Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. However, some reports did cite deficiencies, primarily related to resident care, incident reporting, and safety issues such as pest control and medication documentation. The most recent inspection on October 8, 2025, was a complaint investigation that found no deficiencies and unsubstantiated allegations. Earlier in August 2025, two deficiencies were cited for failure to prevent resident altercations and failure to report incidents properly, showing some ongoing challenges in resident supervision and reporting. Overall, the facility’s record shows improvement with the latest report free of deficiencies after previous isolated issues.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 140
Capacity: 240
Deficiencies: 0
Oct 8, 2025
Visit Reason
An unannounced visit was conducted to investigate a complaint received on 2023-05-22 alleging staff did not prevent physical abuse, did not provide adequate care and supervision, and did not prevent financial abuse of residents.
Findings
The investigation included observations, document reviews, and interviews with staff and residents. The allegations were found to be unsubstantiated based on interviews where residents and staff confirmed adequate care, supervision, and prevention of abuse.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Report Facts
Residents interviewed: 11
Staff interviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Criselda Espiritu Santo | Executive Director | Met with during investigation and exit interview |
| Becky Mann | Licensing Program Analyst | Conducted the complaint investigation |
| Nedra Brown | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 145
Capacity: 240
Deficiencies: 2
Aug 29, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to allegations received on 2025-07-01 regarding resident care and incident reporting at the facility.
Findings
The investigation found one allegation unsubstantiated regarding staff meeting residents' diapering care needs. Two allegations were substantiated: staff did not prevent a resident from hitting others, and staff failed to report resident incidents to appropriate parties. Deficiencies were cited related to personal rights and reporting requirements.
Complaint Details
The complaint investigation was triggered by allegations that staff did not ensure resident diapering care needs were met, did not prevent a resident from hitting others, and did not report resident incidents appropriately. The diapering allegation was unsubstantiated, while the other two were substantiated with deficiencies cited.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure all clients are comfortable and safe, posing an immediate risk to residents' health and safety. | Type A |
| Failure to report incidents threatening the welfare, safety, or health of residents to the licensing agency. | Type A |
Report Facts
Capacity: 240
Census: 145
Deficiencies cited: 2
Plan of Correction Due Date: Aug 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Criselda Espiritu Santo | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Renese Howell-Small | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 144
Capacity: 240
Deficiencies: 0
Aug 14, 2025
Visit Reason
The visit was a Case Management - Other type of unannounced inspection to have the Administrator sign an amended Complaint Investigation Report.
Findings
The Licensing Program Analyst arrived to the facility to have the Administrator sign an amended Complaint Investigation Report. The report was signed by both parties and a copy was left with the facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Arrived to the facility to have Administrator sign amended Complaint Investigation Report. |
| Criselda Espiritu Santo | Administrator | Facility Administrator who signed the amended Complaint Investigation Report. |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 240
Deficiencies: 0
Jul 2, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations including staff not treating residents with dignity or respect, financial abuse by staff, failure to provide medication as prescribed, and failure to keep the facility free from pests.
Findings
All allegations were found to be unsubstantiated after interviews, record reviews, and observations. Staff denied the allegations, records showed no discrepancies in medication administration, pest control was confirmed to be in place, and no evidence supported claims of financial abuse or disrespectful treatment.
Complaint Details
The complaint investigation was unsubstantiated for all allegations: staff did not treat resident with dignity or respect; resident was financially abused by staff; staff did not provide resident medication as prescribed; and staff did not keep the facility free from pests. Evidence did not support the allegations.
Report Facts
Facility capacity: 240
Census: 144
Complaint control number: 56-AS-20240813084641
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Criselda Espiritu Santo | Executive Director | Met during investigation and named in findings discussion |
| Renese Howell-Small | Licensing Program Analyst | Conducted the complaint investigation visit |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 240
Deficiencies: 0
Jun 30, 2025
Visit Reason
Licensing Program Analyst Javier Prieto arrived at the facility to interview additional staff relating to a complaint (18-AS-20211008105248).
Findings
The report documents the interview conducted with the Administrator Criselda Espiritu Santo regarding the complaint. No specific deficiencies or violations are detailed in the report.
Complaint Details
Investigation related to complaint number 18-AS-20211008105248; no substantiation status provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Criselda Espiritu Santo | Administrator | Met with Licensing Program Analyst during complaint-related interview. |
| Javier Prieto | Licensing Program Analyst | Conducted interview related to complaint. |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 240
Deficiencies: 0
May 30, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not prevent verbal altercations between residents and did not provide a safe environment for residents.
Findings
The investigation included interviews with staff and residents and a review of records. Both allegations were found to be unsubstantiated based on the evidence gathered, with residents and staff affirming that staff intervene appropriately and provide a safe environment.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not preventing verbal altercations between residents and not providing a safe environment. Interviews with five staff and nine residents did not support these allegations.
Report Facts
Staff interviewed: 5
Residents interviewed: 9
Complaint control number: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Criselda Espiritu Santo | Executive Director | Met with during investigation and exit interview |
| Renese Howell-Small | Licensing Program Analyst | Conducted the complaint investigation |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 141
Capacity: 240
Deficiencies: 1
May 22, 2025
Visit Reason
The visit was an unannounced required annual inspection conducted by Licensing Program Analysts to evaluate compliance with licensing requirements at the Residential Care Facility for the Elderly.
