Inspection Report Summary
Most inspections found no deficiencies, including the most recent report on October 2, 2025, which was clean with no issues noted. Several complaint investigations were unsubstantiated, showing that many concerns raised by residents or others were not supported by evidence. However, some deficiencies were cited over time, mainly related to resident care and supervision, such as a resident fall caused by staff losing balance in May 2025, and failure to follow a resident’s DNR order in November 2024. The facility also received a $500 civil penalty for the fall incident, but no license suspensions or revocations were reported. The pattern suggests improvement, as recent annual inspections have been free of deficiencies after earlier isolated issues.
Deficiencies (last 5 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a October 2025 inspection.
Census over time
Inspection Report
| Name | Title | Context |
|---|---|---|
| Jessica Padron | Resident Care Director | Met with during the inspection and discussed updated findings. |
| LaVette Farlow | Licensing Program Analyst | Conducted the unannounced visit and amended the report. |
| Matt Ryan | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Matt Ryan | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview. |
| Jessica Padron | Resident Care Director | Accompanied Licensing Program Analyst during inspection and participated in exit interview. |
| Daniel Belk | Building Service Director | Accompanied Licensing Program Analyst during inspection. |
| Lavette Farlow | 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| Name | Title | Context |
|---|---|---|
| Sarina Ramirez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Matt Ryan | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lavette Farlow | Licensing Program Analyst | Conducted the complaint investigation |
| Matt Ryan | Executive Director | Met with Licensing Program Analyst during investigation |
| Leeann Hefner | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lavette Farlow | Licensing Program Analyst | Conducted the complaint investigation |
| Matt Ryan | Executive Director | Met with Licensing Program Analyst during investigation |
| Leeann Hefner | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lavette Farlow | Licensing Program Analyst | Conducted the complaint investigation |
| Ted Burgess | Interim Administrator | Facility representative met during the investigation |
| Nedra Brown | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lavette Farlow | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ted Burgess | Interim Administrator | Facility representative met during the investigation and exit interview |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Jessica Padron | Resident Care Director | Met with Licensing Program Analysts during the inspection and named in the exit interview. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Melody Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Efren Malagon | Licensing Program Manager | Oversaw the complaint investigation |
| Patricia Gustin | Executive Director | Facility representative met during the investigation and exit interview |
| Helen Jaquez | Business Office Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Patricia Gustin | Executive Director | Met with Licensing Program Analyst during investigation |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Amber Coleman | Licensing Program Analyst | Conducted the unannounced complaint visit and licensing evaluation. |
| Gabriel Salazar | Resident Care Director | Met with Licensing Program Analyst during the visit and agreed to coordinate completion of Physician's Reports. |
| Leeann Hefner | Administrator | Named in relation to the deficiency regarding outdated Physician's Reports. |
| Nedra Brown | Licensing Program Manager / Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Amber Coleman | Licensing Program Analyst | Conducted the complaint investigation |
| Patricia Gustin | Executive Director | Met with Licensing Program Analyst during investigation |
| Mark Cunningham | Building Services Director | Provided information on call light system and kitchen dishwasher |
| Leeann Hefner | Administrator | Facility administrator named in report header |
| Nedra Brown | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Amber Coleman | Licensing Program Analyst | Conducted the inspection and authored the report |
| Nedra Brown | Licensing Program Manager | Supervisor overseeing the inspection |
| Helen Jaquez | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Leeann Hefner | Administrator | Named in deficiency for failure to ensure resident supervision and unit security |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Amber Coleman | Licensing Program Analyst | Made the unannounced case management visit and obtained signatures. |
| Gabriel Salazar | Resident Care Director | Met with the Licensing Program Analyst during the visit. |
| Nedra Brown | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Ted Burgess | Facility Executive Leadership | 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 as Licensing Program Manager |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Amber Coleman | Licensing Program Analyst | Conducted the complaint investigation |
| Helen Jaquez | Administrator | Met with Licensing Program Analyst during investigation |
| Gabriel Salazar | Resident Care Director | Participated in exit interview reviewing the report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Amber Coleman | Licensing Program Analyst | Conducted the complaint investigation |
| Ted Burgess | Administrator | Facility representative met during investigation |
| Nedra Brown | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| LeeAnn Hefner | Administrator | Facility administrator interviewed during investigation |
| Karen Clemons | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| LeeAnn Hefner | Administrator | Facility administrator met during the investigation and exit interview |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the unannounced annual inspection visit. |
| Ruth Durham Villa | LVN | Met with the Licensing Program Analyst during the inspection. |
| Angelita H. Jaquez | Business manager who confirmed no COVID-19 cases/exposures. |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Lee Ann Hefner | Executive Director | Met with Licensing Program Analyst during the visit. |
| Rohit Lama | Licensing Program Analyst | Conducted the Case Management Visit and inspection. |
| Nedra Brown | Licensing Program Manager | Named in the report header. |
Inspection Report
Original Licensing| Name | Title | Context |
|---|---|---|
| Lee Ann Hefner | Administrator/Executive Director | Conducted inspection with Licensing Program Analyst |
| Stephanie Williams | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Efren Malagon | Licensing Program Manager | Named in report header and signature |
Inspection Report
Original Licensing| Name | Title | Context |
|---|---|---|
| Leeann Hefner | Executive Director | Applicant/administrator who participated in the licensing evaluation and interview. |
| Jude De La Concepcion | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Bethany Hunter | Licensing Program Analyst | Named as Licensing Program Analyst on the report. |
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