Inspection Reports for
Angels Nursing Center
415 S Union Ave, Los Angeles, CA 90017, United States, CA, 90017
Back to Facility ProfileCitations (last 6 years)
Citations (over 6 years)
9.8 citations/year
Citations are regulatory findings recorded during state inspections.
145% worse than California average
California average: 4 citations/yearCitations per year
28
21
14
7
0
Occupancy
Latest occupancy rate
90% occupied
Based on a February 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 37
Capacity: 41
Citations: 0
Date: Feb 11, 2026
Visit Reason
The visit was an unannounced initial complaint investigation conducted in response to allegations received on 2026-02-06 regarding staff not assisting residents with their care needs and violating residents' personal rights.
Complaint Details
The complaint allegations were determined to be unfounded, meaning the allegations were false, could not have happened, and/or were without a reasonable basis.
Findings
The investigation found the allegations to be unfounded after reviewing documentation and conducting interviews. No deficiencies were cited during the visit.
Report Facts
Capacity: 41
Census: 37
Estimated Days of Completion: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martin Vega | Licensing Program Analyst | Conducted the complaint investigation |
| Brandon Weber | Administrator | Met with Licensing Program Analyst during investigation |
| Steven Cruz | Regional Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Census: 40
Capacity: 41
Citations: 2
Date: Oct 30, 2025
Visit Reason
The visit was an unannounced case management inspection conducted by Licensing Program Analyst Brianna Miranda to evaluate compliance with licensing requirements, specifically regarding fire clearance and safety measures.
Findings
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 car was observed double parked, creating a potential safety hazard. Deficiencies were cited under Title 22, and a civil penalty was issued.
Citations (2)
Failure to ensure fire clearance includes approval of locked exterior doors or perimeter fence gates and that staff have access to equipment to unlock them, posing an immediate health, safety, or personal rights risk.
Failure to notify the licensing agency of updates to fire clearance, including the addition of a knock box, posing a potential health, safety, or personal rights risk.
Report Facts
Capacity: 41
Census: 40
Plan of Correction Due Date: Oct 31, 2025
Plan of Correction Due Date: Nov 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during inspection and named in findings |
| Brianna Miranda | Licensing Program Analyst | Conducted the inspection and authored the report |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 41
Citations: 0
Date: Oct 30, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2025-10-04 alleging staff manipulation of a resident and rejection of care services for a resident.
Complaint Details
The complaint involved allegations that staff were manipulating a resident and rejecting care services. The investigation found the allegations unsubstantiated due to lack of evidence.
Findings
The investigation included interviews and record reviews. The resident was observed and found to be able to make their own choices. There was no preponderance of evidence to prove the alleged violations occurred, and the allegations were determined to be unsubstantiated.
Report Facts
Capacity: 41
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brenda Chan | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Census: 41
Capacity: 41
Citations: 0
Date: Oct 8, 2025
Visit Reason
The visit was an unannounced case management inspection conducted by Licensing Program Analyst B. Miranda to evaluate the facility and review resident documentation.
Findings
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.
Report Facts
Capacity: 41
Census: 41
Date for fire clearance submission: Oct 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during inspection |
| Brianna Miranda | Licensing Program Analyst | Conducted the unannounced case management visit |
| Anthony Barbato | Licensee | Responsible for providing approved fire clearance documentation |
Inspection Report
Complaint Investigation
Citations: 1
Date: Jun 5, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to maintain accountability for controlled substances, specifically 17 unaccounted Percocet tablets for a resident.
Complaint Details
The investigation was triggered by a complaint regarding missing Percocet tablets for Resident 1. The complaint was substantiated as the facility failed to properly account for the medications and follow narcotic inventory procedures.
Findings
The facility failed to maintain proper accountability for 17 Percocet tablets prescribed to Resident 1, leading to potential drug diversion, opioid abuse, and accidental overdose. Multiple licensed nurses did not perform required narcotic inventory checks during shift changes, and medication cart keys were left unsecured, increasing risk of unauthorized access.
Citations (1)
F 0755: The facility failed to maintain accountability for 17 Percocet tablets prescribed to Resident 1, resulting in unaccounted medications after discontinuation. Narcotic inventory sheets were not properly reconciled at each shift change, and medication cart keys were left unsecured, allowing potential unauthorized access.
