Inspection Report Summary
Most inspections found deficiencies related to resident care, staffing, and safety, with several complaint investigations substantiating issues such as delayed assistance with incontinence care and failure to observe changes in residents’ medical conditions, posing potential health and safety risks. The facility received an immediate $500 civil penalty in November 2024 for fire safety violations and a $100 penalty in April 2025 for fingerprint clearance violations and communication problems with staff. Several complaint investigations were unsubstantiated, including allegations of staff misconduct and improper hygiene care. The most recent report from July 30, 2025, cited one deficiency for untimely incontinence care but found other complaints unsubstantiated, showing some ongoing concerns but no new enforcement actions. There is no clear pattern of improvement or decline, as serious issues have recurred intermittently over the past year.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
145% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
83% occupied
Based on a July 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 1
Date: Jul 30, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not assist a resident with incontinence care needs in a timely manner, interfered with the resident's visit, made inappropriate comments to the resident, and retaliated against the resident.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not assist the resident with incontinence care needs in a timely manner. The investigation included interviews with the reporting party, authorized representative, resident, and staff, as well as review of relevant documents. Other allegations of staff interfering with the resident's visit, making inappropriate comments, and retaliating against the resident were unsubstantiated.
Findings
The investigation substantiated the allegation that staff failed to assist the resident timely with incontinence care needs due to staff absence, posing a potential health and safety risk. The other allegations regarding interference with the resident's visit, inappropriate comments, and retaliation were found to be unsubstantiated based on the preponderance of evidence.
Deficiencies (1)
Staff did not assist resident timely with incontinence care needs which posed a potential health and safety risk to residents in care.
Report Facts
Facility Capacity: 6
Census: 5
Plan of Correction Due Date: Aug 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raufat Ikharo-Umaru | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation visit |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 6
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not meet a resident's hygiene needs which led to the resident developing a UTI.
Complaint Details
The complaint alleged that staff did not meet the resident’s hygiene needs which led to the resident developing a UTI. The investigation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found the allegation to be unsubstantiated. Interviews and document reviews indicated that the resident received regular hygiene care, including full baths twice weekly and diaper changes every three hours. The resident was observed to be clean, odor free, and well groomed.
Report Facts
Facility capacity: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Raufat Ikharo-Umaru | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 2
Date: Jul 2, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following allegations that staff failed to observe a change in a resident's condition and failed to meet the resident's medical needs in a timely manner.
Complaint Details
The complaint investigation was substantiated based on interviews with the reporting party, authorized representative, resident, and staff, as well as review of resident records. The resident was diagnosed with a stroke and urinary tract infection after staff failed to recognize changes in condition and delayed medical response.
Findings
The investigation substantiated both allegations, finding that staff did not observe the resident's change in condition and failed to meet the resident's medical needs promptly, which posed a potential health and safety risk to the resident.
Deficiencies (2)
Staff failed to observe resident’s change in condition which posed a potential health & safety risk to resident in care.
Staff failed to meet resident’s medical needs in a timely manner which posed a potential health & safety risk to resident in care.
Report Facts
Capacity: 6
Census: 5
Plan of Correction Due Date: Jul 25, 2025
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raufat Ikharo-Umaru | Administrator | Named in findings related to failure to observe resident's condition and timely medical response |
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation |
| Bennett Fong | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 4
Capacity: 6
Deficiencies: 0
Date: May 29, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff were not assisting a resident with glucose testing and that staff falsified the resident's glucose readings.
Complaint Details
The complaint involved two allegations: 1) staff not ensuring assistance with glucose testing, and 2) staff falsifying resident's glucose readings. Both allegations were investigated and found unsubstantiated or unfounded based on interviews and medical record reviews.
Findings
The investigation found no preponderance of evidence to prove the alleged violations occurred. The allegation that staff did not assist with glucose testing was unsubstantiated, and the allegation of falsifying glucose readings was unfounded. No deficiencies were cited.
