Most inspections found no deficiencies, with the facility consistently clean, sanitary, and in good repair. The most recent report from May 7, 2025, was perfect with no deficiencies cited. An isolated staffing deficiency was noted in January 2023 related to a resident leaving the facility unattended, but no injuries occurred and no further enforcement actions were taken. Several complaint investigations, including one in November 2024 about a resident fall, were unsubstantiated. The facility’s record shows improvement since the staffing issue, with recent inspections showing no deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)0.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
95% better than California average
California average: 4 deficiencies/year
Deficiencies per year
43210
2021
2022
2023
2024
2025
Census
Latest occupancy rate82% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
An unannounced, required annual inspection was conducted to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies cited. Resident rooms, safety equipment, and emergency preparedness were all compliant. Interviews and record reviews revealed no regulatory concerns.
Report Facts
Residents in care: 49Licensed capacity: 60Hospice waiver capacity: 20Bedridden capacity: 15Days of perishable food stored: 2Days of non-perishable food stored: 7Date of most recent emergency drill: Jan 26, 2025
Employees Mentioned
Name
Title
Context
Denise Notter
Executive Director
Met during inspection and participated in facility tour and exit interview
Arian Golbakhsh
Licensing Program Analyst
Conducted the inspection and reviewed facility records
An unannounced complaint investigation was conducted in response to an allegation that staff left a resident on the floor after a fall.
Findings
The investigation found no evidence to support the allegation; the resident was observed crawling voluntarily and was not left unattended after a fall. The complaint was unsubstantiated.
Complaint Details
The complaint alleged that staff left Resident 1 on the floor after a fall on October 27, 2024. Interviews and record reviews showed Resident 1 chose to crawl and was not injured or left unattended. The allegation was unsubstantiated.
Report Facts
Facility capacity: 60Census: 53
Employees Mentioned
Name
Title
Context
Iby Strong
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Denise Notter
Executive Director
Met with Licensing Program Analyst during the investigation and exit interview
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies observed or cited during the inspection. All required safety measures, equipment, and postings were present and in order.
An unannounced required one-year inspection was conducted to ensure substantial compliance with Title 22 regulations.
Findings
The facility was found to be in substantial compliance with regulations, with operational safety features, sanitary conditions, proper food storage, adequate staff certifications, and resident dignity maintained throughout the visit.
Report Facts
Residents bedridden allowed: 15Hospice waiver approved residents: 20Sampled resident units during tour: 10Food supply days: 2Food supply days: 7
Employees Mentioned
Name
Title
Context
Mark Alsop
Administrator
Facility Administrator who accompanied the Licensing Program Analyst during the inspection and was involved in the exit interview.
Amy Rodgers
Licensing Program Analyst
Conducted the unannounced one-year inspection and authored the report.
An unannounced Case Management visit was conducted by the Licensing Program Analyst to secure report signatures and deliver an amended report.
Findings
The Licensing Program Analyst identified himself, explained the purpose of the visit to the Executive Director, secured report signatures, delivered an amended report, and conducted an exit interview with the Executive Director.
Employees Mentioned
Name
Title
Context
Mark Alsop
Executive Director
Met during the visit and participated in the exit interview.
The visit was an unannounced Case Management inspection conducted in response to an Incident Report and a Death Certificate submitted for Resident #1, who sustained a fall and subsequently passed away.
Findings
No health and safety concerns were identified and no deficiencies were cited during the visit. A tour of the facility was conducted and pertinent records were secured.
Employees Mentioned
Name
Title
Context
Mark Alsop
Executive Director
Met during the visit and involved in exit interview
The visit was initiated to cite a deficiency in response to a self-reported incident where a resident was absent without leave (AWOL) from the facility and returned by local law enforcement on the same day.
Findings
A deficiency was cited for failure to ensure an adequate number of direct care staff to support residents, evidenced by the AWOL incident involving one resident who left the facility unobserved and was absent for approximately one hour.
Complaint Details
The visit was complaint-related due to a self-reported incident of a resident absent without leave (AWOL) on November 29, 2022. The resident was returned by law enforcement the same day. No injuries were reported.
Deficiencies (1)
Description
Failure to ensure an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal, evidenced by an AWOL incident involving one resident.
Report Facts
Deficiencies cited: 1Resident count during visit: 50Total licensed capacity: 60
Employees Mentioned
Name
Title
Context
Mark Alsop
Director
Facility Director involved in the visit and Plan of Correction development
The inspection was an unannounced Required 1-Year Visit conducted to evaluate the facility's compliance with licensing requirements and infection control practices.
Findings
The Licensing Program Analyst observed the facility's implementation of the COVID-19 Mitigation Plan and infection control measures, finding the facility in compliance with no deficiencies noted during the visit.
Employees Mentioned
Name
Title
Context
Denise Notter
Program Director
Met with Licensing Program Analyst during the inspection and participated in the exit interview.
Sabel Martinez
Licensing Program Analyst
Conducted the unannounced Required 1-Year Visit and evaluation.
The visit was an unannounced Case Management Visit to follow up on events self-reported by the licensee, specifically regarding an unusual incident and death report involving a resident.
Findings
The Licensing Program Analyst toured the facility, performed welfare checks, and reviewed pertinent care records. The case requires further investigation, and no deficiencies were cited during this visit.
Complaint Details
The visit was triggered by an LIC624 Unusual Incident Report and an LIC624A Death Report concerning Resident #1, who was found deceased with head trauma after being last seen two hours earlier. The reports were self-reported by the licensee.
Report Facts
Capacity: 60Census: 29
Employees Mentioned
Name
Title
Context
Mark Alsop
Executive Director
Met with Licensing Program Analyst during the visit and involved in the exit interview
Licensing Program Analyst Laarni Santiago visited the facility to conduct an annual required licensing inspection.
Findings
The inspection verified compliance with infection control practices including COVID-19 mitigation measures. No deficiencies were cited during the visit.
Employees Mentioned
Name
Title
Context
Mark Alsop
Administrator
Met with Licensing Program Analyst during inspection and discussed the purpose of the visit.
Laarni Santiago
Licensing Program Analyst
Conducted the annual required licensing inspection.
Simon Jacob
Licensing Program Manager
Named in the report as Licensing Program Manager.
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