Most inspections at Almond Grove Assisted Living Facility found no deficiencies, with several complaint investigations unsubstantiated. However, some reports cited deficiencies related primarily to resident supervision and medication management, including a substantiated medication error posing an immediate health risk in the most recent report dated October 6, 2025. Earlier issues involved failures to properly supervise a resident who left the facility unattended, resulting in immediate civil penalties, and infection control lapses during a COVID-19 case in April 2023. The facility showed improvement in infection control and incident reporting over time, but supervision and medication errors remain areas of concern. Several complaint investigations found no violations, indicating that many allegations were unsubstantiated.
The inspection visit was conducted as a Case Management visit regarding an incident that occurred on 2025-09-29 involving a medication error at the facility.
Findings
The facility administered wrong medications to resident R1, which posed an immediate health and safety risk to residents in care. Deficiencies were cited pursuant to California Code of Regulations, Title 22, Section 87465(a)(4).
Complaint Details
The visit was complaint-related due to a medication error incident reported on 2025-09-29, substantiated by incident report, staff interviews, and medication record review.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by administering wrong medications to resident R1, posing an immediate health and safety risk.
Type A
Report Facts
Facility capacity: 78Resident census: 62Plan of Correction due date: Oct 7, 2025
Employees Mentioned
Name
Title
Context
Tiffany Gibson
Staff, LVN
Met with during inspection and associated with medication error incident
Talwinder Bains
Licensing Program Analyst
Conducted the inspection visit and signed the report
An unannounced complaint investigation visit was conducted in response to multiple allegations including failure to follow infection control guidelines, preventing outbreak of contagious disease, ensuring staff training, providing adequate food service, and following reporting requirements.
Findings
The investigation found all allegations to be unfounded. The facility was following infection control guidelines during a recent COVID-19 outbreak, staff had required training, food services were adequate despite temporary dining room closure, and reporting requirements were properly followed.
Complaint Details
The complaint investigation was triggered by allegations that staff did not follow infection control guidelines, failed to prevent a contagious disease outbreak, lacked required training, did not provide adequate food service, and did not follow reporting requirements. All allegations were found to be unfounded after observations, record reviews, and interviews with staff and residents.
The visit was an unannounced case management incident follow-up conducted by Licensing Program Analyst Talwinder Bains to review an incident reported by the facility involving residents R1 and R2.
Findings
The department followed up on the incident report sent by the facility and confirmed that law enforcement and the long term care ombudsman were notified. The case is under review with no citations issued at this time per Title 22 Regulations.
Report Facts
Capacity: 78Census: 59
Employees Mentioned
Name
Title
Context
Tiiffany Gibson
Staff, LVN
Met with Licensing Program Analyst during the visit
The visit was an unannounced case management visit conducted regarding an incident report and SOC 341 received by the department concerning residents R1 and R2 for the date 05/30/2025.
Findings
The facility took appropriate action regarding the incident involving residents R1 and R2. Both residents were at their baseline with no other related incidents, and the facility notified all required parties. No deficiencies were cited due to this incident.
Employees Mentioned
Name
Title
Context
Darrell Price
Administrator
Met with Licensing Program Analyst during the case management visit and involved in incident review.
Talwinder Bains
Licensing Program Analyst
Conducted the unannounced case management visit and incident review.
The visit was an unannounced case management inspection conducted to review incident reports related to several residents, including hospitalizations and safety concerns, as well as a complaint investigation regarding pre-admission appraisal documentation.
Findings
The facility appropriately managed incidents involving residents, including hospitalizations and falls, with no deficiencies cited. However, a complaint investigation found missing signatures on a pre-admission appraisal document. Technical Assistance was issued but no regulatory deficiencies were cited.
Complaint Details
During the complaint investigation (59-AS-20250502153659), it was noted that the pre-admission appraisal for resident R4 lacked signatures from the resident and/or responsible party as required by regulations.
