Inspection Reports for Almond Heights

The visit was a Case Management visit regarding an incident that occurred around 2025-09-16 involving a resident not receiving prescribed medication.

The facility failed to administer prescribed medication Carbamazepine ER 400mg to resident R1 on 2025-09-17 and 2025-09-18 due to running out of medication, posing an immediate health and safety risk to residents in care. Deficiencies were cited per California Code of Regulations, Title 22, Section 87465(a)(4).

The visit was complaint-related due to an incident report submitted by the facility stating resident R1 did not receive prescribed medication on specified dates. The deficiency was substantiated based on incident report, staff interviews, and medication record review.

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The visit was conducted as a case management follow-up regarding an incident reported by the facility that occurred on 09/16/2025, where a resident was found unresponsive and later pronounced deceased.

The Licensing Program Analyst met with the facility administrator to review the incident and requested relevant documents related to the event. The incident is under review and further follow-up will be conducted if warranted.

The inspection was conducted as a case management follow-up on a recent AWOL incident involving resident R1 who left the facility unattended on 09/12/2025.

The facility failed to provide adequate care and supervision for resident R1, who has Mild Cognitive Impairment and cannot leave unassisted, resulting in R1 leaving the facility unassisted. Violations were cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

The visit was complaint-related due to an AWOL incident involving resident R1. The incident was substantiated as the facility failed to provide adequate supervision.

An unannounced case management visit was conducted to confirm orders for immediate exclusion of an individual from all facilities.

The facility was informed of an immediate exclusion effective May 14, 2025, prohibiting the excluded individual (S1) from working, living in, or having contact with clients in any residential facility licensed by the California Department of Social Services. The facility was ordered to remove S1 from any contact with clients and prevent physical presence in the facility.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2025-04-10 regarding resident care issues at Almond Heights facility.

The investigation found all allegations either unsubstantiated or unfounded after record reviews, interviews with residents and staff, and facility observations. The complaint that a resident sustained an injury was unsubstantiated, and all other allegations including improper feeding, dirty clothing, untimely hospital pickup, unclean rooms, overmedication, and failure to safeguard belongings were found to be unfounded.

The complaint involved multiple allegations: resident sustained an injury while in care; staff not ensuring proper feeding; staff leaving resident in dirty clothing; staff not picking resident up from hospital timely; staff not cleaning resident's room; staff over medicating a resident; and staff not safeguarding resident's personal belongings. The injury allegation was unsubstantiated, and all other allegations were unfounded based on evidence gathered through interviews, record reviews, and observations.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2025-03-26 regarding wrongful eviction of a resident and failure to issue a refund to the responsible party.

The investigation found both allegations to be unsubstantiated after record reviews, staff and witness interviews. The resident was hospitalized and moved to another facility without eviction notice or refund issues as per the admission agreement and facility ledger.

The complaint involved two allegations: 1) Staff wrongfully evicted a resident, and 2) Staff did not issue a refund to the responsible party. Both allegations were investigated and found to be unsubstantiated based on evidence including hospital records, admission agreement terms, and facility billing records.

The visit was an unannounced case management incident investigation following a report from the facility about missing cash belonging to a resident.

The department followed up on a report that $360 in cash was missing from a resident's room on two separate occasions. The facility and family conducted searches, and the incident is under review with no citations issued at this time.

The complaint involved missing cash totaling $360 from Resident R1's room, reported by the resident and family. The department is reviewing the incident and will follow up if warranted. No substantiation status was stated.

Licensing Program Analysts arrived unannounced to conduct the annual inspection to ensure the health and safety of residents in care.

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 in compliance, and medication administration was correct with no errors.

A virtual meeting was conducted to discuss a situation regarding resident R1's nonpayment of monthly charges and the facility's subsequent actions including eviction notice and potential legal conservatorship.

The facility found that resident R1 was noncompliant with payment policies despite multiple notices and assistance, leading to a 30-day eviction notice. The facility plans to request legal conservatorship to ensure R1's health and safety.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations of staff mistreatment of a resident and illegal eviction.

The investigation included record reviews, staff and resident interviews, and facility observations. Both allegations were found to be unfounded based on evidence that staff acted professionally and no eviction notice was issued.

The complaint involved two allegations: 1) Staff mistreated the resident in care, and 2) Illegal eviction. Both allegations were investigated and found to be unfounded after review of records and interviews with staff and resident R1.

