Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, reflecting generally good compliance with regulations. The most recent report from August 29, 2025, was a complaint investigation that found all allegations unsubstantiated and no deficiencies. Some earlier reports identified isolated issues, primarily related to medication management and facility cleanliness, including a few substantiated medication errors that posed immediate health risks and a finding of unclean conditions with odor in May 2025. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows improvement over time, with the latest inspections free of deficiencies after addressing prior concerns.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
68% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
69% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 145
Capacity: 210
Deficiencies: 0
Date: Aug 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations including restrictive facility environment for a resident, medication mismanagement, improper admission procedures, and violation of personal rights.
Complaint Details
The complaint included allegations that staff implemented a restrictive environment for resident R1, mismanaged medications, did not conduct proper admission procedures, and violated personal rights. The investigation concluded all allegations were unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found all allegations unsubstantiated based on thorough review of documentation, assessments, medication records, and interviews. The resident's environment was not restrictive beyond physician orders, medications were properly managed with documented refusals, and admission procedures were properly conducted.
Report Facts
Capacity: 210
Census: 145
Complaint received date: Apr 22, 2025
Medication review period: 75
Assessment period: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kimberley Mota | Licensing Program Manager | Oversaw the complaint investigation |
| Karrie Silvey | Executive Director | Facility representative who met with the Licensing Program Analyst during the investigation |
| Carol Dowell | Administrator | Facility administrator mentioned in the report |
Inspection Report
Annual Inspection
Census: 141
Capacity: 210
Deficiencies: 0
Date: Jul 29, 2025
Visit Reason
The inspection was an unannounced required 1-year annual inspection conducted to evaluate compliance with licensing requirements for the assisted living and memory care facility.
Findings
The inspection found the facility to be in compliance with regulations, including proper storage of medications and toxins, adequate hygiene and food handling practices, and up-to-date fire safety inspections. No citations were issued.
Report Facts
Hospice waiver residents: 9
Resident files reviewed: 5
Employee files reviewed: 4
Fire extinguisher inspection date: Jul 3, 2025
Emergency fire drill date: Jul 12, 2025
Fire alarm inspection date: Apr 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection |
| Karrie Silvey | Executive Director | Met with Licensing Program Analyst during inspection and exit interview |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 210
Deficiencies: 1
Date: Jul 9, 2025
Visit Reason
The inspection was conducted to review a Case Management - Incident Report regarding a resident who took a pill found on the floor of their apartment, which could not be safely identified, prompting hospital observation.
Complaint Details
The visit was complaint-related, triggered by an incident report dated 06/08/2025 where a resident took a pill found on the floor. The resident was transported to the hospital for observation and returned the same day. The complaint was substantiated with a cited deficiency.
Findings
The facility conducted re-training with medication technicians on the Six Rights of Medication Administration to ensure proper medication administration. A Type B deficiency was cited for failure to assist residents with self-administered medications safely, based on the incident.
Deficiencies (1)
Failure to assist residents with self-administered medications when needed, evidenced by a resident self-administering a pill found on the floor posing a potential health and safety risk.
Report Facts
Capacity: 210
Census: 142
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection and incident report review |
| Karrie Silvey | Executive Director | Met with Licensing Program Analyst regarding incident report and facility corrective actions |
| Kimberley Mota | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 210
Deficiencies: 0
Date: Jul 9, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff did not ensure a resident's room was properly operating.
Complaint Details
The complaint was unsubstantiated. The resident reported the broken air conditioning unit multiple times, a work order was filed, and repairs were scheduled. The facility was found to be in the process of making repairs.
Findings
The investigation found that the resident's air conditioning unit was inoperable but the facility had taken steps to address the issue, including providing a temporary portable unit and scheduling repairs. The allegation was determined to be unsubstantiated due to insufficient evidence.
Report Facts
Facility capacity: 210
Census: 142
Complaint control number: 21-AS-20250701115424
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Karrie Silvey | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 210
Deficiencies: 0
Date: Jul 9, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the facility did not issue a refund to a resident in care and charged a resident for services not rendered.
Complaint Details
The complaint alleged the facility did not issue a refund to a resident who was hospitalized and charged for services not rendered after the resident moved out due to unmet care needs. Both allegations were found unsubstantiated after review of lease agreements and staff interviews.
Findings
The investigation found both allegations to be unsubstantiated. The facility's lease agreement specifies no refunds for absences including hospital stays, and the resident did not provide the required 30-day notice to terminate the lease, making charges for that period valid.