Findings
The facility was found to be operating within approved capacity and generally in good repair with safe conditions for residents. One deficiency was cited related to improper storage of bleach and cleaning supplies with food, posing an immediate health and safety risk. Technical assistance was provided and a plan of correction was required.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Bleach and cleaning supplies were not stored separate from food supplies, posing an immediate health, safety or personal rights risk to persons in care. | Type A |
Report Facts
Resident units inspected: 6
Staff files reviewed: 5
Resident files reviewed: 6
Bottles of bleach observed: 6
Water temperature: 117
Facility temperature: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Criselda Espiritu Santo | Executive Director | Met with Licensing Program Analysts during inspection and named in findings |
| Renese Howell-Small | Licensing Program Analyst | Conducted inspection and signed report |
| Becky Mann | Licensing Program Analyst | Conducted inspection |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 240
Deficiencies: 0
Mar 17, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff was financially abusing a resident.
Findings
The investigation included interviews with staff, residents, and a resident's family member. The allegation of financial abuse was found to be unsubstantiated as there was no preponderance of evidence to prove the violation occurred.
Complaint Details
The complaint alleged that facility staff was financially abusing a resident. The allegation was investigated through interviews and record review and was determined to be unsubstantiated.
Report Facts
Capacity: 240
Census: 147
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Criselda Espiritu Santo | Executive Director | Met with during the investigation and named in the report |
| Renese Howell-Small | Licensing Program Analyst | Conducted the complaint investigation visit |
| Karen Clemons | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 240
Deficiencies: 0
Feb 6, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff were not ensuring that a resident was receiving services prescribed by their physician.
Findings
The allegation was found to be unsubstantiated after interviews with the resident and staff, and review of records showed that the resident was escorted to appointments and received prescribed services at the facility.
Complaint Details
The complaint alleged that staff were not ensuring that a resident was receiving services prescribed by their physician. The allegation was unsubstantiated based on interviews and record review.
Report Facts
Capacity: 240
Census: 143
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Criselda Espiritu Santo | Executive Director | Met with during the investigation and named in the report |
| Renese Howell-Small | Licensing Program Analyst | Conducted the complaint investigation visit |
| Karen Clemons | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 240
Deficiencies: 0
Dec 23, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of illegal eviction received on 2024-09-11.
Findings
The investigation found that Resident #1 was currently living in the facility and had refused assistance with personal care multiple times. A 30-Day Eviction letter was issued to Resident #1 on 2024-09-10, consistent with the facility's eviction procedures and admissions agreement. The allegation of illegal eviction was unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged illegal eviction. The allegation was unsubstantiated as there was no preponderance of evidence to prove the violation occurred.
Report Facts
Refusals of personal care: 19
Facility capacity: 240
Census: 143
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renese Howell-Small | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit. |
| Criselda Espiritu Santo | Executive Director | Facility representative met during the investigation. |
| Karen Clemons | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 240
Deficiencies: 0
Dec 23, 2024
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that staff do not prevent residents from being hit by other residents.
Findings
The allegation was found to be unsubstantiated after interviews and record review. Resident #1 had been moved to another facility, and staff and residents denied witnessing any incidents of residents hitting other residents.
Complaint Details
The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violation occurred.
Report Facts
Capacity: 240
Census: 143
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Criselda Espiritu Santo | Executive Director | Met with during the investigation and named in the report |
| Renese Howell-Small | Licensing Program Analyst | Conducted the complaint investigation visit |
| Karen Clemons | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 148
Capacity: 240
Deficiencies: 0
Dec 11, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff do not ensure residents are not eating expired or moldy food.
Findings
The investigation found no evidence to corroborate the allegation. Interviews with residents and staff, as well as observations of food supplies, confirmed that residents were served fresh food and no expired or moldy food was found or served. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff do not ensure residents are not eating expired/moldy food. The allegation was unsubstantiated based on interviews, observations, and records review.
Report Facts
Capacity: 240
Census: 148
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Criselda Espiritu Santo | Executive Director | Met during the investigation and involved in exit interview |
| Melody Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Efren Malagon | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 148
Capacity: 240
Deficiencies: 1
Dec 11, 2024
Visit Reason
The visit was a case management inspection initiated to investigate deficiencies related to staff certification compliance.
Findings
The inspection found that Staff #8 did not have the required Food Handlers Training certification, resulting in a deficiency being issued.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff #8 does not have the required Food Handlers Training certification, violating general food service requirements. | Type B |
Report Facts
Capacity: 240
Census: 148
Plan of Correction Due Date: Dec 20, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Criselda Espiritu Santo | Executive Director | Met during inspection and named in report |
| Melody Brown | Licensing Program Analyst | Conducted the inspection and authored the report |
| Efren Malagon | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 240
Deficiencies: 0
Dec 5, 2024
Visit Reason
The inspection visit was conducted to interview additional residents relating to a complaint identified as 56-AS-20240805145702.
Findings
Licensing Program Analyst Javier Prieto toured the facility and interviewed residents with the assistance of Administrator Alexandra Villacis. The report documents the completion of these activities without specifying any deficiencies or violations.