Report Facts
Facility capacity: 78Census: 57Incident dates: 5
Employees Mentioned
Name
Title
Context
Darrell Price
Administrator
Met with Licensing Program Analyst during inspection and involved in incident management
Talwinder Bains
Licensing Program Analyst
Conducted the unannounced case management visit and complaint investigation
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2025-05-02 regarding inadequate supervision resulting in resident elopement and inadequate bathing service to resident care.
Findings
The investigation found both allegations to be unsubstantiated. The resident did elope but it was not due to lack of staff supervision, and bathing services were provided adequately with no concerns noted.
Complaint Details
The complaint alleged that facility staff did not provide adequate supervision resulting in resident elopement and did not provide adequate bathing service to resident care. After records review and staff interviews, it was concluded that the elopement was not due to staff negligence and bathing services were adequate. Therefore, the allegations were found to be unsubstantiated.
Report Facts
Facility capacity: 78Census: 57Complaint received date: May 2, 2025Resident shower assistance count: 5Resident shower assistance count: 6
Employees Mentioned
Name
Title
Context
Darrell Price
Administrator
Met with Licensing Program Analyst during the complaint investigation
The inspection was conducted as a case management visit related to a SOC341 (Report of Suspected Abuse) involving two residents, following an incident reported on 05/02/2025.
Findings
The facility timely reported the incident to the Department, law enforcement, family members, and physicians. No injuries were sustained by the residents involved, and no deficiencies were issued in this report.
Complaint Details
The complaint involved an incident on 05/01/2025 where one resident grabbed another by the shirt and threw a cup of ice. The incident was reported by the facility on 05/02/2025. The complaint was substantiated as the incident occurred, but no injuries resulted.
Report Facts
Capacity: 78Census: 57
Employees Mentioned
Name
Title
Context
Tiiffany Gibson
Licensed Vocational Nurse (LVN)
Met with during inspection and involved in incident response
The visit was an unannounced case management incident inspection to follow up on a report of alleged abuse of resident R1, as reported by the facility on 04/04/25.
Findings
The department interviewed resident R1 and staff regarding the alleged abuse incident. Facility records showed no visible injuries to R1 and that R1 was at their baseline. No citations were issued during this visit, and the case remains under review with further follow-up if warranted.
Complaint Details
The complaint involved an allegation by resident R1 of abuse while in care. The facility notified R1's responsible party, law enforcement, and the Long-Term Care Ombudsman. The complaint is currently under review with no substantiation or citations issued at this time.
Employees Mentioned
Name
Title
Context
Talwinder Bains
Licensing Program Analyst
Conducted the unannounced case management visit and interviewed staff and resident regarding the incident.
Jasmine Malone
Staff
Met with Licensing Program Analyst during the visit and provided information regarding the incident.
Darrell Price
Administrator/Director
Named as facility administrator/director in the report header.
The visit was an unannounced annual inspection conducted to ensure the health and safety of residents in care at Almond Grove Assisted Living Facility.
Findings
The facility was found to be clean, safe, sanitary, and in good condition with no deficiencies observed or cited. Staff and resident files were reviewed and found to be compliant, medications were properly managed and secured, and required drills and safety measures were in place.
Report Facts
Residents files reviewed: 5Staff files reviewed: 5Residents medications reviewed: 2Facility temperature range: 72Hot water temperature range: 110Facility capacity: 78Facility census: 56
Employees Mentioned
Name
Title
Context
Darrel Price
Administrator
Met with Licensing Program Analyst and assisted with the inspection
Talwinder Bains
Licensing Program Analyst
Conducted the annual inspection
Tosha Devi
Assistant Director
Met with Licensing Program Analyst and explained the purpose of the visit
The visit was an unannounced case management incident follow-up to review an incident involving resident R1, as reported by the facility on 01/02/25.
Findings
No visible injuries were found on resident R1 after the incident, and R1 was at their baseline. The department interviewed involved parties and requested related documents, with no citations issued at this time.