Report Facts
Capacity: 210
Census: 142
Complaint Control Number: 21-AS-20250512101522
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Karrie Silvey | Executive Director | Met with Licensing Program Analyst to discuss findings |
Inspection Report
Complaint Investigation
Census: 155
Capacity: 210
Deficiencies: 1
Date: May 1, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the licensee did not ensure that residents' rooms were kept clean, the facility was not odiferous, and that staff met residents' hygiene needs.
Complaint Details
The complaint was substantiated regarding unclean resident rooms and facility odor but unsubstantiated regarding staff meeting residents' hygiene needs.
Findings
The investigation substantiated that some resident rooms were malodorous and had stained carpeting, posing an immediate health and safety risk. However, the allegation that staff did not meet residents' hygiene needs was unsubstantiated based on interviews, record reviews, and observations.
Deficiencies (1)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by stains in carpet and strong urine smell posing an immediate health, safety or personal rights risk to persons in care.
Report Facts
Capacity: 210
Census: 155
Rooms inspected: 9
Rooms with issues: 2
Deficiency due date: May 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Carol Dowell | Administrator | Met with Licensing Program Analyst during investigation |
| Kimberley Mota | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 159
Capacity: 210
Deficiencies: 0
Date: Nov 15, 2024
Visit Reason
The visit was an unannounced Case Management visit regarding multiple incidents around resident R1.
Findings
The Administrator and staff are monitoring resident R1 for any changes in condition and seeking supports for his care. No deficiencies or citations were issued at the time of the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the Case Management visit and collected documents. |
| Barbara Fleck | Administrator | Met with Licensing Program Analyst via phone; was not on site at time of visit. |
| Andrew Conley | Manager on Duty | Reviewed and signed the report on behalf of the Administrator. |
Inspection Report
Annual Inspection
Census: 156
Capacity: 210
Deficiencies: 0
Date: Jul 19, 2024
Visit Reason
The inspection was an unannounced annual comprehensive inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, well maintained, and comfortable with no deficiencies or citations issued. Safe food handling procedures were followed, and residents were appropriately cared for with positive feedback from staff and residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the annual inspection and accompanied the facility administrator on the tour. |
| Barbara Fleck | Administrator | Accompanied the Licensing Program Analyst during the inspection and was involved in the facility tour. |
Inspection Report
Annual Inspection
Census: 156
Capacity: 210
Deficiencies: 0
Date: Jul 16, 2024
Visit Reason
The inspection was an unannounced required 1-year annual inspection conducted to evaluate compliance with licensing regulations at the assisted living and memory care facility.
Findings
The inspection found no deficiencies or citations. Resident and employee files were complete, medications were properly stored and handled, and all required postings and safety measures were in place.
Report Facts
Residents with hospice waiver: 9
Resident files reviewed: 5
Employee files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Fleck | Administrator | Met with Licensing Program Analyst during inspection |
| Susan Alexander | Resident Services Director | Met with Licensing Program Analyst during inspection |
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 210
Deficiencies: 0
Date: Feb 1, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations that staff were not providing adequate care and supervision to residents and that the facility was not clean and sanitary.
Complaint Details
The complaint alleged inadequate care and supervision of residents, including isolation of Memory Care residents due to a COVID outbreak, and unsanitary living conditions. The complaint was determined to be unsubstantiated based on observations, interviews, and document review.
Findings
The investigation found that residents were clean, groomed, and appropriately cared for with adequate staffing observed. The facility was found to be clean, comfortable, and well-maintained. There was insufficient evidence to substantiate the allegations, resulting in an unsubstantiated complaint.
Report Facts
Staff present during inspection: 7
Capacity: 210
Census: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Fleck | Administrator | Met with Licensing Program Analyst during inspection |
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberley Mota | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 210
Deficiencies: 0
Date: Dec 15, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not ensuring residents' medication was being administered as prescribed.
Complaint Details
The complaint alleged that staff were not ensuring resident's medication was administered as prescribed. The investigation found no preponderance of evidence to substantiate the complaint, and it was deemed unsubstantiated.
Findings
The investigation included site visits, interviews, and document reviews. It was determined that resident R1 received medications as prescribed, and there was insufficient evidence to prove the allegations true or false. Therefore, the complaint was unsubstantiated.
Report Facts
Complaint Control Number: 21-AS-20231030091516
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Kimberley Mota | Licensing Program Manager | Named in the report as Licensing Program Manager. |
| Barbara Fleck | Administrator | Facility Administrator met during the investigation. |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 210
Deficiencies: 0
Date: Sep 18, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff were not providing food service for the residents, specifically that dining room service was not being provided as of September 12.
Complaint Details
The complaint alleged that staff were not providing food service to residents and that dining room service was not being provided since September 12. The allegation was unsubstantiated after investigation, which included interviews and document review confirming tray service was provided in accordance with infection control plans and health department guidance.