Report Facts
Unaccounted Percocet tablets: 17
Percocet tablets delivered: 24
Percocet tablets administered after discontinuation: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN3 | Licensed Vocational Nurse | Medication nurse who did not perform inventory check of discontinued Percocet and did not report narcotic discrepancies. |
| LVN4 | Licensed Vocational Nurse | Performed narcotic inventory with LVN3 but left medication cart key unsecured and did not perform inventory with incoming nurse LVN6. |
| LVN6 | Licensed Vocational Nurse | Assigned to Med Cart 1 and performed narcotic inventory with LVN3; no discrepancies reported. |
| RN1 | Registered Nurse | On duty nurse who did not receive reports of narcotic discrepancies from LVN6. |
| Director of Nursing | Director of Nursing | Provided statements on proper medication cart key handling and risks of unsecured keys. |
Inspection Report
Annual Inspection
Census: 41
Capacity: 41
Citations: 0
Date: Jun 5, 2025
Visit Reason
The inspection was an unannounced Required Annual Inspection conducted to evaluate compliance with licensing requirements for Redwood Senior Living Bakersfield facility.
Findings
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.
Report Facts
Water temperature: 98
Water temperature: 103.2
Food supply: 2
Food supply: 7
Emergency water supply: 4
Resident bedrooms observed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during inspection |
| Rachel Bruce | Licensing Program Analyst | Conducted the inspection |
| Barbara Martin | Med Tech | Granted entry to facility and assisted with tour and medication audit |
| Sabrina Arnelas | Assistant Administrator | Accompanied Licensing Program Analyst during facility tour |
Inspection Report
Routine
Citations: 6
Date: May 22, 2025
Visit Reason
Routine inspection of Angels Nursing Health Center to assess compliance with regulatory requirements including resident rights, pressure ulcer care, medication administration, dietary services, food safety, and waste management.
Findings
The facility failed to ensure proper documentation of advance directives for sampled residents, maintain appropriate Low Air Loss Mattress settings, inform residents about medications during administration, follow standardized dietary menus, maintain sanitary food preparation practices, and properly manage trash disposal.
Citations (6)
F 0578: The facility failed to ensure three sampled residents had documented advance directives upon admission or readmission, risking unknown resident wishes for medical treatment.
F 0686: The facility failed to maintain appropriate Low Air Loss Mattress settings for two sampled residents, potentially causing discomfort and worsening pressure ulcers.
F 0755: The facility failed to inform two sampled residents of the medications administered to them, violating resident rights and medication administration policies.
F 0803: The facility failed to follow standardized recipes and menu plans, resulting in residents not receiving fortified diets or correct meal components, risking nutritional deficits.
F 0812: The facility failed to ensure sanitary food preparation practices including handwashing after glove removal, maintaining clean kitchen and storage areas, cleaning coffee machine parts, and serving clean dishes.
F 0814: The facility failed to maintain trash dumpsters in a sanitary manner, with one dumpster overfilled and uncovered, risking pest harborage.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 2
Residents affected: 7
Residents affected: 14
Residents affected: 35
Medications administered: 9
Medications administered: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Administered medications to Residents 24 and 250 without informing them of medication names or purposes |
| RN 1 | Registered Nurse | Interviewed regarding advance directive follow-up for Resident 28 |
| SSD | Social Services Director | Interviewed regarding advance directive policies and residents 18, 26, and 28 |
| DON | Director of Nursing | Interviewed regarding medication administration and advance directives |
| DA1 | Dietary Aide | Failed to read fortified diet orders and did not wash hands after glove removal |
| Cook1 | Cook | Failed to follow menu and served incorrect meals; did not notice dirty plates |
| DS | Dietary Supervisor | Interviewed regarding food service and kitchen sanitation issues |
| MS | Maintenance Supervisor | Interviewed regarding trash dumpster sanitation |
Inspection Report
Complaint Investigation
Citations: 1
Date: Apr 24, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident (Resident 1) who was found unattended outside the facility in the parking lot, raising concerns about supervision and safety.
Complaint Details
The complaint investigation was triggered by Resident 1 being found unattended in the facility parking lot on 4/13/25. The facility did not investigate how Resident 1 left her room. The complaint was substantiated with findings of inadequate supervision and lack of documentation.
Findings
The facility failed to investigate and determine how Resident 1 left her room unattended and was found in the parking lot. The facility lacked documentation and did not follow policy to ensure adequate supervision to prevent accidents.
Citations (1)
F 0689: The facility failed to ensure the nursing home area was free from accident hazards and did not provide adequate supervision to prevent Resident 1 from leaving her room unattended and being found in the parking lot. The facility did not investigate how Resident 1 exited her room or document the incident.
Report Facts
Residents Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Named in relation to finding Resident 1 in the parking lot and not documenting the incident. |
| Guard 1 | Reported finding Resident 1 in the parking lot. | |
| Guard 2 | Reported seeing Resident 1 in the parking lot and escorting her back inside. | |
| Director of Nursing | Director of Nursing | Interviewed regarding the incident and lack of documentation. |
| Administrator | Administrator | Interviewed regarding the facility's lack of investigation. |
Inspection Report
Complaint Investigation
Citations: 1
Date: Mar 4, 2025
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to protect a resident from physical abuse by another resident, specifically an incident where Resident 1 hit Resident 2.