Report Facts
Facility capacity: 6
Census: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raufat Ikharo-Umaru | Administrator | Met with Licensing Program Analyst during investigation and involved in interviews |
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation visit |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 3
Capacity: 6
Deficiencies: 2
Date: Apr 15, 2025
Visit Reason
The visit was an unannounced Case Management inspection conducted on 04/15/2025, including a complaint investigation (15-AS-20241104220736) related to fingerprint clearance and staff communication issues.
Complaint Details
The complaint investigation (15-AS-20241104220736) revealed that a staff member was not fingerprinted and could not communicate in English, which posed an immediate health and safety risk.
Findings
The inspection found that a staff member (S2) was not fingerprinted or associated with the facility and was unable to communicate in English, posing an immediate health and safety risk. An immediate civil penalty of $100 was assessed for fingerprint clearance violations.
Deficiencies (2)
S2 staff member was not fingerprinted and associated with the facility, violating criminal record clearance requirements.
No staff available on premises able to communicate with residents, violating training and communication requirements.
Report Facts
Civil penalty amount: 100
Plan of Correction due date: Apr 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raufat Ikharo-Umaru | Administrator | Spoke with Licensing Program Analyst via telephone during inspection |
| Laura Hall | Licensing Program Analyst | Conducted the inspection and complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 3
Capacity: 6
Deficiencies: 2
Date: Apr 15, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff did not meet residents' diapering needs, did not respond timely to residents' calls for assistance, and did not provide adequate food service.
Complaint Details
The complaint investigation was substantiated based on interviews, observations, and record reviews. Allegations included unmet diapering needs, delayed response to resident calls due to staffing shortages and lack of call system, and inadequate food service. The facility was cited accordingly.
Findings
The investigation substantiated the allegations that staff failed to timely change incontinent residents, respond promptly to residents' calls for assistance due to insufficient staffing and lack of call system, and provided inadequate food service with meals high in carbohydrates and insufficient perishables. The facility was cited under California Code of Regulations for these deficiencies.
Deficiencies (2)
Failure to ensure incontinent residents are checked and changed timely, including during the night.
Failure to provide care, supervision, and services that meet individual needs and are delivered by sufficient, qualified, and competent staff, including timely response to resident calls.
Report Facts
Facility capacity: 6
Resident census: 3
Plan of Correction due date: Apr 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Hall | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Harpreet Humpal | Licensing Program Manager | Oversaw the complaint investigation |
| Raufat Ikharo-Umaru | Administrator | Facility administrator involved in the investigation and plan of correction |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 30
Date: Nov 12, 2024
Visit Reason
An unannounced annual required inspection was conducted to evaluate compliance with licensing regulations and assess the facility's condition and resident care.
Findings
The inspection revealed multiple deficiencies including incomplete staff and resident files, lack of hot water in the shared bathroom, unlocked cabinets containing hazardous materials, broken exit door with a bolt lock, inadequate food supplies, missing health care plans, failure to conduct fire drills, and improper medication storage. An immediate $500 civil penalty was assessed for fire safety violations.
