Inspection Report Summary
Most inspections found no deficiencies, with the most recent report on November 12, 2024, showing full compliance with health and safety regulations and no violations. Earlier complaint investigations in 2023 substantiated that staff did not respond promptly to resident call buttons, but other concerns like staffing levels and resident dignity were unsubstantiated. In 2021, the facility had deficiencies related to restricting resident visitation and failing to report serious incidents, which posed immediate health and safety risks at that time. Since then, inspections have been clean, indicating improvement in compliance and resident care practices. Several complaint investigations were unsubstantiated, and no fines or enforcement actions were listed in the available reports.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
0.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
80% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
69% occupied
Based on a November 2024 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 25
Capacity: 36
Deficiencies: 0
Date: Nov 12, 2024
Visit Reason
The inspection was an unannounced required annual evaluation visit to assess compliance with Title 22 regulations for a Residential Care Facility for the Elderly (RCFE).
Findings
The facility was found to be in compliance with health and safety regulations, including proper food service, clean and appropriate furnishings, adequate emergency preparedness, and proper medication storage. No hazards or violations were observed during the inspection.
Report Facts
Maximum capacity: 36
Bedridden residents allowed: 10
Hospice care waiver: 20
Inspection start time: 12
Inspection end time: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Phillips | Licensing Program Analyst | Conducted the inspection and authored the report |
| Dalia Gutierrez | Associate Executive Director | Facility representative who met with the Licensing Program Analyst during the inspection |
| Mitchell Leichter | Administrator/Director | Facility Administrator named in the report |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 22
Capacity: 36
Deficiencies: 1
Date: Dec 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 07/09/2021 regarding staff response times to resident call buttons and other resident care concerns.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not answer resident call buttons in a timely manner. Other allegations regarding staffing sufficiency, rough handling, dignity, and safeguarding belongings were unsubstantiated.
Findings
The investigation substantiated that staff did not respond to resident call buttons in a timely manner, with documented response times exceeding 20 minutes on multiple occasions. Other allegations including insufficient staffing, rough handling of residents, lack of dignity in staff-resident relationships, and failure to safeguard belongings were found to be unsubstantiated.
Deficiencies (1)
Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall... This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when the signal system went unanswered for an extended period of time, which posed a potential health and safety risk to residents in care.
Report Facts
Call response times: 20
Call response times: 10
Call response times: 4
Call response times: 1
Call response times: 2
Facility capacity: 36
Facility census: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation and issued final findings |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation report |
| Dahlia Gutierrez | Business Office Manager | Met with Licensing Program Analyst during the investigation |
| Mitchell Leichter | Administrator | Facility administrator mentioned in relation to staff performance and investigation |
Inspection Report
Annual Inspection
Census: 26
Capacity: 36
Deficiencies: 0
Date: Nov 20, 2023
Visit Reason
The inspection was an unannounced Annual facility Site Inspection Visit conducted to ensure compliance with Title 22 Regulations for a Residential Care Facility for the Elderly (RCFE).
Findings
The facility was found to be in compliance with health and safety regulations, including proper kitchen sanitation, safe medication storage, adequate infection control measures, and well-maintained common areas and resident rooms. No deficiencies were cited during the inspection.
Report Facts
Licensed capacity: 36
Current census: 26
Bedridden residents allowed: 10
Hospice waiver residents: 20
Inspection start time: 930
Inspection end time: 1530
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mitchell Leichter | Administrator | Met with Licensing Program Analyst during inspection |
| Brian Phillips | Licensing Program Analyst | Conducted the annual inspection |
Inspection Report
Annual Inspection
Census: 25
Capacity: 36
Deficiencies: 0
Date: Oct 20, 2022
Visit Reason
The inspection was a required unannounced 1-year infection control annual visit to evaluate compliance with infection control policies and procedures.
Findings
The facility demonstrated full implementation and adherence to infection control protocols including screening, PPE use, isolation procedures, and staff training. The facility maintains adequate PPE supplies, follows current guidance, and has valid certifications and safety equipment inspections.
