Inspection Reports for
Almond Heights

The visit was complaint-related, triggered by an incident report submitted by the facility on 09/26/25 regarding missed medication doses for resident R1. The deficiency was substantiated based on incident report, staff interviews, and medication record review.

The facility failed to administer prescribed medication Carbamazepine ER 400mg to resident R1 on 09/17/25 and 09/18/25 due to running out of medication, posing an immediate health and safety risk to residents in care. Deficiencies were cited under California Code of Regulations, Title 22, Section 87465(a)(4).

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.

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 facility was found deficient for failing to provide adequate care and supervision to prevent resident R1 from leaving unassisted, posing an immediate risk to resident health and safety. Staff training on AWOL risks was conducted and the plan of correction was cleared.

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 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, 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 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.

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 safety and food compliance.

The visit was complaint-related, triggered by a recent AWOL incident involving residents R1 and R2. The facility did not meet mandatory reporting requirements and failed to provide adequate supervision.

The facility failed to provide adequate care and supervision to residents R1 and R2, who left the facility unassisted, and did not report the AWOL incident as required. Additionally, the facility lacked an updated medical assessment for resident R1 with dementia.

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 visit was triggered by a complaint related to resident R1's AWOL incidents. The facility was found to have not provided adequate supervision and failed to report the second AWOL incident, resulting in substantiated violations.

The facility failed to provide adequate care and supervision to resident R1, who left the facility unattended twice, once on 10/12/2023 and again on 11/01/2023. The second AWOL incident was not reported to the department as required, posing a safety risk to the resident and violating reporting regulations.

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 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 visit was complaint-related due to an incident where resident R1 eloped from the facility on 10/12/23. The facility notified the Department via incident report. The Department requested records related to R1 but did not receive them despite multiple follow-ups, resulting in citations.

The facility failed to provide requested documents related to resident R1's elopement incident despite multiple requests, posing potential health and safety risks. Citations were issued for failure to comply with Title 22 requirements.

The complaint investigation was substantiated. The resident (R1) fell on 02/14/2023 while being assisted by staff (S1), resulting in a fractured neck requiring surgery and hospice care. The fall was attributed to staff's lack of supervision and improper transfer. Staff interviews revealed miscommunications and inadequate care. Facility management had received complaints about S1's work ethic. Additional allegations about activities, cleanliness, and dining access were investigated and found to be unfounded.

The investigation substantiated two allegations: a resident sustained a fractured spine due to a fall caused by staff lack of supervision, and the facility was not meeting the resident's needs. Three other allegations regarding activities availability, room cleanliness, and dining room access were found to be unfounded.

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 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.

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 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.

The complaint was substantiated regarding failure to report incidents as required, but unsubstantiated regarding the allegation that a resident was given alcohol resulting in a fall.

The investigation found that the facility failed to submit required incident reports to the licensing agency, substantiating the complaint regarding reporting requirements. However, the allegation that the resident was given alcohol leading to a fall was unsubstantiated as the resident died of a heart attack and there was insufficient evidence to confirm alcohol was given.