Complaint Details
The visit was related to a case management incident involving resident R1. The case is under review and no substantiation status is provided.
Report Facts
Capacity: 78Census: 52
Employees Mentioned
Name
Title
Context
Talwinder Bains
Licensing Program Analyst
Conducted the case management visit and interview
Tosha Devi
Assistant Director
Met with Licensing Program Analyst during the visit
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2024-10-29 regarding staff misconduct and facility conditions at Almond Grove Assisted Living Facility.
Findings
The investigation included record reviews, facility observations, and interviews with four residents and four staff members. All nine allegations, including staff stealing money, mishandling medication, missing meals, facility disrepair, searching personal belongings, lack of clean towels, disrespectful treatment, and staff testing positive for COVID, were found to be unfounded based on evidence and interviews.
Complaint Details
The complaint investigation was triggered by nine allegations: staff stealing resident’s money, mishandling medication, not providing lunch, facility heat and air conditioner disrepair, searching residents' personal belongings, not providing comfortable room temperature, lack of clean towels, disrespectful treatment, and staff testing positive for COVID. All allegations were investigated and found to be unfounded.
Report Facts
Number of allegations: 9Residents interviewed: 4Staff interviewed: 4
Employees Mentioned
Name
Title
Context
Talwinder Bains
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Tosha Devi
Assistant Director
Met with Licensing Program Analyst during the visit
Darrell Price
Administrator
Facility administrator named in the report
Laura Munoz
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
The visit was an unannounced complaint investigation conducted to investigate allegations that staff were not following residents' medical care plans and that staff did not conduct resident's medical assessments prior to admissions.
Findings
The investigation found the allegation that staff were not following residents' medical care plans to be unsubstantiated, with interviews and record reviews indicating care needs were met and followed. The allegation that staff did not conduct resident medical assessments prior to admission was found to be unfounded, with documentation showing assessments were completed timely and appropriately.
Complaint Details
The complaint investigation was triggered by allegations that staff were not following residents' medical care plans and did not conduct medical assessments prior to admissions. The first allegation was found unsubstantiated, and the second was found unfounded.
Report Facts
Capacity: 78Census: 56
Employees Mentioned
Name
Title
Context
Talwinder Bains
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Tosha Devi
Assistant Director
Met with Licensing Program Analyst during the visit
The unannounced case management visit was conducted due to an incident involving resident R1 leaving the facility unattended on 2024-11-02, which was reported in an Unusual Incident/Injury Report submitted on 2024-11-04.
Findings
The facility failed to provide proper care and supervision to resident R1, who has dementia and cannot leave unassisted, resulting in R1 leaving the facility unattended. Immediate civil penalties were assessed due to repeat violations of the same regulation within 12 months.
Complaint Details
The visit was complaint-related due to an incident where resident R1 left the facility unattended. The incident was substantiated as the facility failed to provide adequate supervision, posing an immediate risk to resident safety.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Facility did not provide proper care or supervision to resident R1 on 11/02/24, resulting in R1 leaving the facility unattended, posing an immediate risk to health and safety of residents.
Type A
Report Facts
Civil penalty amount: 250Deficiency count: 1
Employees Mentioned
Name
Title
Context
Talwinder Bains
Licensing Program Analyst
Conducted the unannounced case management visit and authored the report.
Tosha Devi
Assistant Director
Met with Licensing Program Analyst during the visit.
Darrell Price
Administrator/Director
Named as facility administrator/director.
Laura Munoz
Licensing Program Manager
Supervisor and Licensing Program Manager overseeing the evaluation.
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not provide adequate supervision to residents and did not have adequate staffing to meet residents' needs.
Findings
The allegation that staff did not provide adequate supervision was substantiated based on evidence that a resident left the facility unattended, posing an immediate risk to health and safety. The allegation regarding inadequate staffing was found to be unsubstantiated after review of records and interviews indicating adequate staffing levels.