Complaint Details
The complaint investigation substantiated that Resident 1 struck Resident 2 after Resident 2 refused to give Resident 1 money. Resident 2 did not sustain injuries. The facility transferred Resident 1 to the hospital for psychiatric evaluation. The investigation found failures in behavior documentation, care plan updates, and timely physician notification.
Findings
The facility failed to follow its behavior management policies by not documenting aggressive behaviors and not updating care plans timely. Resident 1 exhibited multiple aggressive behaviors in February 2025, culminating in hitting Resident 2 on 2/25/2025. The facility delayed physician notification and care plan updates after the incident.
Citations (1)
F 0600: The facility failed to protect residents from physical abuse by not documenting Resident 1's aggressive behaviors and not updating care plans after behavioral changes, resulting in Resident 1 hitting Resident 2 on 2/25/2025.
Report Facts
Aggressive behavior instances: 17
Medication dosage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor 1 | RN Supervisor | Witnessed Resident 1 strike Resident 2 and intervened during the incident. |
| Director of Rehabilitation | Director of Rehabilitation | Observed Resident 1 upset and witnessed the altercation on 2/25/2025. |
| Director of Nursing | Director of Nursing | Reported on documentation practices and medication changes related to Resident 1's behavior. |
| Licensed Vocational Nurse 2 | LVN | Provided information on care plan update policies and physician notification practices. |
Inspection Report
Complaint Investigation
Census: 48
Citations: 1
Date: Feb 27, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to readmit a resident after hospitalization, potentially violating the facility's readmission policy.
Complaint Details
The complaint was substantiated. The facility denied readmission to Resident 1 due to the resident being on three IV antibiotics and staffing limitations. The facility also cited lack of available female beds, though records showed one bed was held for another resident without discharge documentation.
Findings
The facility failed to readmit Resident 1 on 2/13/2025 after hospitalization despite discharge orders. The resident remained hospitalized unnecessarily, placing them at risk for psychosocial harm. The facility cited staffing and bed availability issues as reasons for denial.
Citations (1)
F 0626: The facility failed to permit a resident to return after hospitalization or therapeutic leave exceeding the bed-hold policy, resulting in the resident remaining hospitalized despite discharge orders.
Report Facts
Total census: 48
Total census: 47
Total census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility Case Manager | Interviewed regarding communication with hospital case manager about resident discharge | |
| GACH Discharge Coordinator | Interviewed regarding discharge plan and facility readmission denial | |
| Director of Nursing | Interviewed regarding facility staffing and bed availability related to readmission denial |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Citations: 0
Date: Jan 31, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility did not provide adequate food services to residents.
Complaint Details
The complaint alleging inadequate food services was investigated and found to be unsubstantiated due to lack of preponderance of evidence.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel A Bruce | Licensing Program Analyst | Conducted the complaint investigation visit and delivered investigation findings. |
| Beatriz Ponce | Administrator | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Plan of Correction
Citations: 1
Date: Dec 17, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan requirements, specifically the revision and updating of care plans for residents with mental health diagnoses.
Findings
The facility failed to revise the bipolar care plan on a quarterly basis for one of three sampled residents, which could negatively affect the provision of care and services. The Director of Nursing confirmed that care plans should be updated quarterly and as needed, and the facility policy requires periodic review and revision of comprehensive care plans.
Citations (1)
F 0657: The facility failed to revise a bipolar care plan quarterly for one of three sampled residents, potentially impacting care quality. The care plan was last revised on 5/25/2024 and was not updated as required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding care plan update requirements and facility policy. |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 41
Citations: 0
Date: Oct 28, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 41
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during the investigation and provided statements |
| Beatriz Ponce | Administrator | Named as facility administrator |
Inspection Report
Census: 40
Capacity: 41
Citations: 0
Date: Oct 24, 2024
Visit Reason
An unannounced case management inspection was conducted to discuss care and supervision following an incident report involving an altercation between two residents.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with during inspection and mentioned in relation to facility administration. |
| Rachel A Bruce | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager in the report. |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 41
Citations: 0
Date: Oct 24, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Complaint Control Number: 24-AS-20240505222013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel A Bruce | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Beatriz Ponce | Administrator | Facility administrator met during the investigation and named in the report |
| Sergiy Pidgirny | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Routine
Census: 43
Citations: 1
Date: Aug 1, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically regarding COVID-19 transmission prevention policies and procedures.