The visit was a Case Management visit regarding an incident that occurred on 2024-09-19 involving a medication error where a resident was given medications not prescribed by their physician.

The facility administered wrong medications to a resident, posing immediate health and safety risks. Deficiencies were cited related to failure to follow physician's medication orders.

The visit was complaint-related due to a medication error incident reported by the facility. The incident was substantiated based on record review, staff interviews, and medication record review.

The visit was an unannounced case management visit to follow up on incidents reported by the facility involving resident care and interactions.

The department reviewed two incidents involving residents: one alleging rough care by staff with no findings after law enforcement involvement, and another involving a resident injury caused by another resident during dinner. No citations were issued, and the incidents remain under review with possible follow-up.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-04-04 alleging staff do not respond to residents' calls for assistance in a timely manner and other related allegations.

The investigation included interviews with residents and staff, record reviews, and observations. The allegation that staff did not respond timely to call lights was found unsubstantiated due to lack of preponderance of evidence. Additional allegations regarding inadequate staff training, unsafe resident transfers, failure to rotate residents to prevent pressure injuries, and untrained staff dispensing medications were all found to be unfounded after interviews and record reviews.

The complaint alleged that staff do not respond to residents' calls for assistance in a timely manner. After investigation, including interviews with six residents and five staff members and review of call light logs, the allegation was found unsubstantiated. Other allegations related to staff training, resident transfers, resident rotation, and medication dispensing were found unfounded.

The visit was an unannounced case management incident follow-up related to a resident fall incident reported by the facility on 05/20/2024.

The department followed up on a reported resident fall incident where no visible injuries were found. The facility notified the responsible party, law enforcement, and long term care ombudsman. No citations were issued at this time, and the case remains under review with further follow-up planned.

The complaint involved resident R1 who alleged a fall into bed on 05/20/2024 while being assisted by staff. The facility reported no visible injuries and notified appropriate parties. Interviews were conducted with the resident and attempts made with staff. The case is under review with no substantiation or citations issued yet.

The visit was an unannounced case management inspection triggered by incidents involving residents R1 and R2, including a follow-up on an incident report for R1 and an investigation of an AWOL incident involving R2.

The investigation found that staff assisted resident R1 to bed without consent, violating Resident's Rights, and that resident R2 left the facility unassisted despite having dementia and a wander guard. Immediate civil penalties were assessed due to repeat violations.

The visit was complaint-related, investigating incidents involving residents R1 and R2. The incident for R1 involved a violation of Resident's Rights by staff assisting R1 to bed without consent. The incident for R2 involved the resident leaving the facility unassisted, despite dementia diagnosis and use of a wander guard. Immediate civil penalties of $250 were assessed due to repeat violations.

The visit was an unannounced case management visit to follow up on an incident report and SOC 341 submitted by the facility regarding an incident involving resident R1 on 2024-04-18.

The department conducted an interview with the resident involved and reviewed related documents. No citations were issued per Title 22 Regulations. The case is under review and further follow-up will be conducted as needed.

The visit was a plan of correction (POC) follow-up conducted to verify correction of citations issued on 2024-03-20.

The facility submitted documentation to clear the citations, but the Department did not accept the staff training sign-in sheets due to discrepancies in date, time, and attendance. The plan of correction remains outstanding as of the visit date.

The visit was an unannounced case management follow-up on an incident report regarding an allegation that a staff member hit a resident with a hard towel during care.

The department found no injuries on the resident and no findings from law enforcement. Interviews were conducted with residents and staff, and the case remains under review with no citations issued.

The complaint involved an allegation that staff member S1 hit resident R1 with a hard towel on the face during care on 03/18/24. The facility reported the incident to law enforcement, which found no evidence of wrongdoing. The resident was checked by the facility nurse with no injuries found. The department conducted interviews with 3 residents and 3 staff members. The case is under review with follow-up planned as needed.

The visit was an unannounced office Non-Compliance conference conducted due to substantial compliance issues identified at the facility, aiming to discuss noncompliance and develop a plan to bring the facility back into compliance.

The Department identified multiple substantial compliance issues including staffing, record keeping, reporting responsibilities, lack of care and supervision (falls and AWOLs), medication administration, leadership accountability, and internal audits. The facility has had 4 residents AWOL and multiple falls reported.

A virtual meeting was conducted to discuss a situation regarding resident R1, specifically related to nonpayment of board and care fees by R1's responsible party since September 2023.