Complaint Details
The visit was triggered by complaint number 56-AS-20240805145702. No substantiation status is provided in the report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted resident interviews and toured the facility during the complaint investigation. |
| Alexandra Villacis | Administrator | Accompanied the Licensing Program Analyst during the facility tour and resident interviews. |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 240
Deficiencies: 0
Nov 7, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of wrongful eviction received on 2024-08-01.
Findings
The investigation included interviews and record reviews which found no evidence supporting the allegation of wrongful eviction. The allegation was determined to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged wrongful eviction of Resident 1 (R1). Interviews with staff and outside parties revealed unawareness of any eviction, and no written notice or record of eviction was found. The allegation was unsubstantiated.
Report Facts
Capacity: 240
Census: 143
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Criselda Espiritu Santo | Administrator | Facility administrator met during the investigation |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 240
Deficiencies: 0
Oct 14, 2024
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that staff did not keep the facility free of bed bugs.
Findings
The allegation that staff did not keep the facility free from bed bugs was found to be unsubstantiated after a facility tour, interviews, observations, and record review. Documentation of monthly extermination service and preventive measures were verified.
Complaint Details
The complaint alleging staff did not keep the facility free of bed bugs was investigated and found to be unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violation occurred.
Report Facts
Capacity: 240
Census: 134
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renese Howell-Small | Licensing Program Analyst | Conducted the complaint investigation and facility visit |
| Criselda Espiritu Santo | Executive Director | Facility representative met during the investigation |
| Karen Clemons | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 138
Capacity: 240
Deficiencies: 0
Aug 27, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of lack of supervision resulting in a physical altercation between residents.
Findings
The investigation included interviews and record reviews. The allegation was found to be unsubstantiated as there was no preponderance of evidence to prove the incident occurred as alleged. Residents and staff reported feeling safe and no past incidents were found.
Complaint Details
The complaint alleged lack of supervision resulting in a physical altercation between residents. The allegation was determined to be unsubstantiated based on interviews and record review.
Report Facts
Capacity: 240
Census: 138
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paola Guerrero | Licensing Program Analyst | Conducted the complaint investigation visit |
| Efren Malagon | Licensing Program Manager | Named in report as Licensing Program Manager |
| Norma Alexandra Villacis | Facility Nurse | Met with Licensing Program Analyst during investigation and received report |
| Criselda Espiritu Santo | Administrator | Facility Administrator named in report |
Inspection Report
Census: 134
Capacity: 240
Deficiencies: 1
Aug 15, 2024
Visit Reason
An unannounced visit was conducted to commence a Case Management Deficiency inspection due to observed deficiencies.
Findings
The facility was found to be non-compliant with Health and Safety Code 1569.311 for failing to have the required carbon monoxide detectors, posing an immediate health, safety, and personal rights risk to residents.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility does not have the required carbon monoxide alarm, posing an immediate health, safety, and personal rights risk to residents. | Type A |
Report Facts
Plan of Correction Due Date: Aug 16, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Criselda Espiritu Santo | Executive Director | Met with Licensing Program Analysts during inspection and acknowledged deficiency |
| Melody Brown | Licensing Program Analyst | Conducted the inspection and authored the report |
| Efren Malagon | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 138
Capacity: 240
Deficiencies: 0
Aug 6, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that staff were not allowing residents to have visitors in their rooms and were not providing comfortable accommodations for residents.
Findings
The investigation found that the facility allows residents to have visitors according to the visitation policy and provides comfortable accommodations for residents, including designated visiting areas and appropriate spaces for spiritual services. The allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on interviews with the CEO, residents, and staff, and review of facility policies. The allegations regarding visitor restrictions and uncomfortable accommodations were not supported by evidence.
Report Facts
Capacity: 240
Census: 138
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Edna Medrano | President CEO | Interviewed during the investigation and provided facility policies |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 240
Deficiencies: 0
Jul 11, 2024
Visit Reason
Unannounced complaint investigation visit conducted due to allegations of staff physically assaulting and verbally abusing residents.
Findings
The investigation found no substantiated evidence of physical assault or verbal abuse by staff towards residents. Interviews with residents and staff denied the allegations, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint involved allegations that staff physically assaulted residents resulting in injuries and verbally abused residents. The investigation concluded these allegations were unsubstantiated due to lack of corroborating evidence.
Report Facts
Capacity: 240
Census: 129
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paola Guerrero | Licensing Program Analyst | Conducted the complaint investigation |
| Efren Malagon | Licensing Program Manager | Named in report as Licensing Program Manager |
| Norma Villacis | Facility LVN | Met with Licensing Program Analyst during investigation |
| Criselda Espiritu Santo | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 240
Deficiencies: 0
Jun 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff sexually assaulted a resident.
Findings
The investigation included interviews with staff and the resident, as well as a review of records. All parties denied the allegation, and based on the evidence, the allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff sexually assaulted a resident. The allegation was investigated and found to be unsubstantiated due to lack of corroborating evidence.
Report Facts
Capacity: 240
Census: 144
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paola Guerrero | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Criselda Espiritu Santo | Facility Director | Met with Licensing Program Analyst during the investigation |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 144
Capacity: 240
Deficiencies: 0
May 17, 2024
Visit Reason
The visit was an unannounced required comprehensive annual inspection of the Residential Care Facility for Elderly (RCFE).
