Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance with regulations. The most recent report from October 1, 2025, cited deficiencies related to incomplete staff records, missing CPR certifications, and personnel record maintenance, resulting in an immediate civil penalty due to repeated violations. Earlier reports from October 2024 also noted issues with CPR-certified staff on each shift, emergency drills, liability insurance, and facility maintenance concerns such as a malfunctioning elevator and safety risks from broken gates. The facility addressed some safety issues promptly, but staffing documentation and training remain areas needing improvement. Overall, while many complaint investigations found no problems, the facility has recurring deficiencies in staff certification and recordkeeping that have led to enforcement actions.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
85% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 83
Capacity: 98
Deficiencies: 3
Date: Oct 1, 2025
Visit Reason
An unannounced 1-year required visit was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was generally clean and well-maintained with sufficient food supplies and proper safety measures. However, deficiencies were cited related to incomplete staff records, missing CPR certifications, and personnel record maintenance. An immediate civil penalty was assessed due to repeated violations.
Deficiencies (3)
Four staff files were incomplete, missing criminal record statements, proof of 20 hours of training, health screening reports, and valid CPR certification.
Failure to ensure at least one staff member with CPR and first aid training is on duty at all times.
Personnel records were not properly maintained for four employees, missing required documentation.
Report Facts
Civil penalty amount: 250
Number of staff files reviewed with deficiencies: 4
POC due date: Oct 2, 2025
POC due date: Oct 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Gephart | Administrator | Named as facility administrator with valid certification and CPR certification. |
| Destiny Quijada | Activities Director | Met during inspection and received report and appeal rights. |
| Javina George | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Carolyn Tuba | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 98
Deficiencies: 0
Date: Apr 27, 2025
Visit Reason
The visit was conducted to investigate a complaint alleging that staff did not prevent a resident from threatening another resident at the facility.
Complaint Details
The complaint alleged that a resident was threatened several times by another resident and that the issue was reported to management but not addressed. Interviews with staff and residents showed mixed awareness of the allegation, with most staff and residents stating they felt safe. The allegation was ultimately unsubstantiated.
Findings
Based on interviews with staff and residents, review of records, and observation, the allegation was found to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited during this visit.
Report Facts
Staff interviewed: 5
Residents interviewed: 8
Facility capacity: 98
Facility census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvira Gonzalez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Destiny Quijada | Activities Director | Met with investigator during the visit and participated in exit interview |
| David Alspach | Administrator | Named as facility administrator |
| Stephanie Cifuentes | Licensing Program Manager | Named as licensing program manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 98
Deficiencies: 0
Date: Apr 27, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2021-12-23 regarding unexplained injuries to a resident and residents being left in soiled diapers for extended periods.
Complaint Details
The complaint involved two allegations: 1) a resident sustained unexplained injuries while in care, and 2) residents were left in soiled diapers for extended periods. Interviews with 5 staff and 8 residents revealed no awareness or evidence supporting the allegations. The findings concluded both allegations were unsubstantiated.
Findings
The investigation included interviews with staff and residents, review of records, and observation. Both allegations were found to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited during the visit.
Report Facts
Staff interviewed: 5
Residents interviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvira Gonzalez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on report |
| Destiny Quijada | Activities Director | Met with during investigation and exit interview |
Inspection Report
Complaint Investigation
Capacity: 98
Deficiencies: 1
Date: Apr 27, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/19/2024 regarding pest infestation, safeguarding of resident belongings, and bathing care.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not keep the facility free of insects. The allegations that staff did not safeguard resident's personal belongings and that staff were not bathing a resident in care were unsubstantiated.
Findings
The investigation substantiated that staff did not keep the facility free of insects, confirming a bed bug infestation that was treated. The allegations that staff did not safeguard resident belongings and that a resident was not being bathed were unsubstantiated based on interviews and record reviews.
Deficiencies (1)
CCR 87303(a) Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times... safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by bed bugs observed by multiple residents in multiple bedrooms.