The facility reported nonpayment issues for resident R1 and issued a 30-day eviction notice. Adult Protective Services and the Long-Term Care Ombudsman are involved due to suspected financial misuse. No citations were issued per Title 22 Regulations.

The inspection was conducted as the required annual unannounced inspection to evaluate compliance with regulatory standards.

Deficiencies were observed related to medication storage for residents with dementia and incomplete personnel records including missing forms and certifications. The facility was toured and found to be generally compliant with health and safety standards such as fire and disaster drills and operational safety equipment.

The inspection was an unannounced case management follow-up visit to review a choking incident involving resident R1 that occurred on 2024-03-11.

The facility took appropriate measures during the choking incident, including performing the Heimlich maneuver, notifying required parties, and no citations were issued per Title 22 Regulations.

The visit was triggered by a reported choking incident on 2024-03-11 involving resident R1. The facility's response was reviewed and found appropriate with no substantiated deficiencies.

The inspection was an unannounced case management visit conducted to follow up on a recent AWOL incident involving two residents, R1 and R2, who left the facility unassisted on 02/26/2024.

The facility failed to provide adequate supervision to residents R1 and R2, both diagnosed with dementia, resulting in their unassisted AWOL incident. The facility did not report the AWOL incident as required and lacked an updated medical assessment for R1, violating Title 22 regulations. Immediate civil penalties were assessed due to repeat violations.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not properly supervise a resident, resulting in the resident being sexually assaulted while in care.

The investigation found no evidence to substantiate the allegation. Medical exams and interviews indicated no signs of sexual assault occurred at the facility on the reported date. No deficiencies were cited.

The complaint alleged that staff failed to properly supervise a resident who was sexually assaulted by an unknown male in the facility on 01/24/2024. The allegation was found to be unsubstantiated after investigation including medical exams and interviews.

Unannounced complaint investigation visit conducted to investigate allegation that the licensee is not ensuring that resident(s) receive services as agreed to in the Admissions Agreement.

The investigation included resident and staff interviews and records review. The allegation was found to be unsubstantiated as evidence did not prove that the alleged violations occurred. Residents and staff confirmed laundry services were provided timely and as needed.

Allegation that licensee is not ensuring residents receive services as agreed in the Admissions Agreement was investigated and found unsubstantiated based on interviews and record reviews.

The unannounced case management inspection was conducted to follow up on a recent AWOL (Absent Without Leave) incident involving resident R1 at the facility.

The facility had two AWOL incidents involving resident R1, one on 10/12/2023 and another on 11/01/2023. The second incident was not reported to the department as required, and the facility failed to provide adequate supervision to prevent R1 from leaving unassisted, posing a safety risk.

The visit was a Case Management - Incident visit conducted to investigate an incident where resident R1 eloped from the facility on 10/12/23 and returned after being located by law enforcement.

The facility failed to provide requested resident records related to R1's elopement incident despite multiple requests, posing potential health and safety risks. Citations were issued for failure to submit required documentation and Proof of Correction by the due date.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2023-09-08 regarding medication administration, medical documentation, response to resident requests, harassment, food services, dignity, and privacy.

The investigation involved records review, facility observations, and interviews with staff and residents. All allegations were found to be unsubstantiated or unfounded, indicating that the facility was providing proper medication administration, medical documentation, timely response to resident requests, adequate food services, and maintaining resident dignity and privacy.

The complaint investigation addressed multiple allegations including improper medication administration, mismanagement of medical documentation, delayed response to resident requests, harassment between residents, inadequate food services, and failure to accord dignity and privacy to residents. All allegations were found to be unsubstantiated or unfounded after thorough investigation.

An unannounced complaint investigation was conducted due to an allegation that staff were not following a licensed physician's order for a resident.

The investigation included interviews, record review, and facility observations. It was found that the resident had a neck fracture and an order to wear a neck brace, but no specific instructions on duration. Staff followed the doctor's orders and the allegation was unsubstantiated.

The complaint allegation that staff were not following a licensed physician's order for a resident was investigated and found to be unsubstantiated.

Unannounced complaint investigation visit conducted due to allegations that the facility is in disrepair and staff did not meet residents' needs.

The investigation found the facility to be clean, safe, sanitary, and in good repair with no substantiated issues regarding maintenance or staff meeting residents' needs. Residents and staff interviews, observations, and record reviews indicated no concerns, and all allegations were unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included facility disrepair and staff not meeting residents' needs. The Licensing Program Analyst conducted interviews, observations, and record reviews and found no evidence to support the allegations.