Findings
The facility was found to be operating within its licensed capacity and in good repair with safe conditions for residents. No deficiencies were cited during the inspection, and all reviewed resident and staff files were in compliance with regulations.
Report Facts
Resident files reviewed: 5
Staff files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Criselda Espiritu Santo | Executive Director | Facility Administrator met during inspection and named in report |
| Paola Guerrero | Licensing Program Analyst | Conducted the inspection visit |
| Efren Malagon | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 144
Capacity: 240
Deficiencies: 0
May 17, 2024
Visit Reason
An unannounced visit was conducted for the purpose of a Health & Safety check to assess the facility's compliance with health and safety standards.
Findings
No imminent health and/or safety concerns or hazards were observed inside or outside the facility. Sufficient staff were present to provide care, and food supplies were adequate to meet residents' needs.
Report Facts
Perishable food supply days: 3
Non-perishable food supply days: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paola Guerrero | Licensing Program Analyst | Conducted the unannounced visit and inspection |
| Criselda Espiritu Santo | Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Census: 133
Capacity: 240
Deficiencies: 0
Apr 19, 2024
Visit Reason
Licensing Program Analyst Paola Guerrero conducted an unannounced visit to the facility on 4/19/2024 at 11:45 AM for the purpose of a Health & Safety check.
Findings
No imminent health and/or safety concerns were observed during the visit. The facility had sufficient staff and adequate food supplies to meet the needs of the residents in care.
Report Facts
Food supply duration: 3
Food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Criselda Espiritu Santo | Executive Director | Met with Licensing Program Analyst during inspection |
| Paola Guerrero | Licensing Program Analyst | Conducted the unannounced visit and inspection |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Capacity: 240
Deficiencies: 1
Mar 27, 2024
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that the facility failed to notify a resident's authorized representative about medical treatment.
Findings
The investigation found that the resident's representative was receiving communication about the resident's condition and was aware of the medical treatment situation. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged failure to notify a resident's authorized representative about medical treatment. The allegation was found unsubstantiated after review of records and interviews.
Deficiencies (1)
| Description |
|---|
| Facility failed to notify resident authorized representative about medical treatment. |
Report Facts
Capacity: 240
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Fannell | Licensing Program Analyst | Conducted the complaint investigation visit |
| Criselda Espiritu Santo | Administrator | Facility administrator present during the visit |
| Edna Medrano | Licensee | Advised of the purpose of the visit |
Inspection Report
Complaint Investigation
Capacity: 240
Deficiencies: 0
Dec 7, 2023
Visit Reason
The visit was an unannounced complaint investigation initiated due to allegations received on 2023-11-30 regarding staff assistance with resident transfers, medication administration, and authority over resident's social security payee and power of attorney.
Findings
All allegations were found to be unsubstantiated after review of records and staff interviews. The resident was able to transfer independently, had refused medication services since August 2023, and the facility denied attempting to become the resident's payee or filing power of attorney without consent.
Complaint Details
The complaint involved four allegations: staff not assisting resident with transfers, not giving medications for two years, attempting to become resident's social security payee, and becoming resident's power of attorney without consent. All allegations were unsubstantiated based on evidence and interviews.
Report Facts
Facility capacity: 240
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Javier Prieto | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Criselda Espiritu Santo | Administrator | Facility administrator interviewed during the investigation |
| Nedra Brown | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 240
Deficiencies: 1
Sep 12, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that a resident sustained pressure injuries due to neglect and that staff left a resident in a soiled adult brief.
Findings
The allegation that a resident sustained pressure injuries due to neglect was substantiated based on interviews and record reviews, including failure to assist the resident with home health services and inadequate wound care. The allegation that staff left a resident in a soiled adult brief was unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for the allegation that Resident #1 sustained pressure injuries due to neglect. The resident developed a Stage 4 pressure injury and was not provided adequate wound care or assistance with home health services as ordered. The allegation that staff left the resident in a soiled adult brief was unsubstantiated due to insufficient evidence.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow doctor's orders and assist Resident #1 with obtaining home health services, posing a potential health, safety, and personal rights risk. | Type B |
Report Facts
Civil penalty: 500
Plan of Correction due date: Sep 26, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Joel Esquivel | Licensing Program Manager | Oversaw the complaint investigation. |
| Criselda Espiritu Santo | Administrator | Facility administrator met during investigation and exit interview. |
| Kevin Villacorte | Assistant Living Coordinator | Interviewed regarding failure to assist resident with home health services. |
Inspection Report
Complaint Investigation
Census: 138
Capacity: 240
Deficiencies: 0
Aug 16, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff violated a resident's confidentiality.
Findings
The investigation found that whiteboards with residents' names and room numbers were visible behind the medication room counter, but no diagnoses were listed. Staff and resident interviews indicated that residents bring discharge paperwork to the medication room and discuss it with licensed staff, with other residents usually ushered out. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff violated resident's confidentiality. The allegation was found unsubstantiated after investigation.