Findings
The facility failed to ensure that a Licensed Vocational Nurse who tested positive for COVID-19 immediately left the facility, resulting in potential exposure of approximately 20 residents. The deficient practice increased the risk of COVID-19 transmission to all 43 residents and staff.
Citations (1)
F 0880: The facility failed to implement an infection prevention and control program by allowing a Licensed Vocational Nurse who tested positive for COVID-19 to remain at work and prepare medications for approximately 20 residents. This practice increased the risk of COVID-19 transmission to residents and staff.
Report Facts
Residents affected: 43
Residents affected by medication preparation: 20
Date of positive test: Jul 27, 2024
Isolation period: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 3 | Licensed Vocational Nurse | Named in infection control deficiency for working after testing positive for COVID-19 |
| Director of Nursing | Director of Nursing | Provided statements regarding COVID-19 positive staff work restrictions and contact tracing |
| Director of Staff Development | Director of Staff Development | Stated that LVN 3 should have left the facility immediately after testing positive |
| Infection Preventionist | Infection Preventionist | Provided interview about infection control policies and LVN 3's positive test |
| Public Health Nurse | Public Health Nurse | Stated staff must leave facility once testing positive |
Inspection Report
Complaint Investigation
Citations: 4
Date: Jul 31, 2024
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to properly implement care plans and supervision to prevent elopement of a resident, as well as concerns about staff competencies and medication monitoring.
Complaint Details
The complaint investigation focused on Resident 1's elopement incident on 7/17/2024, where the resident left the facility unsupervised and was hospitalized. The investigation found failures in care plan implementation, supervision, documentation, and staff competency related to this incident.
Findings
The facility failed to implement a comprehensive care plan and adequate supervision to prevent elopement of Resident 1, who left the facility unsupervised and was hospitalized. Additionally, the facility did not ensure staff maintained required CPR certification and failed to properly monitor psychotropic medication behaviors for the resident.
Citations (4)
F 0656: The facility failed to implement a complete care plan that meets the resident's needs, specifically for Resident 1's risk of elopement, resulting in potential negative impact on health and safety.
F 0689: The facility failed to ensure adequate supervision to prevent elopement of Resident 1, resulting in the resident leaving the facility unsupervised and being transferred to a hospital due to chest pain.
F 0726: The facility failed to maintain and update basic life support/Cardiopulmonary Resuscitation (BLS/CPR) certification for one staff member, placing residents at risk during emergencies.
F 0758: The facility failed to ensure proper behavior monitoring was ordered and implemented for Resident 1's psychotropic medications, risking unnecessary medication use and adverse effects.
Report Facts
Residents sampled: 5
Staff sampled: 8
Psychotropic medications ordered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 2 | Licensed Vocational Nurse | Observed Resident 1 eloping and did not document or notify physician |
| Treatment Nurse 1 | Treatment Nurse | Observed Resident 1 eloping, did not document or notify physician |
| Director of Nursing | Director of Nursing | Reported Resident 1 elopement incident and noted failures in documentation and care plan implementation |
Inspection Report
Complaint Investigation
Citations: 1
Date: Jul 16, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a fall incident involving Resident 1, who was assessed as high risk for falls and suffered injury due to lack of adequate supervision and assistance.
Complaint Details
The complaint investigation involved Resident 1 who was found on the floor bleeding from a head injury after ambulating without assistance despite being high risk for falls. The fall was unwitnessed, and the resident did not use the call light for help. The incident was substantiated with evidence from medical records, staff interviews, and physical therapy assessments.
Findings
The facility failed to provide necessary assistance and supervision to Resident 1 during ambulation to the bathroom, resulting in a fall with a head laceration and subdural hematomas. Interviews and record reviews confirmed Resident 1 was high risk for falls and required assistance, which was not provided at the time of the incident.
Citations (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent Resident 1's fall, resulting in actual harm with a head laceration and subdural hematomas.
Report Facts
Fall Risk Assessment score: 80
Laceration size: 4
Subdural hematoma measurements: 7
Subdural hematoma measurements: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Assigned to Resident 1 on 7/5/2024 and reported finding Resident 1 on the floor bleeding |
| CNA 2 | Certified Nursing Assistant | Observed Resident 1 walking without call light use and witnessed the fall |
| PT 1 | Physical Therapist | Provided evaluation stating Resident 1 required assistance and supervision when ambulating |
| RNS 1 | Registered Nurse Supervisor | Found Resident 1 on the floor after fall and confirmed lack of call light use and need for assistance |
| DON | Director of Nursing | Confirmed Resident 1's high fall risk and need for assistance per care plan |
Inspection Report
Annual Inspection
Census: 41
Capacity: 41
Citations: 1
Date: Jun 13, 2024
Visit Reason
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.
Findings
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.
Citations (1)
Training documents for residents and staff were found to be not up to date.
