Inspection Reports for Angels Nursing Center

The visit was an unannounced case management inspection conducted to evaluate compliance with licensing requirements, specifically regarding fire clearance and safety measures.

The facility failed to maintain proper fire clearance documentation reflecting changes such as the installation of a knock box and the use of a double dead-bolt on the outside gate. Additionally, a staff member's car was observed double parked, creating a potential safety hazard. Deficiencies were cited under Title 22 and a civil penalty was issued.

The visit was an unannounced case management inspection conducted by Licensing Program Analyst B. Miranda to evaluate the facility and review resident documentation.

The Licensing Program Analyst observed a resident (R3) between the poles of an iron fence with staff attempting to redirect the resident. The fence opening mechanism was discussed and noted as potentially dangerous. Copies of resident R3's physical, reappraisal, and appraisal forms were obtained. The licensee was to provide approved fire clearance documentation by 10/13/2025, with a follow-up visit possible if citations are issued.

The inspection was an unannounced Required Annual Inspection conducted to evaluate compliance with licensing requirements for Redwood Senior Living Bakersfield facility.

The facility was found to be generally well maintained with no immediate health or safety risks observed. The medication storage and documentation were in full compliance. Some bathrooms were noted to need painting, with patching repairs completed but paint pending. The inspection was not fully completed due to time constraints and will be continued at a later date.

An unannounced complaint investigation visit was conducted in response to an allegation that the facility did not provide adequate food services to residents.

The complaint was investigated through interviews with staff and residents. The allegation was determined to be unsubstantiated as residents are provided alternative menu options and appropriate efforts are made to accommodate their preferences.

The complaint alleging inadequate food services was investigated and found to be unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-08-28 regarding medication management and staff communication with residents.

The investigation found that Resident 1 was receiving medications as prescribed despite hiding medication, and staff communication with residents was appropriate. There was insufficient evidence to substantiate the allegations, resulting in an unsubstantiated finding.

The complaint included allegations that staff did not ensure medications were properly managed and did not speak appropriately to residents. The investigation concluded both allegations were unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff did not provide resident medication as prescribed and did not safeguard resident's belongings.

The investigation found that Resident 1 was receiving medications as prescribed and that although the allegations may have happened or be valid, there was not a preponderance of evidence to prove the alleged violations occurred. Therefore, both allegations were unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included failure to provide medication as prescribed and failure to safeguard resident belongings. Evidence did not support the allegations sufficiently to confirm violations.

An unannounced case management inspection was conducted to discuss care and supervision following an incident report involving an altercation between two residents.

The inspection found that the altercation was witnessed by staff who intervened appropriately, no injuries occurred, and the necessary notifications were made. Staff were reminded to remain vigilant and take appropriate action when needed, and residents reported staff handle issues effectively.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-05-05 regarding inadequate food service, failure to prevent resident fighting, and staff behavior posing a risk to residents.

The investigation found all allegations to be unfounded after reviewing facility files, interviewing staff and residents, and touring the facility. It was determined that food service was adequate, staff appropriately intervened in resident behavior, and financial matters were handled according to regulation.

The complaint investigation was triggered by allegations that staff did not provide adequate food service, did not prevent residents from fighting, and that staff behavior posed a risk to residents. The investigation concluded these allegations were unfounded.

An unannounced annual continuation visit was conducted to evaluate the facility's compliance with regulations and assess the condition of the facility and resident care.

The facility was generally well maintained with clean and organized areas including kitchen, dining, living room, bedrooms, backyard, and staff room. Some deficiencies were cited related to training documents not being up to date, and a request for submission of various compliance documents was made.

The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations at Redwood Senior Living Bakersfield facility.

The inspection found deficiencies related to the improper use of full bed rails without hospice approval for 2 of 3 residents and incomplete annual training in 3 of 4 staff files. The facility was otherwise found to be in good condition with proper food storage, medication security, and functioning safety equipment.

The visit was an unannounced complaint investigation triggered by a complaint received on 2024-03-05 alleging that staff were disclosing personal information about a resident.

The investigation substantiated the allegation that staff were using personal communication devices to communicate resident medical information, including pictures and text, which posed a potential personal rights risk to persons in care.

The complaint was substantiated based on interviews, observations, and record reviews. Staff were found to be disclosing personal information about a resident via personal communication devices.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not ensure the facility was free from pests and were not taking universal precautions during an outbreak.

The investigation found no live cockroaches or other pests during the facility tour, and pest control services were documented monthly. Staff and administrator were found to be in compliance with current COVID guidance during the outbreak. The complaint was determined to be unfounded.