Report Facts
Capacity: 240
Census: 138
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the complaint investigation and visit |
| Edna Medrano | Administrator | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 240
Deficiencies: 0
Jul 17, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2023-06-27 regarding financial abuse, failure to send medication with a resident upon moving, and presence of bed bugs at the facility.
Findings
The investigation found all allegations to be unsubstantiated after reviewing records, conducting interviews, and inspecting the facility. No evidence supported financial abuse, medication withholding, or bed bug presence.
Complaint Details
The complaint included allegations of financial abuse involving unauthorized withdrawal of $3009 from a resident's government benefit account, failure to send medication with a resident upon discharge, and presence of bed bugs in the facility. All allegations were found unsubstantiated or unfounded after investigation.
Report Facts
Amount allegedly withdrawn: 3009
Capacity: 240
Census: 147
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kevin Villacorte | Assistant Administrator | Met with Licensing Program Analyst during investigation |
| Criselda Espiritu Santo | Administrator | Facility administrator named in the report |
| May Cabrera | Administrator | Participated in exit interview and received report copy |
Inspection Report
Annual Inspection
Census: 143
Capacity: 240
Deficiencies: 0
Jun 14, 2023
Visit Reason
The visit was an unannounced required comprehensive annual inspection of the Residential Care Facility for the Elderly (RCFE) to assess compliance with licensing regulations.
Findings
The facility was found to be operating within its licensed capacity and in good repair with safe conditions for clients. No deficiencies were cited during the inspection. The facility had sufficient staff coverage, proper record keeping, and appropriate medication management.
Report Facts
Client files reviewed: 8
Staff files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Criselda Espiritu Santo | Facility Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Paola Guerrero | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
| Efren Malagon | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Capacity: 240
Deficiencies: 0
May 8, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-05-02 regarding staff handling residents roughly, inappropriate staff speech to residents, and failure to maintain personnel records.
Findings
The investigation found all allegations to be unsubstantiated after interviews with residents and staff, observations, and record reviews. Staff were not observed or reported to handle residents roughly or speak inappropriately, and personnel records were maintained as required, though a technical assistance was issued regarding staff training documentation.
Complaint Details
The complaint investigation was unsubstantiated for all three allegations: rough handling of residents, inappropriate speech by staff, and failure to maintain personnel records. No evidence supported the allegations.
Report Facts
Facility capacity: 240
Number of personnel records reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Criselda Espiritu Santo | Administrator | Facility administrator met during investigation and exit interview |
| Nedra Brown | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 133
Capacity: 240
Deficiencies: 0
Apr 10, 2023
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that staff did not prevent a resident from attacking another resident while in care.
Findings
The investigation found that Resident 1 was residing at the facility during the relevant time, but Resident 2 was not known to staff and no incident reports involving Resident 2 were found. The allegation was determined to be unfounded.
Complaint Details
The complaint alleged that staff did not prevent Resident 2 from attacking Resident 1 while in care. The allegation was found to be unfounded after staff interviews and record reviews.
Report Facts
Facility capacity: 240
Census: 133
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the complaint investigation and visit |
| May Cabrera | Administrator | Met with the Licensing Program Analyst during the investigation |
| Kevin Villacorte | Assistant Administrator | Met with the Licensing Program Analyst during the investigation and received the report |
Inspection Report
Complaint Investigation
Capacity: 240
Deficiencies: 2
Apr 6, 2023
Visit Reason
The visit was an unannounced investigation to deliver findings related to complaint number 56-AS-20230330134902.
Findings
Technical violations were found including 8 medications scheduled for evening or bedtime marked as already administered in Resident 1's medication record, and the facility lacking a modified menu for residents with diabetes.
Complaint Details
Complaint number 56-AS-20230330134902 was investigated; technical violations were substantiated.
Deficiencies (2)
| Description |
|---|
| 8 medications scheduled for the evening or bedtime were marked as already administered in Resident 1's medication record. |
| Facility does not have a modified menu for residents with diabetes. |
Report Facts
Medications marked as administered: 8
Facility capacity: 240
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the unannounced visit and investigation |
| May Cabrera | Administrator | Met with Licensing Program Analyst during the visit and received report and appeal rights |
Inspection Report
Capacity: 240
Deficiencies: 0
Apr 6, 2023
Visit Reason
The visit was a Case Management - Incident type, unannounced, to address incidents involving residents who had been issued 30 day notices due to observed illegal drugs and a resident pulling a knife on staff.
Findings
The report documents incidents involving Resident 1 observed with illegal drugs in their room and Resident 2 pulling a knife on a staff member. Licensing staff advised the facility to proceed with the eviction process ensuring compliance with regulations.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Named in relation to the incident involving residents and eviction process advice. |
| Kevin Villacorte | Assistant Administrator | Named in relation to the incident involving residents and eviction process advice. |
| May Cabrera | Met with during the visit regarding residents issued 30 day notices. | |
| Criselda Espiritu Santo | Administrator | Facility administrator named in the report header. |
Inspection Report
Complaint Investigation
Capacity: 240
Deficiencies: 1
Apr 6, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff do not ensure resident records are properly maintained and do not properly communicate with residents' medical provider.
Findings
The complaint that staff did not ensure resident records were properly maintained was substantiated due to medication records not reflecting the appropriate dosage administered for a resident's variable dose medication. The complaint that staff did not properly communicate with the resident's medical provider was unsubstantiated as evidence showed communication and scheduling of medical appointments.