Report Facts
Capacity: 41
Census: 41
Document submission deadline: Jun 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during inspection and involved in inspection process |
| Lissett Padgett | Licensing Program Analyst | Conducted the inspection visit |
| Sergiy Pidgirny | Licensing Program Manager | Named in report as Licensing Program Manager |
| Steven Cruz | Regional Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Census: 39
Capacity: 41
Citations: 2
Date: May 31, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations at Redwood Senior Living Bakersfield facility.
Findings
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.
Citations (2)
Use of full bed rails without hospice care approval for 2 of 3 residents in hospital beds.
Failure to complete required annual training, including dementia care and postural supports, in 3 of 4 staff files reviewed.
Report Facts
Residents with full bed rails without hospice approval: 2
Staff files lacking required training: 3
Plan of Correction Due Date: 06/13/2024 for bed rails deficiency
Plan of Correction Due Date: 07/05/2024 for staff training deficiency
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during inspection and involved in plan of correction |
| Lissett Padgett | Licensing Program Analyst | Conducted the inspection and authored the report |
| Sergiy Pidgirny | Licensing Program Manager / Supervisor | Supervisor overseeing the inspection and report |
| Steven Cruz | Regional Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Citations: 13
Date: Apr 30, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including timely submission of Minimum Data Set (MDS) assessments, development of comprehensive care plans, appropriate treatment for residents with swallowing difficulties, fall prevention, medication disposal, therapeutic diet adherence, staff competency evaluations, infection control, and care for residents with feeding tubes and ostomies.
Citations (13)
F 0640: The facility failed to submit complete Minimum Data Set (MDS) assessments for four sampled residents within 14 days of initiation, potentially delaying proper healthcare monitoring.
F 0656: The facility failed to develop comprehensive, person-centered care plans for three residents, including plans for gastrostomy tube feeding, pain management, and antipsychotic/antidepressant medication.
F 0684: The facility failed to provide appropriate care for a resident with dysphagia, resulting in immediate jeopardy due to the resident receiving regular textured food instead of a pureed diet, leading to respiratory distress and death.
F 0689: The facility failed to ensure three residents received care to prevent falls, including accurate fall risk assessments and development of fall prevention care plans, resulting in a resident sustaining a hip fracture.
F 0691: The facility failed to provide appropriate ileostomy care for a resident, including monitoring bowel sounds and documenting stoma site assessments as ordered, risking infection and skin breakdown.
F 0692: The facility failed to implement physician orders for weekly weights for a resident at risk for severe weight loss, placing the resident at risk for nutritional decline and dehydration.
F 0693: The facility failed to ensure a resident with a gastrostomy tube received tube feeding without disconnection and failed to ensure the resident wore an abdominal binder as ordered to prevent tube dislodgement.
F 0726: The facility failed to perform required annual competency evaluations for three licensed nursing staff, risking inadequate care delivery.
F 0755: The facility failed to properly dispose of unused medications, storing them unsecured in a container, risking diversion and misuse.
F 0805: The facility failed to ensure a resident received the prescribed mechanical soft fortified finely chopped diet, serving food not finely chopped, risking aspiration and weight loss.
F 0813: The facility failed to implement policies for food brought in from outside sources, resulting in a resident with dysphagia receiving regular textured food from family, leading to respiratory distress and death.
F 0880: The facility failed to conduct annual fit testing for N95 respirators for six staff members, risking respiratory infections among residents.
F 0882: The facility failed to employ a qualified Infection Preventionist Nurse as required, potentially affecting infection prevention and control.
Report Facts
Residents with delayed MDS submission: 4
Weight loss in pounds: 23
Weight loss percentage: 18.11
Fall risk assessment score: 15
Fall risk assessment score: 55
Fall risk assessment score: 90
Fall risk assessment score: 75
Medication counts in unsecured container: 13
Staff fit test last date: Aug 26, 2022
Staff competency evaluation missing years: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Involved in Resident 43 care and reporting |
| RN 2 | Registered Nurse | Involved in Resident 43 care, missing competency evaluations |
| LVN 1 | Licensed Vocational Nurse | Missing competency evaluations |
| LVN 2 | Licensed Vocational Nurse | Missing competency evaluations |
| LVN 3 | Licensed Vocational Nurse | Facility Infection Preventionist, last fit test 8/26/2022 |
| CNA 1 | Certified Nursing Assistant | Observed Resident 43 eating wrong diet |
| CNA 2 | Certified Nursing Assistant | Last fit test 8/26/2022 |
| RNA 1 | Restorative Nurse Aide | Last fit test 8/26/2022 |
| Administrator | Facility Administrator | Oversight of facility operations and infection control |
| DSD | Director of Staff Development | Oversight of staff competency and infection control |
| RD 1 | Registered Dietician | Involved in diet order clarifications and nutritional assessments |
| Medical Director | Physician | Oversight of medical care and physician notifications |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Citations: 1
Date: Apr 18, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Citations (1)
All information and records obtained from or regarding residents shall be confidential. This requirement was not met as staff used personal communication devices to communicate resident medical information using pictures and text.