Report Facts
Facility capacity: 98
Plan of Correction due date: May 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Urena | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| David Alspach | Administrator | Facility Administrator named in the report |
| Destiny Quijada | Activities Director | Met with Licensing Program Analyst during visits |
| Javina George | Licensing Program Analyst | Conducted initial unannounced visit to initiate investigation |
| Jennifer Gephart | Executive Director | Met with Licensing Program Analyst during initial investigation visit |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 98
Deficiencies: 0
Date: Apr 18, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 11/30/2022 concerning neglect, inadequate care, insufficient staffing, poor housekeeping, and failure to safeguard resident's personal items at Alta Vista Senior Living Facility.
Complaint Details
The complaint involved multiple allegations including neglect/lack of care and supervision, unresolved wounds, unmet dietary needs, insufficient staffing, poor housekeeping, and failure to safeguard personal items. The findings were unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews, record reviews, and observations indicated that the resident's wound was treated by hospice nurses, dietary needs were met, staffing was adequate, housekeeping was scheduled and effective, and personal items were safeguarded according to facility policy.
Report Facts
Weight loss: 6
Facility capacity: 98
Resident census: 81
Hospice nurse visits: 2.5
Housekeepers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Venus Mixson | Licensing Program Analyst | Conducted the complaint investigation |
| Jazmond D Harris | Licensing Program Manager | Oversaw the complaint investigation |
| Jennifer Gephart | Executive Director | Facility representative interviewed during investigation |
| David Alspach | Administrator | Facility administrator interviewed regarding allegations |
| Diane Domingo | Executive Director | Provided information about resident's service plan and family communication |
| Dr. Bonomo | Attending Physician | Provided medical information regarding resident's fall and injuries |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 98
Deficiencies: 0
Date: Apr 13, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation of unlawful eviction received on 2024-06-25.
Complaint Details
The complaint alleged unlawful eviction notices were issued to Resident #1 in December 2023 and January 2024 due to nonpayment. The investigation revealed the resident's Power of Attorney was responsible for payments but failed to pay, leading to eviction notices and a search for alternative placement. Law enforcement authorized removal on 2024-07-03. The allegation was unsubstantiated.
Findings
The investigation found insufficient evidence to support the allegation of unlawful eviction related to Resident #1. The eviction notices were issued due to nonpayment by the resident's Power of Attorney, and law enforcement had an approved Eviction Restoration Notice for removal on 2024-07-03. The allegation was deemed unsubstantiated.
Report Facts
Facility capacity: 98
Census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Beatrice Soliven | Memory Care Director | Met with the Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 98
Deficiencies: 0
Date: Apr 13, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-01-31 regarding resident care management, rough handling, special diet adherence, and residents being left slumped in wheelchairs.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to manage resident care needs, rough handling of residents, failure to follow special diets, and leaving residents slumped over in wheelchairs. After interviews, record reviews, and observations, none of these allegations were supported by sufficient evidence.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Staff were found to provide care according to updated care plans, communicate regularly with physicians, and residents reported no concerns about care or handling. Residents were appropriately assisted and not left slumped in wheelchairs for extended periods.
Report Facts
Capacity: 98
Census: 81
Hours left slumped: 8
Number of residents interviewed: 5
Number of staff interviewed: 4
Number of residents reviewed for medication: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Beatrice Soliven | Memory Care Director | Met with Licensing Program Analyst during investigation |
| David Alspach | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 98
Deficiencies: 0
Date: Feb 21, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff do not safeguard resident's personal belongings and do not ensure resident’s room is free of tripping hazards.
Complaint Details
The complaint was unsubstantiated. Allegations included staff failing to safeguard resident's personal belongings and failing to ensure rooms were free of tripping hazards. Investigations included interviews with residents, staff, and administrator, observations, and record reviews. No evidence supported the allegations.
Findings
Based on observations, interviews with staff and residents, and record review, the allegations were found to be unsubstantiated. There was no evidence that Resident #2 entered other residents' rooms or took belongings, and no hazardous uneven floors were observed that caused falls.
Report Facts
Facility capacity: 98
Census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Armando Perez | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Monica Flores | Business Office Manager | Met with Licensing Program Analyst during the investigation and received the report |
| David Alspach | Administrator | Provided information during interviews related to the allegations |
| Jazmond D Harris | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 98
Deficiencies: 0
Date: Jan 14, 2025
Visit Reason
The inspection was an unannounced visit to investigate a complaint alleging that staff did not ensure the hot water was working properly at the facility.
