
| Bethany Moellers | Supervisor | Supervisor overseeing the investigation |
| Nicanor Aquino | Administrator | Facility administrator named in report header |
Inspection Report
Census: 31
Capacity: 40
Deficiencies: 0
Date: Sep 14, 2023
Visit Reason
The visit was an unannounced case management follow-up on a self-incident report filed by the facility Administrator regarding a resident's hospital admission for COPD exacerbation and shortness of breath.
Findings
The Licensing Program Analysts reviewed the resident's records and discharge documents and determined that the Administrator took appropriate measures to address the incident. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicanor Aquino | Administrator | Facility Administrator involved in the incident report and case management follow-up |
Inspection Report
Plan of Correction
Census: 30
Capacity: 40
Deficiencies: 0
Date: Aug 25, 2023
Visit Reason
The visit was an unannounced plan of correction inspection to follow up on deficiencies cited during the July 20, 2023 Annual Required inspection and to review a self-incident report filed by the facility administrator.
Findings
All previously cited deficiencies have been corrected. No deficiencies were cited during this inspection. The self-incident report involved a resident who sustained a nasal bone fracture after a fall, with no follow-up appointment required.
Report Facts
Deficiencies corrected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angelita Aquino | Licensee | Met with Licensing Program Analyst during plan of correction visit |
Inspection Report
Annual Inspection
Census: 30
Capacity: 40
Deficiencies: 4
Date: Jul 20, 2023
Visit Reason
The inspection was an unannounced annual required inspection to evaluate compliance with licensing regulations.
Findings
The facility was generally compliant with regulations regarding environment, safety, and resident care plans. However, deficiencies were found related to maintenance and sanitation of a bathroom, staff training hours, and medication storage and documentation.
Deficiencies (4)
CCR 87303(a) Maintenance and Operation: One of four resident bathrooms had a urine smell, peeling ceiling, dirty bathtub, and a curtain needing replacement, posing an immediate health and safety risk.
HSC 1569.625(b)(2) Other Provisions: Three out of six staff did not complete the required additional 20 hours of training, posing a potential health and safety risk.
CCR 87465(h)(5) Incidental Medical and Dental Care Services: Evening medications were pre-poured and stored in separate containers, violating medication storage regulations and posing a potential health risk.
CCR 87465(h)(6) Incidental Medical and Dental Care Services: The facility did not maintain a Centrally Stored Medication Log for at least one year, posing a potential health and safety risk.
Report Facts
Staff training deficiency count: 3
Resident medication log deficiency count: 10
Residents with pre-poured medications: 6
Inspection Report
Capacity: 40
Deficiencies: 0
Date: Jun 28, 2023
Visit Reason
The informal meeting was conducted to address concerns regarding Administrator Certification for this facility and the Licensee's other facility.
Findings
No deficiencies were cited during the meeting. The Licensee has submitted training documents to renew the Administrator Certificate and agreed to submit a written plan for oversight while certification is pending.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicanor Aquino | Administrator | Named in relation to Administrator Certification and training renewal. |
Inspection Report
Follow-Up
Census: 29
Capacity: 40
Deficiencies: 1
Date: Mar 28, 2023
Visit Reason
The visit was an unannounced case management follow-up on two self-incident reports filed by the facility regarding resident falls and injuries.
Findings
The inspection found that two residents had incidents involving falls and injuries, and care plans for these residents were not current or signed within the last 12 months. The administrator agreed to update care plans and submit documentation for review.
Deficiencies (1)
CCR 87463(c) requires the licensee to arrange a meeting with the resident or representative when there is a significant change or annually. This was not met as care plans for 2 residents were not performed or signed within the last 12 months, posing a potential risk to resident health and safety.