Report Facts
Capacity: 41
Census: 41
Plan of Correction Due Date: Apr 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lissett Padgett | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Beatriz Ponce | Administrator | Facility administrator met during the investigation |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 41
Citations: 1
Date: Feb 1, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Citations (1)
The facility was not clean, safe, sanitary, and in good repair as evidenced by a thick layer of unknown white powder in 4 resident rooms, posing an immediate health, safety, or personal rights risk.
Report Facts
Capacity: 41
Census: 39
Deficiencies cited: 1
Plan of Correction Due Date: Feb 2, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with during investigation and named in report |
| Lissett Padgett | Licensing Program Analyst | Conducted the complaint investigation |
| Sergiy Pidgirny | Licensing Program Manager | Named in report as licensing program manager |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Citations: 0
Date: Dec 5, 2023
Visit Reason
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.
Complaint Details
The complaint involved allegations of staff abandoning a resident and illegal eviction. The allegations were investigated and found to be unsubstantiated.
Findings
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.
Report Facts
Capacity: 41
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during the complaint investigation |
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Citations: 0
Date: Sep 6, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Incident report date: Aug 7, 2023
Incident date: Jul 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Barbato | Licensee Representative | Met with Licensing Program Analyst during the visit and participated in the exit interview |
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the unannounced Case Management visit and record review |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Citations: 0
Date: Jul 19, 2023
Visit Reason
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.
Complaint Details
The complaint was unsubstantiated. The allegations that staff did not assist residents with care needs and were rude were not supported by sufficient evidence.
Findings
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.
Report Facts
Capacity: 41
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with the Licensing Program Analyst during the complaint investigation |
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Annual Inspection
Census: 40
Capacity: 41
Citations: 1
Date: Apr 20, 2023
Visit Reason
The visit was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate compliance with regulations at Redwood Senior Living Bakersfield.
Findings
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.
Citations (1)
Medication was not administered to a resident for 16 consecutive days as ordered by the physician, posing a potential health, safety, or personal rights risk.
Report Facts
Deficiency duration: 16
Capacity: 41
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during inspection and exit interview |
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the annual inspection and authored the report |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Citations: 1
Date: Dec 30, 2022
Visit Reason
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.
Complaint Details
The complaint was substantiated based on interviews and record reviews. An immediate civil penalty of $500 was assessed, with additional penalties pending review.
Findings
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.
Citations (1)
87411(a) Personnel Requirements - Facility personnel were not sufficient in numbers and competent to provide necessary services to meet resident needs, contributing to failure to prevent non-consensual sexual relations.
Report Facts
Civil penalty amount: 500
Capacity: 41
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during inspection and findings delivery. |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 41
Citations: 0
Date: Nov 10, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that animals pose a risk to the residents while in care.
Complaint Details
The complaint was unsubstantiated based on the preponderance of evidence standard not being met.
Findings
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.
Report Facts
Capacity: 41
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mai Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during investigation |
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 41
Citations: 0
Date: Sep 22, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 41
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Beatrice Ponce | Administrator | Met with Licensing Program Analyst during investigation |
| Anthony Barbato | Licensee | Informed of the purpose of the visit |
Inspection Report
Follow-Up
Census: 38
Capacity: 41
Citations: 0
Date: Aug 23, 2022
Visit Reason
The visit was a Case Management follow-up on an incident that occurred on 2022-07-15.
Findings
The facility followed proper procedures related to the incident. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during the visit and participated in exit interview. |
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the Case Management visit and interview. |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 41
Citations: 0
Date: Aug 11, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 41
Census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during complaint investigation and named in findings |
| Malia Thao | Licensing Program Analyst | Conducted the complaint investigation |
| Melinda Hoffmann | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 41
Citations: 0
Date: Jul 21, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of unlawful eviction received on 2022-04-22.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 41
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint investigation visit |
| Barbara Martin | Medtech/Staff | Met with Licensing Program Analyst during investigation |
| Kenny Espinal | Administrator | Facility administrator named in report header |
Inspection Report
Annual Inspection
Census: 38
Capacity: 41
Citations: 0
Date: May 11, 2022
Visit Reason
The Licensing Program Analyst conducted an unannounced Annual Inspection focused on Infection Control at the facility.
Findings
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.