The complaint alleged that staff did not ensure the facility was free from pests and were not taking universal precautions for an outbreak. The complaint was investigated and found to be unfounded.

The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that staff were not providing a safe environment for residents in care.

The investigator observed a thick layer of unknown white powder in four resident bedrooms and under the kitchen stove, accessible to residents. The licensee did not comply with safety and sanitation regulations, posing an immediate health and safety risk.

The complaint was substantiated. The allegation was that staff were not providing a safe environment for residents in care. The investigation confirmed the presence of an unsafe condition with the unknown white powder accessible to residents.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-08-28 regarding allegations including staff abandoning a resident and illegal eviction.

The investigation found that the resident wanted to leave the facility voluntarily and was taken to a shelter who signed a statement indicating the resident's intent to leave. Based on interviews and observations, the allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint involved allegations of staff abandoning a resident and illegal eviction. The allegations were investigated and found to be unsubstantiated.

The visit was an unannounced Case Management inspection conducted in response to an incident report received on 2023-08-07 regarding an incident on 2023-07-31 where a resident was found with an open wound on the head.

No deficiencies were cited during this Case Management visit. The Licensing Program Analyst reviewed the resident's records and conducted interviews, and will review additional documentation when received to determine if follow-up is necessary.

The visit was triggered by an incident report alleging a resident was found with an open head wound. The Licensing Program Analyst conducted a record review and interviews but found no deficiencies during the visit.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-04-14 alleging that staff were not assisting residents with their care needs and were rude to residents.

The investigation found no evidence to substantiate the allegations based on interviews with staff, residents, and the administrator, as well as observations. Although some incidents may have occurred, they were not reported to management, and there was insufficient evidence to prove the allegations.

The complaint was unsubstantiated. The allegations that staff did not assist residents with care needs and were rude were not supported by sufficient evidence.

The visit was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate compliance with regulations at Redwood Senior Living Bakersfield.

The inspection found that the facility was generally compliant with regulations regarding safety, medication storage, and resident accommodations; however, a deficiency was cited related to medication administration where medication was not given to a resident for 16 consecutive days, posing a potential health and safety risk.

Unannounced complaint investigation visit conducted due to a complaint received on 08/22/2022 alleging the licensee did not prevent a resident from having non-consensual sexual relations with other residents in care.

The investigation found that the facility failed to prevent resident R1 from engaging in non-consensual sexual relations with other residents. The allegation was substantiated and an immediate civil penalty of $500 was assessed.

The complaint was substantiated based on interviews and record reviews. An immediate civil penalty of $500 was assessed, with additional penalties pending review.

An unannounced complaint investigation visit was conducted in response to allegations that residents were using drugs in the facility.

The investigation included interviews and observations. Staff, residents, and the administrator denied drug use, but some residents' rooms had odors of drugs. Family members also complained of drug odors. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that residents were using drugs in the facility. The investigation found no substantiated evidence to support the allegations, resulting in an unsubstantiated finding.

An unannounced complaint investigation was conducted in response to an allegation that animals pose a risk to the residents while in care.

The investigation found insufficient evidence to prove or disprove that stray animals were in areas where residents sleep. The allegation was determined to be unsubstantiated.

The complaint was unsubstantiated based on the preponderance of evidence standard not being met.

The inspection was an unannounced complaint investigation visit triggered by complaints alleging that the facility pressured a resident's representative to place the resident on hospice and that facility staff did not seek medical attention in a timely manner.

The investigation found the allegation that the facility pressured the resident's representative to place the resident on hospice to be unfounded, with hospice documents signed by family/POA and medical personnel. The allegation that staff did not seek medical attention timely was unsubstantiated due to insufficient evidence to prove negligence.

Two complaints were investigated: 1) Facility pressured resident's representative to place resident on hospice, found unfounded. 2) Facility staff did not seek medical attention in a timely manner, found unsubstantiated due to lack of preponderance of evidence.

The visit was a Case Management follow-up on an incident that occurred on 2022-07-15.

The facility followed proper procedures related to the incident. No deficiencies were cited during the visit.

The inspection was an unannounced complaint investigation conducted in response to allegations received on 2022-06-10 regarding inappropriate touching of residents and medication administration issues.

The investigation found the allegation of inappropriate touching unsubstantiated, with the licensee admitting physical contact but denying any sexual or inappropriate nature. The medication administration allegation was found unfounded, with no evidence of errors or refusal to administer medication.

The complaint involved allegations that staff were inappropriately touching residents and not administering medication as prescribed. The first allegation was unsubstantiated, and the second was unfounded.

An unannounced complaint investigation visit was conducted in response to an allegation that facility staff hit a resident with a broom stick.