Complaint Details
The complaint alleged that on 01/07/2025, the facility did not have hot water for a couple of hours. The allegation was found to be unsubstantiated after investigation.
Findings
The investigation found conflicting resident reports about hot water availability, but staff interviews and facility checks confirmed that hot water was restored the same day and is currently functioning properly. Therefore, the allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Hot water temperature: 120.3
Hot water temperature: 113.7
Hot water temperature: 115.1
Staff interviews conducted: 5
Resident interviews conducted: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janira Arreola | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Jennifer Gephart | Executive Director | Met with Licensing Program Analyst during investigation |
| David Alspach | Administrator | Facility administrator named in report header |
| Tricia Danielson | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 98
Deficiencies: 1
Date: Oct 9, 2024
Visit Reason
An unannounced complaint investigation visit was conducted due to a complaint alleging that staff did not ensure the facility elevator was in good repair.
Complaint Details
The complaint was substantiated based on evidence that the elevator was red tagged and not operable due to maintenance issues. The elevator was repaired on 09/13/2024 and verified to be in working order during the visit.
Findings
The investigation substantiated the complaint that the elevator was not in good repair, as it was red tagged and prohibited from use due to non-operable outlet and light fixtures. However, at the time of the visit, the elevator was verified to be in working order and fully illuminated.
Deficiencies (1)
The licensee did not ensure that the elevator was in good repair, which posed a potential health, safety and personal rights risk to persons in care.
Report Facts
Capacity: 98
Census: 80
Deficiency Type Count: 1
Plan of Correction Due Date: Oct 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jennifer Gephart | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Monica Flores | Business Office Manager | Interviewed regarding elevator maintenance and inspection history |
| David Alspach | Administrator | Named as facility administrator |
| Tricia Danielson | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 98
Deficiencies: 2
Date: Oct 9, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not ensure the facility was in good repair and did not provide a safe environment.
Complaint Details
The complaint was substantiated. Allegations included staff not ensuring the facility was in good repair (specifically two gates, one disabled) and not providing a safe environment (a malfunctioning locked door in memory care leading to a resident eloping). The resident was found safe after law enforcement intervention. The facility implemented two-hour safety checks following the incident.
Findings
The investigation substantiated that the facility gate was out of service and posed a safety risk, and that a memory care resident eloped due to a malfunctioning locked door, leading to implementation of two-hour safety checks.
Deficiencies (2)
The licensee did not ensure that the facility gate was in good repair, posing a potential health, safety and personal rights risk to persons in care.
The licensee did not ensure that the premises was maintained in a safe and healthful environment, posing a potential health, safety and personal rights risk to persons in care.
Report Facts
Capacity: 98
Census: 80
Plan of Correction Due Date: Oct 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jennifer Gephart | Executive Director | Facility representative met during investigation and exit interview |
| Jenna Lazaga | Memory Care Director | Interviewed regarding resident elopement incident |
| David Alspach | Administrator | Facility administrator named in report header |
| Tricia Danielson | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 80
Capacity: 98
Deficiencies: 3
Date: Oct 9, 2024
Visit Reason
The inspection was an unannounced required 1-year visit to evaluate compliance with licensing regulations for the facility.
Findings
The facility was generally compliant with safety and operational standards, including fire safety and medication storage. However, deficiencies were cited for lack of CPR-certified staff on each shift, failure to conduct quarterly emergency drills as required, and absence of valid liability insurance.
Deficiencies (3)
Facility does not have a staff member who is CPR certified working during each shift.
Facility did not conduct required quarterly emergency disaster drills.
Facility does not have proof of valid liability insurance.
Report Facts
Residents receiving hospice services: 14
Fire/safety inspection date: Jul 10, 2024
Emergency disaster drill date: May 24, 2024
Staff files reviewed lacking CPR certification: 6
Emergency drills missed: 1
Plan of Correction due dates: Due dates for POCs are 10/10/2024 for CPR and drills, 10/23/2024 for liability insurance
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Gephart | Executive Director | Met with during inspection and named in exit interview |
| David Alspach | Administrator | Facility administrator named in report header |
| Javina George | Licensing Program Analyst | Conducted the inspection and authored the report |
| Tricia Danielson | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 77
Capacity: 98
Deficiencies: 0
Date: Oct 27, 2023
Visit Reason
The visit was an unannounced required 1-year annual inspection to ensure the facility's compliance with California Code of Regulations, Title 22, Division 6.