Report Facts
PPE supply duration: 30
Resident medication supply duration: 30
Number of residents: 25
Facility capacity: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Corinne Satterthwaite | Licensed Vocational Nurse (LVN) | In charge of infection control and provides training and education to staff, residents, and visitors |
| Mitchell Leichter | Administrator | Facility Administrator with a plan in place for outbreak notification and emergencies |
| Karen Dacome | Associate Executive Director | Met with Licensing Program Analyst during inspection and assisted with facility tour |
| Diego Cortez | Licensing Program Analyst | Conducted the on-site 1-year infection control annual visit |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 26
Capacity: 36
Deficiencies: 0
Date: Sep 29, 2021
Visit Reason
The visit was a Case Management investigation to review various incidents that occurred from 07/18/2021 through 09/29/2021 at the facility.
Complaint Details
Investigation of various incidents reported between 07/18/2021 and 09/29/2021; further investigation planned; no deficiencies issued at this time.
Findings
The Licensing Program Analyst conducted interviews and requested documents related to the investigation but due to time constraints, further investigation was needed. No deficiencies were issued during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mitchell Leichter | Administrator | Met with Licensing Program Analyst during investigation |
| Kristin Kontilis | Licensing Program Analyst | Conducted the Case Management visit and investigation |
| Kelly Burley | Licensing Program Manager | Named in report header |
Inspection Report
Follow-Up
Census: 25
Capacity: 36
Deficiencies: 1
Date: Jul 16, 2021
Visit Reason
This Case Management visit was conducted to address deficiencies noted during a complaint investigation visit on 7/16/2021, specifically to discuss the serious illness/injury reporting requirement as per regulation 87211(a)(1)(D).
Complaint Details
The visit was conducted to address deficiencies noted during Complaint Control #29-AS-20210709080012 investigation visit conducted on 7/16/2021.
Findings
The visit found that four fall incidents occurred between 6/25/2021 and 7/16/2021 that were not reported to the Community Care Licensing (CCL) as required, posing an immediate health and safety risk to residents.
Deficiencies (1)
Failure to report serious illness/injury incidents (four fall incidents between 6/25/2021 and 7/16/2021) to CCL as required by regulation 87211(a)(1)(D).
Report Facts
Fall incidents not reported: 4
Capacity: 36
Census: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dahlia Gutierrez | Business Office Manager | Stated that the falls were not reported to CCL during the visit. |
| Kelly Burley | Licensing Program Manager | Supervisor named in the report. |
| Kristin Kontilis | Licensing Program Analyst | Licensing evaluator who conducted the visit and signed the report. |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 36
Deficiencies: 1
Date: Jul 16, 2021
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 07/09/2021 regarding restricted visitation at the facility.
Complaint Details
The complaint alleging restricted visitation was substantiated based on interviews and document reviews showing visitation was limited to two visitors at specific times and days by appointment only.
Findings
The investigation substantiated that the facility restricted visitation by allowing residents only two visitors at a time on specific days and times by appointment only, which is a violation of residents' personal rights and poses an immediate health and safety risk.
Deficiencies (1)
Failure to allow residents to have visitors, including ombudspersons and advocacy representatives, visit privately during reasonable hours and without prior notice, infringing on residents' personal rights.
Report Facts
Capacity: 36
Census: 25
Visitors allowed: 2
Visitation days: 4
Visitation times per day: 3
Visitation duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation process |
| Dalia Gutierrez | Business Office Manager | Interviewed during investigation and involved in visitation policy discussions |
Inspection Report
Follow-Up
Census: 20
Capacity: 36
Deficiencies: 0
Date: Feb 17, 2021
Visit Reason
The visit was a case management follow-up conducted telephonically due to a self-reported incident involving Resident #1 who alleged personal rights violations by Staff #1 on three occasions.
Complaint Details
The visit was triggered by a complaint from Resident #1 reporting personal rights violations by Staff #1 on three separate occasions. Staff #1 is currently on leave pending investigation.
Findings
No immediate health and safety hazards were observed during the visit. Staff #1 is on leave pending investigation, and further investigation will be conducted by the Community Care Licensing Division's Investigations Branch.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mitchell Leichter | Administrator | Met with Licensing Program Analyst during the case management visit. |
| JoAnn Rosales | Licensing Program Analyst | Conducted the case management visit telephonically. |
| Douglas Real | Investigator | Community Care Licensing Division's Investigations Branch Investigator assigned for further investigation. |
Viewing
Loading inspection reports...