Report Facts
Residents with outdated care plans: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charito Santos | Administrator | Met with Licensing Program Analyst during the visit and agreed to update care plans. |
| Marisol Cuadra | Licensing Program Analyst | Conducted the unannounced case management visit and reviewed incident reports and care plans. |
Inspection Report
Census: 30
Capacity: 40
Deficiencies: 0
Date: Nov 8, 2022
Visit Reason
The Licensing Program Analyst conducted an unannounced case management visit to follow up on a self-incident report filed by the facility Administrator regarding a resident's fall and injury.
Findings
The visit found that the resident sustained a closed wedge compression fracture of the T12 vertebra after an unwitnessed fall. The resident's records were reviewed and found to require updating. No deficiencies were cited during the visit.
Report Facts
Resident follow-up appointment date: Follow-up appointment scheduled for 2022-11-07 and 2022-12-16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charito Santos | Administrator | Met with Licensing Program Analyst during the visit and agreed to update resident's records |
Inspection Report
Census: 31
Capacity: 40
Deficiencies: 0
Date: Sep 15, 2022
Visit Reason
The visit was an unannounced case management incident follow-up to review a self-incident report involving resident aggression filed by the facility administrator.
Findings
The Licensing Program Analyst determined that the administrator took appropriate measures to address the aggressive behavior between residents. No citations were issued during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charito Santos | Administrator | Met with Licensing Program Analyst during the incident follow-up visit. |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 40
Deficiencies: 2
Date: Jun 13, 2022
Visit Reason
An unannounced case management visit was conducted to cite deficiencies discovered during a complaint investigation regarding medication storage and infection control practices.
Complaint Details
Deficiencies were cited based on a complaint investigation. The facility was found not following doctor's orders for marijuana prescriptions and failing to enforce PPE use after residents were diagnosed with a communicable disease.
Findings
The facility failed to follow doctor's orders for two residents regarding marijuana prescriptions and did not ensure staff wore face coverings as required by their mitigation plan after residents were diagnosed with a communicable disease.
Deficiencies (2)
CCR 87470 Infection Control Requirements were not met as staff providing direct care to residents with a communicable disease did not wear appropriate PPE.
CCR 87465 Incidental Medical and Dental Care requirements were not met as two out of four residents who smoke marijuana did not have a signed, dated physician's order and the medication was not centrally stored.
Report Facts
Census: 30
Total Capacity: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charito Santos | Administrator | Met with Licensing Program Analyst during inspection and involved in findings |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 40
Deficiencies: 0
Date: Jun 13, 2022
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations that residents were smoking marijuana inside the facility.
Complaint Details
The complaint alleged residents were smoking marijuana inside the facility. The allegation was found unsubstantiated due to lack of evidence.
Findings
The investigation found no evidence that residents were smoking marijuana inside the facility. The complaint was unsubstantiated, although two residents who smoke marijuana did not have a doctor's order on file.
Inspection Report
Annual Inspection
Census: 30
Capacity: 40
Deficiencies: 2
Date: Jun 13, 2022
Visit Reason
The visit was an unannounced annual required inspection conducted by the Licensing Program Analyst to evaluate compliance with regulations and facility operations.
Findings
The inspection found that the facility had expired food items that posed a health risk and that an individual was working without the required criminal record clearance. The facility maintains COVID-19 mitigation measures including PPE supplies and vaccination rates.
Deficiencies (2)
CCR 87355(e)(1) Criminal Record Clearance was not obtained for an individual prior to working or providing care, posing an immediate health and safety risk. A civil penalty of $100 per day is being assessed.
CCR 87555(a)(8)(28) The facility did not ensure expired food in the pantry and refrigerator was discarded, posing an immediate health and safety risk to residents.
Report Facts
Civil penalty amount: 100
Expired food items: 22
PPE supply duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicanor Aquino | Licensee | Named in relation to failure to obtain criminal record clearance for individual |
| Charito Santos | Administrator | Met with Licensing Program Analyst during inspection |
| Marisol Cuadra | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Census: 32
Capacity: 40
Deficiencies: 0
Date: Dec 3, 2021
Visit Reason
The visit was an unannounced Case Management - Incident inspection to follow up on four incident reports submitted to the Community Care Licensing (CCL) regarding resident falls and medical emergencies.