Complaint Details
The complaint alleged that staff did not provide adequate supervision to residents and did not have adequate staffing to meet residents' needs. The supervision allegation was substantiated; the staffing allegation was unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Failure to provide proper care and supervision to residents with elopement risk, resulting in a resident leaving the facility unattended.
Type A
Report Facts
Capacity: 78Census: 58Plan of Correction Due Date: Jul 19, 2024
Employees Mentioned
Name
Title
Context
Talwinder Bains
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Laura Munoz
Licensing Program Manager
Oversaw complaint investigation
Tosha Devi
Assistant Director
Met with Licensing Program Analyst during inspection
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2024-02-28 regarding alleged failures in timely medical attention, notification of resident's representative, and resident care.
Findings
The investigation found all allegations to be either unfounded or unsubstantiated after interviews with staff, residents, and record reviews. The facility was found to have properly documented and responded to resident health needs, notified responsible parties appropriately, and maintained sanitary conditions.
Complaint Details
The complaint investigation addressed three allegations: 1) Facility staff did not seek medical attention for a resident in a timely manner (unfounded). 2) Staff did not notify resident’s representative of incidents (unfounded). 3) Staff left resident in soiled diapers for an extended period of time (unsubstantiated).
Report Facts
Capacity: 78Census: 58Staff interviewed: 3Residents interviewed: 2Hours between resident checks: 2Hours per day staff supervise residents: 24
Employees Mentioned
Name
Title
Context
Talwinder Bains
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Tosha Devi
Assistant Director
Met with Licensing Program Analyst during the visit
The visit was an unannounced case management inspection conducted to investigate complaints regarding failure to report incidents involving residents R1 and R2 as required by Title 22 regulations.
Findings
The facility failed to report multiple incidents involving residents R1 and R2 to the Department within the required timeframes, violating Title 22 Regulation 87211. Citations were issued for these reporting deficiencies.
Complaint Details
The complaint investigation revealed that resident R1 had fall incidents on 07/20/23 and 10/12/23 and was placed in a Skilled Rehab Facility from 06/26/23 to 07/19/23. Resident R2 had an AWOL incident on 06/23/24 and was found unattended 0.5 miles from the facility. Both incidents were not reported to the Department as required.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Failure to report incidents threatening the welfare, safety, or health of residents R1 and R2 to the Department as required by Title 22 Regulation 87211.
Type B
Report Facts
Facility capacity: 78Resident census: 58Plan of Correction due date: Aug 1, 2024
The visit was an unannounced case management follow-up on an incident report regarding a resident's alleged fall in a transportation vehicle on 05/24/2024.
Findings
The department found no evidence of a fall after reviewing transportation footage and assessing the resident, who refused ambulance assessment but was advised to visit the ER. No injuries were observed and no citations were issued.
Complaint Details
The complaint involved an alleged fall of resident R1 in a non-medical ambulance during transport. The allegation was investigated through interviews, footage review, and resident assessment. The complaint remains under review with no substantiation or citations issued at this time.
Report Facts
Incident report date: May 24, 2024Document submission deadline: May 31, 2024
Employees Mentioned
Name
Title
Context
Talwinder Bains
Licensing Program Analyst
Conducted the case management visit and investigation
Tosha Devi
Assistant Director
Met with Licensing Program Analyst during visit and involved in incident follow-up
The inspection was an unannounced complaint investigation visit conducted in response to allegations that staff did not administer residents' medications as prescribed, did not assist residents with activities of daily living (ADLs), and did not assist residents with ambulating.
Findings
The investigation included facility observations, record reviews, and interviews with staff and residents. All allegations were found to be unsubstantiated as records and interviews indicated proper medication administration, assistance with ADLs, and ambulation support were provided without issues.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to administer medications as prescribed, failure to assist with ADLs, and failure to assist with ambulating. Investigations showed proper medication logs, timely assistance with ADLs despite occasional delays due to staff attending other residents, and adequate ambulation support. No substantiated violations were found.