Report Facts
Food supply: 7
Food supply: 2
Facility capacity: 41
Census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the annual inspection |
| Anthony Barbato | Licensee Representative | Facility representative who granted entry and participated in the inspection |
| Kenny Espinal | Administrator | Facility administrator who participated in the exit interview and signed the report |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 41
Citations: 1
Date: Mar 24, 2022
Visit Reason
Unannounced case management visit regarding an incident report of elopement received by the facility.
Complaint Details
Visit was complaint-related due to an incident report of elopement. The deficiency was substantiated with a civil penalty assessed.
Findings
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.
Citations (1)
Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by failure to ensure Client 1 was provided proper care and supervision.
Report Facts
Civil penalty amount: 500
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the case management visit and cited the deficiency. |
| Brenda White | Licensing Program Manager | Supervisor of the licensing evaluation. |
| Anthony Barbato | Licensee Representative | Met with Licensing Program Analyst during the visit. |
| Kenny Espinal | Administrator | Participated in exit interview. |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 41
Citations: 0
Date: Mar 17, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to a complaint received on 2021-09-17 regarding alleged issues at the facility.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 41
Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Malia Thao | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Andy Xiong | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during the investigation |
Inspection Report
Census: 37
Capacity: 41
Citations: 0
Date: Feb 22, 2022
Visit Reason
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.
Findings
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.
Report Facts
Complaints received: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Barbato | Licensee Representative | Met with Licensing Program Manager and Analyst during the inspection |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 41
Citations: 0
Date: Feb 22, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 41
Census: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint investigation |
| Barbara Martin | Med Tech | Completed temperature check upon entry |
| Kenny Espinal | Administrator | Facility administrator mentioned in report |
| Anthony Barbato | Licensee Representative | Met with investigators during inspection |
| Brenda White | Licensing Program Manager | Named in report as Licensing Program Manager |
| S. Moua | Licensing Program Manager (LPM) | Assisted in conducting the complaint inspection |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 41
Citations: 1
Date: Feb 10, 2022
Visit Reason
An unannounced complaint inspection was conducted to open a complaint investigation regarding the facility's compliance with regulations.
Complaint Details
The visit was complaint-related, and the deficiency was substantiated based on the incomplete Needs and Services Plan for resident R1.
Findings
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.
Citations (1)
The Needs and Services Plan for resident R1 was incomplete, failing to meet the requirement to assess the person's need for personal assistance and care by determining their ability to perform specified activities of daily living.
Report Facts
Deficiency Type: 1
Capacity: 41
Census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Barbato | Licensee Representative | Met during exit interview and acknowledged receipt of report |
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint inspection and authored the report |
| Brenda White | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Routine
Citations: 12
Date: Jan 13, 2022
Visit Reason
Routine inspection of Angels Nursing Health Center to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to notify the Ombudsman of resident discharge, incomplete care plans, improper respiratory care, inaccurate medication management, inadequate staffing information posting, unsafe food storage and preparation, incomplete medical records, infection control lapses, and malfunctioning refrigeration equipment.
Citations (12)
F 0623: Facility failed to send Notice of Transfer/Discharge for Resident 29 to the State Long Term Care Ombudsman when discharged to hospital.
F 0656: Facility failed to develop comprehensive care plans for food preferences for Resident 11 and bathing for Residents 41 and 25.
F 0695: Facility failed to provide respiratory care per physician orders for Resident 16, including administering oxygen at 5 LPM instead of 2 LPM and not changing humidifier and nasal cannula tubing weekly.
F 0732: Facility failed to post actual nurse staffing hours daily and did not complete Direct Care Service Hours per patient day from 11/1/2021 to 1/11/2022.
F 0755: Facility failed to accurately account for controlled substances, perform regular destruction of controlled drugs, and ensure physician orders prior to medication administration for Residents 14 and 16.
F 0758: Facility failed to identify and document involuntary tongue movements as side effects of antipsychotic medication for Resident 32.
F 0761: Facility failed to discard expired glucometer solution, label injectable medication with open date, monitor refrigerator temperature, and store medications per manufacturer requirements.
F 0812: Facility failed to ensure safe food storage and preparation, including expired and unlabeled foods, improper thawing order, dirty dry storage floor, and damaged kitchen floor under dishwashing machine.
F 0814: Facility failed to maintain sanitary trash area with overflowing garbage and presence of roaches outside the facility.
F 0842: Facility failed to maintain complete and accurate medical records for Residents 29 and 30, including missing dialysis monitoring documentation and fall incident record.
F 0880: Facility failed to ensure infection control by allowing CNA to enter isolation room without gloves and failing to post transmission-based precaution signage on isolation rooms.
F 0908: Facility failed to maintain reach-in refrigerator and freezer at proper temperatures, risking foodborne illness for all residents.