The investigation was unable to determine if the alleged incident occurred due to lack of preponderance of evidence; therefore, the allegation was unsubstantiated.

The allegation that facility staff hit a resident with a broom stick was investigated but found unsubstantiated due to insufficient evidence.

An unannounced complaint investigation visit was conducted in response to an allegation of unlawful eviction received on 2022-04-22.

The investigation found that the allegation of unlawful eviction was unfounded. The resident moved voluntarily with family agreement due to inability to pay rent after loss of supplemental income.

The complaint alleging unlawful eviction was investigated and found to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis.

The Licensing Program Analyst conducted an unannounced Annual Inspection focused on Infection Control at the facility.

The facility was found to be in compliance with no deficiencies observed. Infection control measures such as visitor log-in, temperature checks, disinfection stations, and staff facial coverings were in place. Resident rooms and common areas met safety and equipment standards.

Unannounced case management visit regarding an incident report of elopement received by the facility.

The licensee failed to ensure proper care and supervision of Client 1, posing a potential health, safety, or personal rights risk. An immediate $500 civil penalty was assessed.

Visit was complaint-related due to an incident report of elopement. The deficiency was substantiated with a civil penalty assessed.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-02-17 alleging that the facility accepted residents beyond the level of care it could provide.

Based on observations, conversations with residents, and records reviewed, it was determined that the allegation was unfounded. Residents were ambulatory or could self-transfer and could communicate their needs to staff.

The complaint alleged that the facility accepted residents beyond the level of care it could provide. The allegation was investigated and found to be unfounded.

An unannounced complaint investigation was conducted in response to a complaint received on 2021-09-17 regarding alleged issues at the facility.

The investigation found that the resident did not have a change in condition requiring notification to the POA, the resident declined physical activity when offered, and although flies were observed in the facility, the licensee took steps to mitigate the issue. The allegations were determined to be unsubstantiated.

The complaint included allegations that facility staff did not notify the resident's POA of a change of condition, the facility was not providing opportunities for physical activity, and the facility had insects. The investigation found these allegations to be unsubstantiated.

The inspection was conducted as an Informal Meeting with the Licensee regarding the number of complaints the facility has received since licensing on 05/18/2021.

The facility has received 11 complaints since licensing. Discussions covered assessment of potential residents, age acceptance and compatibility, hospice care waivers, staffing, and protocols on unwitnessed falls. No deficiencies were issued during this visit.

The inspection was an unannounced complaint investigation conducted in response to multiple allegations including residents having head lice, insufficient food supply, unclean resident rooms, insufficient staffing at night, and non-adherence to COVID-19 protocols.

The investigation found that the allegations of head lice and insufficient food supply were unfounded, with proper protocols followed and adequate food observed. Allegations regarding unclean rooms, insufficient staffing, and COVID-19 protocol adherence were unsubstantiated due to lack of evidence, with staff interviews confirming daily cleaning and adherence to protocols despite resident resistance.

The complaint investigation was initiated based on allegations received on 02/17/2022. The findings determined the head lice and food supply allegations as unfounded and other allegations as unsubstantiated due to insufficient evidence.

Unannounced complaint investigation visit conducted in response to allegations that staff were not providing adequate care, hygiene care, and dental care to a resident.

The investigation found that the resident was on Hospice and receiving hygiene care two to three times a week. Facility staff denied the allegations, and no specific incidents were discovered. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint was unsubstantiated based on interviews, records review, and observations during the unannounced visit.

An unannounced complaint inspection was conducted to open a complaint investigation regarding the facility's compliance with regulations.

During the investigation, it was found that the Needs and Services Plan for resident R1 was incomplete, resulting in a cited deficiency based on records review in accordance with CCR Title 22.

The visit was complaint-related, and the deficiency was substantiated based on the incomplete Needs and Services Plan for resident R1.

The inspection was an unannounced complaint investigation visit triggered by allegations that there was no heat at the facility and that a resident was pressured to sign paperwork.

The investigation found that heat was operational at the facility and that the resident signed the admission paperwork voluntarily. Both allegations were determined to be unfounded.

The complaint investigation was unannounced and conducted by Evaluator Kamaldeep Kaur. The allegations were that there was no heat at the facility and that the resident was pressured to sign paperwork. Both allegations were found to be unfounded.

The visit was a Case Management follow-up to incidents that occurred on 11/21/2021, focusing on deficiencies related to the facility's condition and reporting requirements.

The inspection found a strong odor of urine in the facility and failure to submit an incident report within the required 7 days, both posing potential health and safety risks to persons in care.