Findings
The Licensing Program Analyst conducted a risk assessment and reviewed incident reports related to resident falls and hospital transports. No deficiencies were issued during the visit.
Report Facts
Incident reports followed up: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charito Santos | Administrator | Met with Licensing Program Analyst during the inspection and provided information on resident incidents. |
Inspection Report
Census: 31
Capacity: 40
Deficiencies: 0
Date: Nov 15, 2021
Visit Reason
The inspection was an unannounced Case Management - Incident visit to follow up on three incident reports submitted regarding a resident's falls and medical conditions.
Findings
The inspection found no deficiencies. The report detailed the resident's falls, injuries, hospital visits, and ongoing medical monitoring.
Report Facts
Incident reports followed up: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charito Santos | Administrator | Met with Licensing Program Analyst during the inspection and provided information about resident incidents. |
Inspection Report
Follow-Up
Census: 30
Capacity: 40
Deficiencies: 0
Date: Oct 7, 2021
Visit Reason
The visit was an unannounced Case Management inspection following up on an incident report involving a resident's breathing difficulty and related health concerns.
Findings
No deficiencies were cited during the inspection. The facility is working with the resident's responsible party and case worker to address smoking habits and improve health outcomes. Staff training on medication management is scheduled.
Inspection Report
Census: 30
Capacity: 40
Deficiencies: 0
Date: Sep 24, 2021
Visit Reason
The visit was an unannounced Case Management - Incident inspection to follow up on three incident reports involving residents with breathing difficulties and to review death certificates for two residents who were not receiving hospice care at the time of death.
Findings
The inspection found no deficiencies. Follow-up confirmed that residents with breathing issues were transported to the hospital and receiving prescribed treatments. Death certificates for two residents were reviewed, with one pending submission.
Inspection Report
Complaint Investigation
Census: 28
Capacity: 40
Deficiencies: 2
Date: Sep 2, 2021
Visit Reason
Unannounced case management inspection following five incident reports involving a resident with breathing difficulties and medication management concerns.
Complaint Details
The visit was triggered by five incident reports involving a resident with breathing difficulties and medication issues. The complaint was substantiated with findings of medication errors and inadequate visitor screening.
Findings
The inspection found multiple medication errors for a resident, failure to update medication records, and lack of visitor screening for COVID-19 symptoms. Civil penalties were issued due to repeat citations.
Deficiencies (2)
CCR 87465(h)(6)(D) Incidental Medical & Dental Care. Licensee did not maintain a record of centrally stored prescription medications including the date filled, posing an immediate health and safety risk to the resident.
CCR 80072(a)(2) Personal Rights. Licensee did not ensure safe and healthful accommodations as staff failed to screen visitors for COVID-19 symptoms, risking resident health and safety.
Report Facts
Civil Penalties: 250
Incident Reports: 5
Medication Errors: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicanor Aquino | Licensee/Administrator | Named in discussions regarding resident care and medication management. |
| Staff (S1) | Involved in medication administration but could not explain missing medication record details. |
Inspection Report
Annual Inspection
Census: 31
Capacity: 40
Deficiencies: 0
Date: Aug 3, 2021
Visit Reason
The inspection was an unannounced annual required inspection focused on infection control procedures and practices at the facility.
Findings
The facility maintained proper infection control measures including visitor screening, staff mask usage, hand hygiene signage, and PPE supplies. No deficiencies were cited during the inspection.
Report Facts
Vaccination rate: 100
Unvaccinated residents: 2
PPE supply duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charito Santos | Administrator | Met with Licensing Program Analyst during inspection |
| Marisol Cuadra | Licensing Evaluator | Conducted the inspection |
| Bethany Moellers | Supervisor | Supervisor overseeing the inspection |
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