Report Facts
Deficiencies cited: 12
Medication doses discrepancy: 1
Shower refusals: 2
Oxygen flow rate: 5
Temperature readings: 55
Temperature readings: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | LVN | Named in medication error finding and respiratory care deficiency |
| Director of Nursing | DON | Interviewed regarding staffing and infection control deficiencies |
| Director of Staff Development | DSD | Interviewed regarding care plan and staffing deficiencies |
| Registered Nurse 1 | RN | Named in antipsychotic medication side effect monitoring deficiency |
| Certified Nursing Assistant 1 | CNA | Observed not wearing gloves in isolation room |
| Dietary Supervisor | DS | Interviewed regarding food storage and refrigerator maintenance |
| Maintenance Supervisor | MS | Interviewed regarding trash and kitchen floor maintenance |
Inspection Report
Follow-Up
Census: 34
Capacity: 41
Citations: 2
Date: Dec 3, 2021
Visit Reason
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.
Findings
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.
Citations (2)
Facility was not free of urine odor which poses a potential health and safety risk to persons in care.
Licensee did not submit incident report within 7 days as required, posing a potential health and safety risk to persons in care.
Report Facts
Capacity: 41
Census: 34
Plan of Correction Due Date: Dec 17, 2021
Plan of Correction Due Date: Dec 3, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Barbato | Licensee Representative | Met with during inspection and exit interview |
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the inspection and signed the report |
| Brenda White | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 41
Citations: 0
Date: Dec 1, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 41
Census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawna Doucette | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Kamaldeep Kaur | Licensing Program Analyst | Assisted in complaint investigation |
| Anthony Barbato | Licensee Representative | Met with investigators and participated in exit interview |
| Kenny Espinal | Administrator | Facility administrator named in report header |
| Sergiy Pidgirny | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 41
Citations: 0
Date: Nov 29, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Complaint Control Number: 24-AS-20210907140249
Capacity: 41
Census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Ayers | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during the investigation |
| Kenny Espinal | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 41
Citations: 1
Date: Nov 4, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Citations (1)
Facility was not clean and sanitary, with grease spots on kitchen backsplash and damaged drywall behind the sink.
Report Facts
Capacity: 41
Census: 38
Deficiencies cited: 1
Plan of Correction Due Date: Nov 11, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during investigation and plan of correction discussion |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 41
Citations: 2
Date: Oct 21, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Citations (2)
Licensee did not ensure Resident 1 was free from being sexually assaulted by another resident, posing an immediate health and safety risk.
Licensee did not ensure an admission agreement was signed by Resident 1 or authorized representative, posing a potential personal rights risk.
Report Facts
Capacity: 41
Census: 39
Deficiencies cited: 2
Plan of Correction Due Dates: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during investigation and discussed plan of correction |
| Kenny Espinal | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 41
Citations: 0
Date: Oct 20, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 41
Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lady Cabrera | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on report |
| Kenny Espinal | Administrator | Facility administrator named in report |
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Citations: 1
Date: Sep 10, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint alleging unlawful eviction received on 2021-08-31.
Complaint Details
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.
Findings
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.
Citations (1)
Licensee issued a 30 Day Notice of Eviction that did not include the reason for eviction, specifically nonpayment of the rate for basic services within ten days of the due date, posing a potential health and safety risk to persons in care.
Report Facts
Estimated Days of Completion: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Anthony Barbato | Licensee interviewed during the investigation and recipient of the report |
Inspection Report
Census: 37
Capacity: 41
Citations: 0
Date: Aug 6, 2021
Visit Reason
An unannounced Case Management visit was conducted regarding a reported AWOL by the facility.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the unannounced Case Management visit and interviews. |
| Barket Hussain | Administrator | Met with Licensing Program Analyst during the visit. |
| Anthony Barbato | Licensee | Interviewed by Licensing Program Analyst during the visit. |
Inspection Report
Original Licensing
Census: 40
Capacity: 41
Citations: 0
Date: May 10, 2021
Visit Reason
The inspection was a prelicensing televisit conducted for the change of ownership of a currently licensed facility.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Barbato | CEO | Met with during the prelicensing televisit. |
| Kenny Espinal | Administrator | Present during the prelicensing televisit. |
Inspection Report
Census: 40
Capacity: 41
Citations: 0
Date: Apr 27, 2021
Visit Reason
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.
Findings
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.
Report Facts
Capacity: 41
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenny Espinal | Administrator | Named as the new administrator participating in COMP II |
| Antony Barbato | Owner | Named as owner participating in COMP II |
| Shannon Betker | Analyst | Community Care Licensing analyst participating in COMP II |
| Jude De La Concepcion | Licensing Program Manager | Named in report header and signature section |
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