Most inspections found no deficiencies, including the most recent annual inspection on May 20, 2025, which was perfect. One complaint investigation on February 19, 2025, was substantiated regarding the facility’s failure to issue a proper refund as required by the admission agreement, but no other serious issues or enforcement actions were noted. Earlier inspections before opening found the facility ready and in compliance with licensing requirements. Several complaint investigations were unsubstantiated or did not result in deficiencies. The facility appears to have addressed previous concerns, with the latest report showing full compliance.
The visit was an unannounced 1-Year Annual Required inspection conducted by Licensing Program Analyst Greg Clark to evaluate compliance with licensing requirements.
Findings
The facility was found to be in full compliance with no deficiencies cited. The inspection included a tour of the facility, review of resident and staff records, and verification of safety equipment and emergency preparedness.
Report Facts
Hot water temperature: 118.5Fire extinguisher last serviced: Feb 10, 2025Emergency Disaster Plan last reviewed: May 1, 2025Emergency disaster drill last conducted: Mar 10, 2025Resident records reviewed: 5Staff records reviewed: 5
Employees Mentioned
Name
Title
Context
Gregory Clark
Licensing Program Analyst
Conducted the inspection and authored the report
Thinn Aye
Administrator
Met with Licensing Program Analyst during inspection
The inspection visit was an unannounced complaint investigation triggered by an allegation that the facility failed to issue a proper refund.
Findings
The investigation found that the licensee did not comply with the admission agreement provisions regarding payment and failed to issue a full refund to the resident's responsible party, substantiating the complaint.
Complaint Details
The complaint was substantiated. The allegation was that the facility failed to issue a proper refund. The investigation included interviews, record reviews, and observations, concluding that the licensee did not comply with the cited regulation and failed to issue the refund.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Admission agreements shall specify payment provisions including a comprehensive description and fee schedule for all basic services not included in the single fee. Licensee failed to issue a full refund to R1's responsible party, posing a potential health, safety, or personal rights risk.
Type B
Report Facts
Capacity: 6Census: 5Deficiencies cited: 1
Employees Mentioned
Name
Title
Context
Gregory Clark
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Yvonne Flores-Larios
Licensing Program Manager
Oversaw the complaint investigation
Inspection Report Original LicensingCapacity: 6Deficiencies: 0May 7, 2024
Visit Reason
The visit was an unannounced pre-licensing inspection conducted to evaluate the facility's readiness for licensing.
Findings
The inspection found no issues; the facility was observed to be ready for licensing with proper furniture, safety equipment, and maintained environmental conditions. The facility currently has no clients and is subject to final approval by the Central Applications Unit.
Report Facts
Facility capacity: 6Census: 0Inspection start time: 930Inspection end time: 1100Fire extinguisher purchase date: Feb 17, 2024Room temperature: 70Hot water temperature: 113.3
Employees Mentioned
Name
Title
Context
Thinn T Aye
Licensee
Met with Licensing Program Analyst during inspection
The visit was a Case Management - Other type of inspection conducted by Licensing Program Analyst K. Nguyen to present Comp III materials to the licensee.
Findings
The licensee, Thinn T Aye, acknowledged understanding the materials presented in Comp III. An exit interview was conducted and a copy of the report was provided via email.
Employees Mentioned
Name
Title
Context
Thinn T Aye
Licensee
Met with during the inspection and acknowledged understanding of Comp III materials.
K. Nguyen
Licensing Program Analyst
Conducted the Comp III presentation and inspection.
Bennett Fong
Licensing Program Manager
Named as Licensing Program Manager on the report.
Inspection Report Original LicensingCapacity: 6Deficiencies: 0Apr 9, 2024
Visit Reason
The visit was an initial licensing evaluation conducted virtually to verify the applicant and administrator's understanding of community care facility licensing laws and readiness for operation.
Findings
The applicant and administrator demonstrated understanding of licensing laws, facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints and reporting, and pre-licensing readiness. No deficiencies or issues were noted.
Employees Mentioned
Name
Title
Context
Nirmala Kuppusamy
Administrator
Administrator named in the licensing evaluation and interview
Thinn T Aye
Applicant
Applicant named in the licensing evaluation and interview
Darla Neeley
Licensing Program Manager
Named as Licensing Program Manager on the report
Ahmad Reshad
Licensing Program Analyst
Named as Licensing Program Analyst on the report
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