Complaint Details
The complaint investigation was substantiated for the allegation that staff do not ensure resident records are properly maintained, posing a potential health and safety risk. The allegation that staff do not properly communicate with the resident's medical provider was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medication records must reflect appropriate dose administered for medications that have variable dose; observed medication record does not reflect dosage administered for medication 1 (M1). | Type B |
Report Facts
Facility capacity: 240
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Criselda Espiritu Santo | Administrator | Facility administrator involved in the investigation |
| May Cabrera | Administrator met during the investigation and exit interview | |
| Edna Medrano | Licensee | Licensee met during the investigation |
Inspection Report
Complaint Investigation
Capacity: 240
Deficiencies: 0
Dec 29, 2022
Visit Reason
Licensing Program Analyst Anna Bueno conducted an unannounced visit to deliver an amended report of complaint control number 56-AS-20220808095722 regarding allegations against staff.
Findings
The findings for the complaint remain unchanged; allegations that staff took money from a resident and did not treat the resident with dignity and respect were found to be unsubstantiated.
Complaint Details
Complaint control number 56-AS-20220808095722 involved allegations that staff took money from a resident and did not treat the resident with dignity and respect; both allegations were unsubstantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Criselda Espiritu Santo | Administrator | Met with Licensing Program Analyst during the visit and signed the amended report. |
| Anna Bueno | Licensing Program Analyst | Conducted the unannounced visit and delivered the amended complaint report. |
| Nedra Brown | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 240
Deficiencies: 0
Nov 17, 2022
Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to allegations received on 2022-09-12 regarding sexual, physical, and financial abuse of a resident while in care.
Findings
The investigation included staff, witness, and resident interviews and records review. All allegations of sexual, physical, and financial abuse were found to be unsubstantiated based on the evidence and interviews conducted.
Complaint Details
The complaint involved allegations that a resident (R1) was sexually abused by unknown individuals, physically abused by a named individual, and financially abused by another resident (R2). All allegations were investigated and found unsubstantiated.
Report Facts
Facility capacity: 240
Resident census: 131
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the complaint investigation |
| Amber Coleman | Licensing Program Analyst | Conducted the complaint investigation |
| Kevin Villacorte | Assistant Administrator | Met with investigators during the visit |
| Criselda Espiritu Santo | Administrator | Facility administrator involved in exit interview |
| Nedra Brown | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 240
Deficiencies: 0
Nov 17, 2022
Visit Reason
An unannounced complaint investigation was conducted following allegations that facility staff did not dispense resident's medication as prescribed, did not ensure timely medication refills, and failed to transport a patient to a medical appointment.
Findings
The investigation found no evidence to support the allegations. Medication records showed all prescribed medications were administered as prescribed, medication refills were timely, and transportation services were provided as scheduled. The complaint was determined to be unsubstantiated.
Complaint Details
The complaint was unsubstantiated as there was no preponderance of evidence to prove the alleged violations occurred.
Report Facts
Facility capacity: 240
Appointments scheduled: 6
Appointments attended: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amber Coleman | Licensing Program Analyst | Conducted the complaint investigation |
| Kevin Villacorte | Assistant Administrator | Interviewed during investigation and provided information on medication and transportation |
| Criselda Espiritu Santo | Administrator | Facility administrator informed of the investigation and present during visit |
| Nedra Brown | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 240
Deficiencies: 0
Nov 17, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 08/08/2022 regarding staff misconduct including taking money from a resident and failure to treat a resident with dignity and respect.
Findings
The investigation found no evidence to substantiate the allegations. Resident and staff interviews did not support claims of staff taking money or disrespecting residents. One resident was confirmed to be under the influence of illegal substances during an incident, and the complaint was deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff taking money from a resident and staff not treating a resident with dignity and respect. Interviews and observations did not support these claims.
Report Facts
Capacity: 240
Census: 131
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Criselda Espiritu Santo | Administrator | Facility administrator met during the investigation and involved in exit interview |
| Nedra Brown | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 133
Capacity: 240
Deficiencies: 0
Oct 24, 2022
Visit Reason
An unannounced complaint investigation was conducted following allegations that staff did not ensure residents attended medical appointments and did not provide transportation to residents in care.
Findings
The investigation found that the client manages their own medical appointments and transportation services are provided up to three times a week, including third-party transportation. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint was unsubstantiated. Allegations included staff not ensuring residents attended medical appointments and not providing transportation. Interviews and records review showed transportation services were provided and clients managed their own appointments.
Report Facts
Residents transported: 8
Transportation frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Villacorte | Assistant Manager | Met with Licensing Program Analysts during complaint investigation and exit interview |
| Anna Bueno | Licensing Program Analyst | Conducted complaint investigation and signed report |
| Nedra Brown | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 240
Deficiencies: 1
Sep 13, 2022
Visit Reason
An unannounced case management visit was conducted for a Health & Safety check in conjunction with complaint control number 56-AS-20220912152449.
Findings
No imminent health and safety concerns were observed. One physician's record was found not up to date, resulting in a technical advisory being issued as the facility has a pre-scheduled appointment for the resident.