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-02-13 regarding allegations of staff not following physician's instructions, not ensuring resident's oxygen tank accessibility, and not providing meals or beverages as requested.
Findings
The investigation involved records review, facility observations, and interviews with staff and residents. All allegations were found to be unsubstantiated based on evidence that the facility followed physician's orders, residents had access to oxygen tanks, and residents were satisfied with food and beverage services.
Complaint Details
The complaint included multiple allegations: staff not following physician's instructions, staff not ensuring resident's oxygen tank accessibility, and staff not providing meals or beverages as requested. The investigation found all allegations to be unsubstantiated.
Report Facts
Complaint Control Number: 59Facility Capacity: 78Census: 60
Employees Mentioned
Name
Title
Context
Talwinder Bains
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Laura Munoz
Licensing Program Manager
Named in report as Licensing Program Manager overseeing the investigation
Tosha Devi
Assistant Director
Met with Licensing Program Analysts during the visit
The inspection was an unannounced required 1 year inspection conducted by Licensing Program Analysts to evaluate compliance with care regulations at Almond Grove Assisted Living Facility.
Findings
The inspection found multiple deficiencies including unsecured access to chemicals in the laundry room, incomplete personnel and resident records, lack of required staff training and certifications, and missing required resident appraisals and medical assessments for dementia care.
Severity Breakdown
Type A: 1Type B: 5
Deficiencies (6)
Description
Severity
Second door of laundry room containing chemicals and cleaning supplies was accessible to residents, posing an immediate health and safety risk.
Type A
2 out of 5 staff files lacked initial training upon hire.
Type B
4 out of 5 staff do not have required first aid certification.
Type B
3 out of 5 resident files lacked pre-admission appraisal (LIC621).
Type B
2 out of 2 residents with dementia diagnosis lacked updated LIC602 and reappraisal.
Type B
4 out of 5 staff files lacked health screening and TB test documentation.
Type B
Report Facts
Staff files lacking initial training: 2Staff lacking first aid certification: 4Resident files lacking pre-admission appraisal: 3Residents with dementia lacking updated LIC602 and reappraisal: 2Staff files lacking health screening and TB: 4
Employees Mentioned
Name
Title
Context
Darrell Price
Administrator
Met with Licensing Program Analysts during inspection and named in plan of correction
An unannounced complaint investigation was conducted in response to an allegation that staff do not provide proper assistance to residents in care.
Findings
The investigation included interviews with staff and residents, record reviews, and facility observations. It was found that residents' activities of daily living (ADLs) were met as required, staff provided care professionally, and residents appeared well cared for. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint allegation was that staff do not provide proper assistance to residents in care. The allegation was found to be unsubstantiated after investigation including interviews and record review.
Report Facts
Capacity: 78Census: 57
Employees Mentioned
Name
Title
Context
Tosha Devi
Assistant Director
Met with Licensing Program Analyst during inspection and exit meeting
The inspection visit was an unannounced complaint investigation conducted in response to an allegation that staff tried to hit a resident in care.
Findings
The investigation included interviews with staff and residents, a facility tour, and observations. No evidence was found to support the allegation, and the complaint was determined to be unfounded. Facility staff were observed treating residents with dignity and respect.
Complaint Details
The complaint alleged that staff tried to hit a resident in care. After investigation, including interviews and observations, the allegation was found to be unfounded, meaning it was false or without reasonable basis.
Report Facts
Capacity: 78Census: 55
Employees Mentioned
Name
Title
Context
Talwinder Bains
Licensing Program Analyst
Conducted the complaint investigation
Laura Munoz
Licensing Program Manager
Named in report as Licensing Program Manager
Tosha Devi
Assistant Director
Met with Licensing Program Analyst during inspection
Unannounced complaint investigation visit conducted due to allegations that the facility did not ensure COVID safety procedures were followed and that staff did not ensure accurate information was provided to residents' responsible parties.