The inspection was an unannounced case management visit to follow up on a recent AWOL incident involving resident R1 who left the facility unattended.

The facility submitted an incident report regarding R1's AWOL on 09/02/23. R1 was found uninjured outside the facility and returned safely. The resident has dementia and cannot leave unassisted. The facility has implemented measures to prevent future AWOL incidents. No citations were issued, only a Technical Advisory.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-05-10 regarding resident injury and facility care concerns.

The investigation substantiated that a resident sustained a fractured neck due to a fall caused by staff's lack of supervision and improper care. The facility was found not to be meeting the resident's needs, resulting in serious bodily injury and a civil penalty. Other allegations regarding activities availability, room cleanliness, and dining room access were found to be unfounded.

The complaint investigation was substantiated for allegations that a resident sustained a spinal fracture due to a fall caused by staff's lack of supervision and care. The facility was also found not meeting the resident's needs. Other allegations about activities, cleanliness, and dining room access were unfounded.

The visit was a Case Management visit regarding an incident that occurred on 2023-07-18 involving an allegation of sexual violation of a resident at the facility.

The investigation found no citations or deficiencies during the visit. Lab results for the resident were unremarkable, and the resident was reported to be back to baseline and doing well.

The complaint involved an allegation that resident R1 was sexually violated on 2023-07-18. The facility reported the incident to law enforcement, the resident's physician, and the responsible party. Law enforcement investigated, and medical tests showed no conclusive evidence of exposure. The complaint was not substantiated with citations.

The visit was a Case Management visit regarding an incident that occurred on 2023-06-04 involving a medication error where a resident was given medications not prescribed by their physician.

The facility administered wrong medications, Fenofibrate 54mg and Fluoxetine 10mg, to a resident which posed an immediate health and safety risk. The resident was sent to the hospital and returned the same day with no changes to their health. Deficiencies were cited related to this medication error.

The visit was triggered by a complaint incident where a resident was given wrong medications on 2023-06-04. The medication error was substantiated based on incident report, staff interviews, and medication record review.

The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure compliance with health and safety standards.

The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed, and no deficiencies were cited during the inspection.

The inspection was an unannounced complaint investigation visit triggered by an allegation that residents engaged in inappropriate sexual interaction while in care.

The investigation concluded that although two residents engaged in sexual relations while living at the facility, the facility cannot restrict consensual sexual relations among residents or visitors as per Title 22 regulations. The allegation was found to be unfounded with no citations issued.

The complaint alleged that residents engaged in inappropriate sexual interaction while in care. The allegation was investigated through interviews and document review and was found to be unfounded.

The inspection was conducted as a case management follow-up on a recent AWOL (Absent Without Leave) incident involving resident R1 who left the facility unattended on two occasions.

The facility submitted incident reports for the AWOL events and has taken measures to prevent future occurrences. Resident R1 was found uninjured and the facility notified the resident's doctor and family. No citations were issued, only a Technical Advisory.

The visit was triggered by complaints related to resident R1 leaving the facility unattended on 10/18/22 and 11/11/22. The resident has a diagnosis of dementia and cannot leave unassisted. The incidents were substantiated by the facility's reports and follow-up actions.

Unannounced complaint investigation visit conducted to investigate multiple allegations including improper medication distribution, failure to follow physician orders, and failure to safeguard resident belongings.

The investigation substantiated allegations that residents did not receive medications as prescribed and that staff failed to properly assist with prosthetic devices such as hearing aids, posing immediate and potential health risks. Other allegations including facility odor, dietary needs, staff retaliation, and call button response were found unsubstantiated.

Complaint was substantiated for medication errors and failure to assist with hearing aids. Other allegations such as facility odor, dietary needs, staff retaliation, and call button response were unsubstantiated.

The visit was conducted as a follow-up on an Unusual Incident Report and SOC 341 received regarding an incident involving a resident (R1) on 08/22/22 where the resident was reported to have been 'thrown on the ground and slapped'.

No deficiencies were cited during the visit. The Licensing Program Analyst interviewed staff and toured the facility to check the health and safety of residents. The incident was reported to police and Ombudsman, and no signs of injury or bruising were found on the resident.

Unannounced complaint investigation visit conducted due to a complaint received on 2022-03-30 regarding reporting requirements and an allegation that facility staff gave a resident alcohol who was not supposed to have it, resulting in a fall.