Findings
The facility was found to be in compliance with all regulatory requirements including infection control, operational requirements, physical plant safety, staffing, personnel training, residents' rights, food service, medication management, disaster preparedness, and care for residents with special needs. No deficiencies were observed during this inspection.
Report Facts
Hospice waiver residents: 15
Staff members on site: 75
Fire drill date: Oct 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monica Flores | Business Office Manager | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Cheryl Goodrich | Licensing Program Analyst | Conducted the inspection |
| Jazmond D Harris | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 98
Deficiencies: 0
Date: Jan 18, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations of lack of supervision resulting in resident injury from a fall and failure to meet residents' care needs.
Complaint Details
The complaint alleged lack of supervision resulting in resident injury from a fall and failure to meet residents' care needs. The investigation found no substantiation for these allegations.
Findings
The investigation included interviews, records review, and a facility tour. It was found that residents with cognitive impairments and fall risks were supervised with increased checks and staff were able to meet residents' needs. The allegations were deemed unsubstantiated based on the evidence.
Report Facts
Capacity: 98
Census: 71
Staffing: 2
Staffing: 4
Staffing: 1
Staffing: 2
Incontinence care checks: 2
Incontinence care times: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Diane Domingo | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 98
Deficiencies: 0
Date: Jan 12, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation received on 09/18/2020 that a staff member inappropriately touched a resident.
Complaint Details
The allegation was that a direct care staff member touched a female resident in an inappropriate manner. Interviews with the resident, staff, and outside sources, as well as records review, did not substantiate the claim. The resident had documented behavioral health concerns and increased anxiety. The allegation was unsubstantiated due to lack of evidence.
Findings
The investigation included interviews and records review, which found insufficient evidence to support the allegation. The complaint was determined to be unsubstantiated.
Report Facts
Capacity: 98
Census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Powell | Licensing Program Analyst | Conducted the complaint investigation |
| Monica Flores | Business Office Manager | Met with Licensing Program Analyst during investigation |
| David Alspach | Administrator | Facility administrator named in report header |
| Icela Estrada | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 98
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
The Licensing Program Analyst conducted an unannounced visit to initiate the investigation into complaint #18-AS-20221130130504.
Complaint Details
Investigation into complaint #18-AS-20221130130504; no health and safety concerns were observed.
Findings
The Licensing Program Analyst toured the interior and exterior areas of the facility and observed no health and safety concerns at the time of the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diane Domingo | Executive Director | Met with Licensing Program Analyst during complaint investigation visit. |
| Stephanie Torres | Licensing Program Analyst | Conducted the unannounced complaint investigation visit. |
| Deborah Mullen | Licensing Program Manager | Named in report header. |
Inspection Report
Census: 74
Capacity: 98
Deficiencies: 0
Date: Nov 3, 2022
Visit Reason
An unannounced case management visit was conducted to deliver an amended complaint report dated 5/7/2020 and to obtain the facility representative's signature on the report.
Findings
The Licensing Program Analyst delivered the amended complaint report and obtained the Executive Director's signature. An exit interview was conducted and the Licensee Appeal Rights were provided.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Ruiz | Licensing Program Analyst | Conducted the unannounced case management visit and delivered the amended complaint report. |
| Diane Domingo | Executive Director | Facility representative who signed the amended complaint report and participated in the exit interview. |
Inspection Report
Annual Inspection
Census: 72
Capacity: 98
Deficiencies: 0
Date: Oct 27, 2022
Visit Reason
An unannounced annual inspection was conducted with an emphasis on infection control to evaluate the facility's compliance with regulations.
Findings
The inspection found sufficient hand hygiene supplies, cleaning and disinfecting provisions, proper use of face coverings, and a designated infection control lead. No citations were issued during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diane Domingo | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview. |
| Stephanie Torres | Licensing Program Analyst | Conducted the unannounced annual inspection visit. |
| Deborah Mullen | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 98
Deficiencies: 2
Date: Oct 27, 2022
Visit Reason
The visit was an unannounced follow-up on an incident reported by the facility involving a staff member slapping a resident.