Unannounced complaint investigation visit conducted in response to multiple allegations including facility cleanliness, unlawful eviction, resident sexual assault, staff hygiene maintenance, timely assistance to residents, resident bladder infection, and rent increase notice.

The investigation found the facility was dirty and had issued an unlawful eviction, but both issues were previously addressed with plans of correction. The sexual assault allegation could not be substantiated as it occurred prior to current licensee. Staff hygiene and timely care allegations were not substantiated based on interviews. The resident's bladder infection was treated properly and the facility provided proper rent increase notice. Overall, allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included facility dirtiness, unlawful eviction, resident sexual assault by another resident, staff not maintaining hygiene, untimely assistance, bladder infection, and failure to provide 60-day rent increase notice. Some issues were previously addressed; sexual assault allegation was indeterminate; other allegations lacked sufficient evidence.

The visit was an unannounced complaint investigation triggered by a complaint received on 09/07/2021 regarding allegations of resident injuries, pest infestation, and cleanliness issues at the facility.

The investigation found no evidence of resident injuries due to inadequate care, no pest infestation other than flies which were controlled, and the facility was clean. All allegations were unsubstantiated and no deficiencies were cited.

The complaint included allegations that residents sustained injuries while in care, the facility had pest infestation, and the facility was not clean. The investigation concluded these allegations were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 07/28/2021 regarding multiple allegations including facility cleanliness and resident care issues.

The investigation substantiated the allegation that the facility was filthy, specifically noting grease spots and damaged drywall in the kitchen area. Other allegations related to resident falls, medication administration, wheelchair condition, bed comfort, patio furniture, and exposed wires were found to be unsubstantiated based on observations, interviews, and record reviews.

The complaint investigation was substantiated for the allegation that the facility was filthy. Other allegations including resident falls with minor injuries, staff leaving resident in soiled diaper, medication administration, wheelchair disrepair, bed discomfort, patio furniture disrepair, and exposed wires were unsubstantiated.

The inspection visit was conducted in response to information on Resident 1's physician report indicating a prohibited health condition.

The Licensee admitted and retained Resident 1 who required total assistance with all activities of daily living, a prohibited health condition, without obtaining an exception as required by regulation.

The visit was complaint-related based on information from Resident 1's physician report. The deficiency cited was under appeal.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 07/01/2021 regarding multiple allegations including sexual assault of a resident, incomplete admission agreements, failure to notify responsible persons, residents left in soiled clothing, and lack of telephone service.

The investigation substantiated that a resident was sexually assaulted while in care and that staff did not complete an individual written admission agreement with the resident or responsible person. The allegation that the resident's responsible person was not notified of an incident was unsubstantiated, as was the allegation that residents were left in soiled clothing. The complaint regarding lack of telephone service was found to be unfounded as the facility had restored phone service.

The complaint investigation was substantiated for the allegation of sexual assault and incomplete admission agreement. The allegation that the resident's responsible person was not notified was unsubstantiated. The allegation that residents were left in soiled clothing was unsubstantiated. The complaint about lack of telephone service was unfounded.

The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was charging a resident for services not provided and that staff were not administering medications according to physician's orders.

The investigation found the allegations to be unfounded. Interviews and records review confirmed the facility continued to provide services and medication to the resident as required.

The complaint alleged that the facility was charging a resident for services not provided and that staff were not administering medications according to physician's orders. The complaint was found to be unfounded and dismissed.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint alleging unlawful eviction received on 2021-08-31.

The investigation found that the 30 Day Notice of Eviction issued to resident R1 on 2021-08-31 was incomplete and therefore unlawful. The allegation of unlawful eviction was substantiated based on interviews and record review.

Complaint alleging unlawful eviction was substantiated based on evidence including an incomplete 30 Day Notice of Eviction issued to resident R1 on 2021-08-31.

An unannounced Case Management visit was conducted regarding a reported AWOL by the facility.

The Licensing Program Analyst toured the facility, interviewed the Administrator and Licensee, and reviewed Resident 1's records. Due to insufficient information, further investigation is required.

The inspection was a prelicensing televisit conducted for the change of ownership of a currently licensed facility.

The facility was observed to be clean, in good repair, properly furnished, and compliant with safety and health requirements. No deficiencies were found during the prelicensing inspection.

The visit was an office type evaluation related to a Change of Ownership (CHOW) application and pre-licensing inspection, including a COVID-19 Mitigation Plan Report.

The applicant and administrator successfully completed Component II (COMP II) by telephone with the Community Care Licensing analyst, confirming understanding of Title 22 and various operational areas including facility operation, staff qualifications, training, grievances, food service, medication management, and application document review.