The complaint regarding failure to report incidents threatening resident welfare was substantiated as the facility did not submit required incident reports to the licensing agency. The allegation that a resident was given alcohol causing a fall was unsubstantiated as the resident died of a heart attack and there was insufficient evidence to confirm alcohol was given.

The complaint was substantiated regarding failure to report incidents threatening resident welfare. The allegation that a resident was given alcohol resulting in a fall was unsubstantiated due to lack of evidence and the resident's death by heart attack.

The visit was an unannounced annual inspection using the infection control tool to ensure compliance with health and safety standards, including COVID-19 protocols.

The facility was found to be in substantial compliance with infection control requirements. No immediate health, safety, or personal rights violations were observed, and no deficiencies were cited.

The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations received on 2021-03-01 regarding medication administration, resident care, communication, staff behavior, medical treatment timeliness, housekeeping, staffing levels, and visitor denial.

The investigation concluded that the allegations were unsubstantiated or unfounded, meaning there was insufficient evidence to prove the alleged violations occurred or the allegations were false. An exit interview was conducted and a copy of the report was left at the facility.

The complaint investigation was triggered by allegations including failure to administer medications, unmet toileting needs, ineffective communication of resident needs, inappropriate staff speech, failure to seek timely medical treatment, lack of housekeeping services, inadequate staffing levels, and denial of visitors. The findings determined the allegations to be unsubstantiated or unfounded.

The inspection was an unannounced complaint investigation triggered by an allegation that staff were not following resident special diets.

The investigation found that the facility maintained lists of residents with special diets, posted menus daily, and provided alternative menu options. The resident in question had no special diet noted in their medical assessment. The allegation was found to be unfounded.

The complaint alleged that staff were not following resident special diets. The allegation was found to be unfounded after review of documentation and interviews.

The visit was an unannounced complaint investigation regarding the allegation that air conditioning was not working in common areas.

The Licensing Program Analyst observed that the temperature in common areas was comfortable and fans were used to address heat issues. The Executive Director stated that the air conditioner part was ready but installation was pending a permit from Sac County. The Department found the allegation unsubstantiated as the facility had taken appropriate measures to address the issue.

The complaint allegation was that air conditioning was not working in common areas. The allegation was found to be unsubstantiated after investigation.

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 inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2021-07-01 regarding facility disrepair and lack of specialized/diabetic menus to meet residents' needs.

The investigation found the allegation of facility disrepair to be unsubstantiated, with evidence showing the facility acted appropriately regarding air conditioner issues. The allegation regarding specialized/diabetic menus was found to be unfounded, as the facility provides a weekly cycle menu with multiple entree choices and specialized diabetic desserts.

The complaint investigation was unannounced and conducted by Evaluator Melissa Lusby. The allegations were found to be unsubstantiated or unfounded after review of documentation, interviews, and facility tour. The complaint control number is 25-AS-20210701155204.

An unannounced complaint investigation was conducted regarding an allegation that staff do not respond to residents' calls in a timely manner.

The investigation included touring the memory care unit, reviewing staffing schedules, and conducting interviews. All interviews confirmed that staff address resident needs in a timely manner, and the allegation was determined to be unfounded.

The allegation that staff do not respond to residents' calls in a timely manner was investigated and found to be unfounded based on interviews and evidence standards not being met.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2020-10-27 regarding staffing sufficiency, response to call buttons, medical care, food temperature, and cleanliness of residents' rooms.

The investigation found the allegations to be unsubstantiated or unfounded. The facility was verified to have sufficient staff, timely response to call buttons, adequate medical care, and proper meal delivery and housekeeping services, with some residents refusing services.

The complaint investigation was triggered by allegations including insufficient staff to meet residents' needs, untimely response to call buttons, neglect of residents' medical needs, cold food being served, and unclean resident rooms. The findings concluded these allegations were unsubstantiated or unfounded based on interviews, documentation, and evidence review.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2020-09-16 regarding resident injuries, medication errors, staff response, communication, and other concerns at Almond Heights facility.

The investigation found no substantiated evidence to support the allegations. The facility conducted safety checks after resident falls, maintained communication with responsible parties, sought medical attention when needed, provided adequate staff training, and there was no evidence of medication errors or missing resident belongings. All allegations were found to be unsubstantiated or unfounded.

The complaint investigation was unannounced and based on allegations including resident injuries due to lack of supervision, wrong medication administration, staff not responding to calls, poor communication, and missing resident belongings. The findings concluded the allegations were unsubstantiated or unfounded due to lack of preponderance of evidence.