Complaint Details
Visit was conducted in conjunction with complaint control number 56-AS-20220912152449. No substantiation status explicitly stated.
Deficiencies (1)
| Description |
|---|
| One physician's record is not up to date. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Criselda Espiritu Santo | Executive Director | Met with Licensing Program Analyst during the visit and discussed the nature of the visit and findings. |
| Anna Bueno | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Nedra Brown | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 240
Deficiencies: 0
Aug 17, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility did not issue a 30 day notice.
Findings
The Licensing Program Analyst verified that the facility had sent a 30 day notice for Resident 1 prior to the complaint being filed. The allegation was determined to be unfounded.
Complaint Details
The complaint alleged that the facility did not issue a 30 day notice. The allegation was found to be unfounded.
Report Facts
Capacity: 240
Census: 143
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the complaint investigation visit |
| Criselda Espiritu Santo | Administrator | Facility administrator met during the investigation |
Inspection Report
Annual Inspection
Census: 141
Capacity: 240
Deficiencies: 0
Jun 23, 2022
Visit Reason
An unannounced required annual inspection was conducted with an emphasis on the infection control domain.
Findings
No health and safety concerns or deficiencies were cited during the inspection. A technical advisory was issued to remind staff about the importance of wearing face coverings.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Criselda Espiritu Santo | Administrator | Met with Licensing Program Analyst during inspection and verified facility conditions. |
| Anna Bueno | Licensing Program Analyst | Conducted the unannounced annual inspection visit. |
| Nedra Brown | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 240
Deficiencies: 0
Oct 12, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of staff verbal abuse, rescheduling of resident appointments without family or medical professional consultation, and lack of assistance with transportation for health appointments.
Findings
The investigation found no evidence to support the allegations. Interviews and documentation reviewed indicated that staff were not verbally abusive, appointments were properly managed and confirmed with medical professionals, and transportation logs were maintained. The allegations were deemed unsubstantiated.
Complaint Details
The complaint included allegations of verbal abuse by staff, improper rescheduling of resident appointments without family or medical professional input, and failure to assist with transportation for health appointments. The complaint was investigated and found to be unsubstantiated.
Report Facts
Capacity: 240
Census: 142
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Criselda Espiritu Santo | Administrator | Facility administrator involved in interviews and providing documentation |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 162
Capacity: 240
Deficiencies: 0
Jul 28, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that a resident was sexually assaulted by facility staff.
Findings
The investigation included interviews and records review. The resident could not provide consistent statements regarding the allegation, and staff reported the resident has a history of delusions and false allegations. Police records indicated no further action was required. The allegation was determined to be unsubstantiated due to lack of evidence.
Complaint Details
The complaint alleged that a resident was sexually assaulted by facility staff. The allegation was found to be unsubstantiated based on investigation findings and police report.
Report Facts
Capacity: 240
Census: 162
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Williams | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Criselda Espiritu Santo | Administrator | Met with Licensing Program Analyst during investigation |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 163
Capacity: 240
Deficiencies: 1
Jul 12, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the licensee did not notify the person responsible for a resident within seven days of the occurrence of an unexplained absence.
Findings
The investigation found that the facility attempted to notify the responsible party via email two days after the resident's absence, but the email address was incorrect and no timely follow-up was made, resulting in notification occurring 17 days later. The allegation was substantiated.
Complaint Details
The complaint was substantiated based on evidence that the licensee did not notify the responsible party within seven days of the unexplained absence of Resident #1. A missing person's report was filed with the police. The preponderance of evidence standard was met.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit a written report to the licensing agency and responsible party within seven days of an unexplained absence of a resident, as required by CCR 87211(1)(D). | Type B |
Report Facts
Capacity: 240
Census: 163
Deficiencies cited: 1
Plan of Correction Due Date: Jul 26, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Joel Esquivel | Licensing Program Manager | Oversaw complaint investigation |
| Criselda Espiritu Santo | Administrator | Facility administrator involved in investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 163
Capacity: 240
Deficiencies: 1
Jun 24, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility has pests.
Findings
The investigation found substantiated evidence of pest infestation including bed bugs, roaches, and mice in the facility. Observations included fresh bites on a resident, dead cockroach, bait traps, and mouse traps in resident rooms and staff areas.
Complaint Details
The complaint was substantiated based on observations, interviews, and record review. The allegation that the facility has pests was confirmed.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility has an ongoing infestation of pests including roaches, bed bugs, and mice, posing an immediate health and safety risk to residents. | Type A |
Report Facts
Capacity: 240
Census: 163
Deficiencies cited: 1
Plan of Correction Due Date: Jun 25, 2021
Combat bait traps observed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation and made findings |
| Joel Esquivel | Licensing Program Manager | Named in report as Licensing Program Manager |
| MaCriselda Espiritu Santo | Administrator | Facility administrator met during investigation and named in findings |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 240
Deficiencies: 0
May 26, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 08/27/2020 regarding resident safety, treatment, and facility conditions.
Findings
All allegations investigated, including failure to safeguard resident possessions, unlawful eviction, staff yelling at residents, lack of dignity in treatment, pest infestation, privacy concerns, safe environment, and medical care refusal rights, were found to be unsubstantiated or unfounded based on interviews, observations, and document reviews.