Findings
The investigation substantiated that the facility failed to separate residents when one tested positive for COVID-19, violating infection control guidelines. Another allegation regarding inaccurate information provided to residents' responsible parties was found unsubstantiated.
Complaint Details
The complaint investigation was substantiated for failure to follow COVID-19 infection control procedures, specifically failure to isolate a COVID-positive resident. The allegation that staff did not provide accurate information to residents' responsible parties was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Facility did not separate R1 from R2 when R2 tested positive for COVID-19 in December 2022, posing potential health risks.
Type B
Report Facts
Capacity: 78Census: 55Plan of Correction Due Date: May 3, 2023
Employees Mentioned
Name
Title
Context
Talwinder Bains
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Laura Munoz
Licensing Program Manager
Oversaw the complaint investigation
Tosha Devi
Assistant Director
Met with Licensing Program Analyst during inspection
The inspection was an unannounced Required 1 Year Inspection conducted to evaluate the facility's compliance, including infection control protocols.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited during this inspection.
Report Facts
Capacity: 78Census: 48
Employees Mentioned
Name
Title
Context
Darrell Price
Administrator
Facility administrator who gave permission to conduct the inspection
Santoshna Devi
Staff
Staff member who met with Licensing Program Analyst and assisted during inspection
Talwinder Bains
Licensing Program Analyst
Conducted the inspection
Laura Munoz
Licensing Program Manager
Named in report header
Inspection Report Original LicensingCensus: 46Capacity: 78Deficiencies: 5Mar 3, 2022
Visit Reason
The visit was a pre-licensing inspection conducted as part of a change in ownership application for Almond Grove Assisted Living Facility to ensure compliance with Title 22 regulations.
Findings
The facility was generally found to be properly furnished and maintained, with operational smoke and carbon monoxide detectors and fire extinguishers. However, deficiencies included one fire extinguisher needing service, a non-operational door sensor, debris and tools in the courtyard, missing items in staff and resident files, and sinks missing hand washing signs and covered trash receptacles. The facility was instructed to correct these issues within 7 days.
Deficiencies (5)
Description
One fire extinguisher needs to be serviced
Sensor on one door was not operational
Debris and tools were in courtyard area
Files for staff and resident were missing items
Sinks were missing hand washing signs and covered trashes
Report Facts
Number of resident files reviewed: 5Number of staff files reviewed: 5Fire clearance capacity: 78Number of bedrooms: 40Number of bathrooms: 40Hot water temperature: 114Perishable food supply: 2Nonperishable food supply: 7
Employees Mentioned
Name
Title
Context
Darrel Price
Administrator
Met with Licensing Program Analysts during pre-licensing visit
Michael Hood
Licensing Program Analyst
Conducted pre-licensing inspection
Talwinder Bains
Licensing Program Analyst
Conducted pre-licensing inspection and signed report
Laura Munoz
Licensing Program Manager
Named in report as Licensing Program Manager
Inspection Report Original LicensingCensus: 47Capacity: 78Deficiencies: 0Feb 22, 2022
Visit Reason
The visit was conducted as a Component II evaluation by the Community Care Licensing Division (CAB) to assess the applicant/administrator's understanding of licensing requirements and facility operation for Almond Grove Assisted Living Facility.
Findings
The applicant/administrator successfully completed the Component II evaluation via telephone, demonstrating understanding of Title 22 regulations, facility operation, staff qualifications, program policies, and other licensing requirements. No deficiencies or violations were noted in the report.
Report Facts
Capacity: 78Census: 47
Employees Mentioned
Name
Title
Context
Darrell Price
Applicant/Administrator
Participated in Component II evaluation
Julia Kim
Licensing Program Manager
Named in report header
Thai Doan
Licensing Program Analyst
Conducted Component II evaluation
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