Deficiencies (30)
Trash and clutter obstructing left side of facility
Two tubes of ointment found on resident's chest of drawers
Cleaning chemicals (comet, glass cleaner, stain remover) on bathroom counter
Slide bolt lock on exit door leading to backyard; door broken and would not stay closed without bolt lock
Unlocked medicine cabinet in kitchen with padlock unlocked
Patio screen off in den area
Sticky trap with dead insects on kitchen counter and several traps around kitchen
Unlocked kitchen cabinet containing Pine-Sol and Fabuloso
Unlocked cabinet with disinfectants and cleaning supplies in laundry area
Facility lacked 7-day supply of non-perishable and 2-day supply of perishable foods
No hot water from faucet in shared bathroom
Three of four resident files missing admission agreement; none had appraisal needs, service plan, or consent for medical treatment
No hospice care plan for resident R4
No health care plan for resident R2
No current and accurate medication list for residents
Two staff missing first aid certification; one staff missing health screening
Facility not conducting fire drills quarterly
Facility had not requested exception for pressure injury
Patio screen in den in disrepair; exit door to backyard in disrepair; refrigerator and freezer unsanitary
Passageway on left side of facility obstructed
Incomplete personnel records for staff
Kitchen area not clean of insects
No written agreement with home health agency for resident R2
Residents R1 and R2 not able to perform own glucose testing or have skilled professional conduct testing
No hospice care plan maintained for resident R4
Bolt lock on door leading to backyard
Medication not kept inaccessible to residents; unlocked ointment and medicine cabinet
Insufficient food supplies: lacking 7-day non-perishables and 2-day perishables
Incomplete resident records
Inaccurate medication records for all residents
Report Facts
Civil penalty: 500
Census: 4
Total capacity: 6
POC due date: Nov 19, 2024
POC due date: Nov 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Hall | Licensing Program Analyst | Conducted inspection and authored report |
| Harpreet Humpal | Licensing Program Manager | Supervisor of inspection |
| Raufat Ikharo-Umaru | Administrator | Facility administrator involved in inspection and plan of correction agreements |
| Bienvenido Espina | Caregiver | Met with Licensing Program Analyst during inspection; involved in medication cabinet correction |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 0
Date: Jul 12, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff made inappropriate comments towards a resident and yelled at the resident.
Complaint Details
The complaint involved allegations that staff made inappropriate comments towards a resident and yelled at the resident. The allegations were found to be unsubstantiated due to lack of evidence.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews with the resident and staff indicated that while disagreements occurred, staff did not yell at or call the resident names. No deficiencies were cited during the visit.
Report Facts
Capacity: 6
Census: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raufat Ikharo-Umaru | Administrator | Named in the investigation and interviewed during the complaint investigation |
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 0
Date: Mar 15, 2024
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation of illegal eviction of a resident.
Complaint Details
Allegation: Illegal eviction of resident. Investigation finding: Unsubstantiated. The resident was observed still residing at the facility, and documentation showed a 30-day eviction notice was sent for non-payment. The administrator is working with the resident's County Conservator for safe relocation.
Findings
The investigation found the allegation of illegal eviction to be unsubstantiated after review of records, interviews, and observations. No deficiencies were cited during the visit.
Report Facts
Capacity: 6
Census: 5
Complaint control number: 15-AS-20240227115411
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation visit |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
| Raufat Ikharo-Umaru | Administrator | Facility administrator involved in investigation and interviews |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 2
Date: Oct 26, 2023
Visit Reason
The visit was an unannounced annual required inspection conducted by the Licensing Program Analyst to evaluate compliance with state regulations.
Findings
The inspection found two deficiencies: an expired fire extinguisher and a missing carbon monoxide detector, both posing potential health and safety risks to residents.
Deficiencies (2)
Expired fire extinguisher (last purchased 10/05/2021)
Missing carbon monoxide detector
Report Facts
Capacity: 6
Census: 4
Temperature: 72
Hot water temperature: 118
Fire extinguisher last purchased: Oct 5, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raufat Ikharo-Umaru | Administrator | Met with Licensing Program Analyst during inspection |
| Daisy Panlilio | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bennett Fong | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 3
Capacity: 6
Deficiencies: 0
Date: Nov 4, 2022
Visit Reason
The visit was an unannounced infection control inspection conducted as part of the required 1-year evaluation.
Findings
The inspection found no deficiencies. The facility had appropriate infection control measures in place, including screening, PPE supplies, social distancing signage, and a mitigation plan. Updated documents were requested for submission.
Report Facts
Food supply duration: 2
Food supply duration: 7
PPE supply duration: 30
Facility temperature: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raufat Ikharo-Umaru | Administrator | Administrator authorized staff to act on his behalf and is the infection control leader |
| Daisy Panlilio | Licensing Program Analyst | Conducted the infection control inspection |
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