Complaint Details
The complaint included nine allegations: failure to safeguard resident possessions, unlawful eviction, staff yelling at resident, resident not treated with dignity, facility infested with pests, resident not afforded privacy, facility failed to provide a safe environment, resident not permitted to reject medical care, and unlawful eviction. All allegations were found to be unsubstantiated or unfounded after investigation.
Report Facts
Capacity: 240
Census: 150
Number of allegations: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Joel Esquivel | Licensing Program Manager | Oversaw the complaint investigation |
| Criselda Espiritu Santo | Administrator | Facility administrator met during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 160
Capacity: 240
Deficiencies: 0
May 26, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2020-09-18 regarding unlawful eviction, resident denied food, facility retaliation against a resident, and failure to transport a resident to doctor appointments.
Findings
All allegations investigated were found to be either unsubstantiated or unfounded. The unlawful eviction and resident denied food allegations were unsubstantiated due to insufficient evidence. The allegations of facility retaliation and failure to transport the resident to doctor appointments were unfounded based on interviews and evidence reviewed.
Complaint Details
The complaint investigation addressed four main allegations: 1) unlawful eviction, 2) resident denied food, 3) facility retaliation against resident, and 4) facility not transporting resident to doctor appointments. The unlawful eviction and resident denied food allegations were unsubstantiated, meaning there was not enough evidence to prove the violations. The retaliation and transportation allegations were unfounded, meaning the allegations were false or without reasonable basis.
Report Facts
Capacity: 240
Census: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Joel Esquivel | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Criselda Espiritu Santo | Administrator | Facility Administrator met during the investigation and involved in findings |
Inspection Report
Complaint Investigation
Census: 160
Capacity: 240
Deficiencies: 2
May 26, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility failed to provide adequate medical treatment and failed to report an incident.
Findings
The investigation substantiated both allegations. Resident #1 experienced a serious medical incident related to untreated high blood sugar and a bump that was not properly addressed. Additionally, the facility failed to report the incident to the responsible party in a timely manner, notifying a sibling instead of the Public Guardian conservator.
Complaint Details
The complaint was substantiated based on evidence that the facility failed to provide adequate medical treatment to Resident #1 and failed to report the incident to the responsible party, the Public Guardian, instead notifying a sibling. The preponderance of evidence standard was met for both allegations.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Based on 1 out of 1 resident was not provided assistance with getting their medical needs met, posing a potential health, safety and personal rights risk. | Type B |
| One incident was not reported to the responsible party within seven days as required, posing a potential health, safety and personal rights risk. | Type B |
Report Facts
Capacity: 240
Census: 160
Deficiencies cited: 2
Plan of Correction Due Date: Jun 8, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joel Esquivel | Licensing Program Manager | Oversaw the complaint investigation |
| MaCriselda Espiritu Santo | Administrator | Facility administrator met during investigation and named in findings |
Inspection Report
Complaint Investigation
Census: 160
Capacity: 240
Deficiencies: 1
May 26, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility was not providing resident's records to the responsible party.
Findings
The investigation substantiated the allegation that the facility failed to provide resident records to the responsible party. The licensee did not ensure that resident records were provided upon request on one occasion.
Complaint Details
The complaint was substantiated based on interviews and record review. The allegation that the facility did not provide resident records to the responsible party was found valid.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide resident records upon request, violating CCR 87506(1) regarding storage and confidentiality of resident records. | Type B |
Report Facts
Capacity: 240
Census: 160
Deficiencies cited: 1
Plan of Correction Due Date: Jun 8, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Joel Esquivel | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Criselda Espiritu Santo | Administrator | Facility Administrator interviewed during the investigation |
Inspection Report
Annual Inspection
Census: 160
Capacity: 240
Deficiencies: 0
May 26, 2021
Visit Reason
An unannounced annual inspection was conducted focused on infection control at the facility.
Findings
No deficiencies were cited during the inspection. Technical assistance was provided regarding proper logging of daily temperature checks.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MaCriselda Espiritu Santo | Administrator | Met with Licensing Program Analyst during the inspection and received a copy of the report. |
| Javina George | Licensing Program Analyst | Conducted the unannounced annual inspection focused on infection control. |
| Joel Esquivel | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 160
Capacity: 240
Deficiencies: 1
May 26, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff did not meet residents' medical needs.
Findings
The investigation included interviews and document reviews, and it was substantiated that the facility staff failed to meet residents' medical needs due to a missed appointment caused by miscommunication and failure to verify information.
Complaint Details
The complaint was substantiated based on evidence gathered from interviews and documentation. The allegation was that facility staff did not meet residents' medical needs, specifically a resident missing an appointment due to being taken to the wrong address caused by miscommunication and failure to verify information.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee failed to provide assistance in meeting necessary medical and dental needs, including transportation, posing a potential health, safety or personal rights risk to persons in care. | Type B |
Report Facts
Capacity: 240
Census: 160
Deficiency count: 1
Plan of Correction Due Date: Jun 9, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Joel Esquivel | Licensing Program Manager | Oversaw the complaint investigation |
| MaCriselda Espiritu Santo | Administrator | Facility administrator met during the investigation and received findings |
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