Inspection Reports for Almond Grove Assisted Living

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.

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).

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The visit was an unannounced annual inspection conducted to ensure the health and safety of residents in care at Almond Grove Assisted Living Facility.

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.

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.

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.

The visit was related to a case management incident involving resident R1. The case is under review and no substantiation status is provided.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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).

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

An unannounced complaint investigation was conducted in response to an allegation that staff do not provide proper assistance to residents in care.

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.

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.

The inspection visit was an unannounced complaint investigation conducted in response to an allegation that staff tried to hit a resident in care.

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.

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.

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.

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.

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.

The inspection was an unannounced Required 1 Year Inspection conducted to evaluate the facility's compliance, including infection control protocols.

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.

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.

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.

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.

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.