Complaint Details
The visit was complaint-related due to an incident where a resident was slapped by a staff member. The incident was substantiated based on staff statements and interviews. The staff member was suspended and terminated. The staff member also lacked fingerprint clearance prior to employment.
Findings
The investigation confirmed the incident occurred with multiple staff statements corroborating the event. The staff member admitted to slapping the resident after being spat on. The staff member was suspended and later terminated. Additionally, the staff member lacked required fingerprint clearance prior to employment, posing a potential threat to residents.
Deficiencies (2)
Resident was not granted the right to be free from punishment/abuse; staff slapped resident on the face.
Staff member was not fingerprint cleared prior to working in the facility.
Report Facts
Staff statements corroborating incident: 4
Facility capacity: 98
Resident census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Torres | Licensing Program Analyst | Conducted the unannounced visit and investigation. |
| David Alspach | Administrator | Facility administrator mentioned in the report. |
| Diane Domingo | Executive Director | Met with Licensing Program Analyst during visit and provided information about the incident and staff actions. |
| Staff One | Staff member who slapped the resident and was terminated. |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 98
Deficiencies: 0
Date: Jun 17, 2022
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility did not issue a refund to a resident after they moved out.
Complaint Details
The complaint alleged the facility did not provide a refund to Resident One after they moved out on April 16, 2022. The allegation was found to be unfounded based on documentation and interviews.
Findings
The investigation found that the facility did issue the refund, which was processed on June 16, 2022, and the allegation was deemed unfounded.
Report Facts
Facility capacity: 98
Census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Torres | Licensing Program Analyst | Conducted the complaint investigation visit |
| Monica Flores | Business Office Manager | Interviewed during the investigation regarding refund allegation |
Inspection Report
Complaint Investigation
Capacity: 98
Deficiencies: 0
Date: Dec 22, 2021
Visit Reason
The visit was an unannounced case management incident investigation following a self-reported incident where a resident eloped from the facility unnoticed and was returned by police without injury.
Complaint Details
The facility self-reported that on December 7, 2021, Resident #1 eloped unnoticed and was returned the same day by police with no injuries noted. The case management visit was conducted to review this incident.
Findings
During the visit, interviews and client records were reviewed. No deficiencies were cited, but further follow-up is needed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carmen Lopez | Licensing Program Analyst | Conducted the unannounced case management visit and reviewed the complaint. |
| Diane Domingo | Executive Director | Met with Licensing Program Analyst during the visit and discussed the complaint. |
Inspection Report
Annual Inspection
Census: 80
Capacity: 98
Deficiencies: 0
Date: Oct 15, 2021
Visit Reason
An unannounced visit was made to conduct an annual required licensing inspection of the facility.
Findings
No deficiencies were observed during the inspection. The inspection focused on infection control protocols including symptom screening, visitor policies, hand hygiene, PPE supplies, and disinfection procedures.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bryan Kane | Maintenance Director | Met with Licensing Program Analyst during inspection and exit interview. |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 98
Deficiencies: 1
Date: Sep 7, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to a complaint received on August 31, 2021, alleging that the facility did not issue a resident a timely refund.
Complaint Details
The complaint was substantiated. The allegation was that the facility did not issue a timely refund to resident #1 after their termination date. Evidence showed the refund was due within 30 days but was not paid by the time of the investigation.
Findings
The investigation substantiated the allegation that the facility failed to issue a timely refund to resident #1. Records and interviews confirmed that the resident was due a refund within 30 days of their termination date on May 26, 2021, but the refund had not been issued as of the inspection date.
Deficiencies (1)
Facility did not issue a timely refund to resident, violating admission agreement refund conditions.
Report Facts
Residents in care: 76
Total licensed capacity: 98
Deficiency count: 1
Plan of Correction due date: Sep 20, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Hamer | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Diane Domingo | Administrator | Facility administrator involved in interviews and plan of correction |
| Denise Powell | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 83
Capacity: 98
Deficiencies: 0
Date: Nov 27, 2020
Visit Reason
The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's staffing, disinfection, testing surveillance, screening protocols as well as the use of personal protective equipment.
Findings
During the visit, no deficiencies were issued. The team interviewed the Administrator and conducted a walkthrough of the facility. An exit interview was conducted and relevant documents were provided to the Administrator.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Alspach | Administrator | Interviewed during the visit and participated in the exit interview |
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