Findings
The investigation found that the facility was mitigating the spread of Covid-19 by closing communal dining areas and providing tray service to each resident, following guidance from the Yolo County Health Department and infection control regulations. Food service was confirmed to be provided, and the allegation was unsubstantiated due to lack of evidence.
Report Facts
Capacity: 210
Census: 143
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation |
| Barbara Fleck | Administrator | Facility administrator met during the investigation |
| Kimberley Mota | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 210
Deficiencies: 1
Date: Sep 5, 2023
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that staff mismanaged resident medication.
Complaint Details
The complaint was substantiated. The allegation was that staff mismanaged resident medication, specifically administering an extra dose to Resident (R1) due to a computer system error.
Findings
The investigation found that Resident (R1) was given an additional dose of medication in excess of the physician's order due to a computer system alert error. The allegation was substantiated based on observations, interviews, and record reviews.
Deficiencies (1)
Based on interviews conducted R1 was given an extra dose of medication. This poses an immediate health risk to residents in care.
Report Facts
Capacity: 210
Census: 140
Deficiency Type: 1
Plan of Correction Due Date: Sep 5, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Barbara Fleck | Administrator | Facility administrator met during the investigation |
| Kimberley Mota | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 143
Capacity: 210
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
The inspection was an unannounced required 1-year annual inspection conducted to evaluate compliance with licensing regulations.
Findings
The facility was found to be clean, orderly, and well-maintained with no deficiencies or citations issued. Safety equipment and emergency drills were up to date, and the kitchen and dining areas met regulatory standards.
Report Facts
Residents in care: 143
Total capacity: 210
Rooms inspected: 10
Fire extinguisher inspection date: Jul 4, 2023
Emergency drill date: Jul 31, 2023
Fire alarm inspection date: May 24, 2023
Fire sprinkler inspection date: May 25, 2023
Hospice waiver residents: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Fleck | Administrator | Met with Licensing Program Analyst during inspection |
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection |
| Kimberley Mota | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Census: 135
Capacity: 210
Deficiencies: 0
Date: Mar 28, 2023
Visit Reason
The visit was an unannounced Case Management - Other inspection to review a self-reported SOC 341 suspected abuse report involving a resident and a family member.
Complaint Details
The visit was complaint-related to a self-reported suspected abuse incident. The report states the mandated reporter heard abusive verbal remarks by a family member toward a resident. The incident was brief with no physical abuse and was cross-reported to other agencies.
Findings
No deficiencies were observed or cited during the visit. The incident involved brief verbal abuse by a family member toward a resident, with no physical abuse, and was cross-reported to other agencies.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Venegas | Administrator | Met with Licensing Program Analyst during the inspection visit. |
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection visit and requested documentation. |
| Kimberley Mota | Licensing Program Manager | Named in the report header. |
Inspection Report
Follow-Up
Census: 146
Capacity: 210
Deficiencies: 1
Date: Jan 23, 2023
Visit Reason
The visit was an unannounced follow-up on an incident report self-reported to the Community Care Licensing Regional Office regarding a medication error that occurred on 01/17/2023.
Findings
The inspection found that a medication error occurred where one resident (R1) was given another resident's prescribed medication, posing an immediate health and safety risk. The resident was taken to the hospital for evaluation and returned with no adverse effects. A deficiency was cited for failure to assist residents with self-administered medications as required.
Deficiencies (1)
87465(a)(5) Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by a medication error where resident R1 was given another resident's medication, posing an immediate health and safety risk.
Report Facts
Census: 146
Total Capacity: 210
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kawana Anthony | Administrator | Met with Licensing Program Analyst during inspection and involved in exit interview |
| Jill Nakagawa | Licensing Program Analyst | Conducted the unannounced follow-up inspection |
| Kimberley Mota | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 210
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
The visit was an unannounced Case Management Investigation regarding the theft/loss of a resident's recumbent bicycle and another resident's recumbent bicycle and adult tricycle.
Complaint Details
Investigation was related to theft/loss of residents' bicycles. No deficiencies were found and no citations issued.
Findings
No deficiencies or citations were found or issued during the investigation. The losses were reported to the Davis Police Department and the facility's corporate office.
Report Facts
Census: 147
Total Capacity: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kawana Anthony | Operations Director | Spoke with Licensing Program Analyst regarding the theft investigation |
| Jill Nakagawa | Licensing Program Analyst | Conducted the unannounced Case Management Investigation |
| Kimberley Mota | Licensing Program Manager | Named in the report header |
Inspection Report
Census: 149
Capacity: 210
Deficiencies: 0
Date: Nov 3, 2022
Visit Reason
The visit was an unannounced Case Management visit conducted to review the facility's reporting guidelines, staff training, and current resident conditions.
Findings
The facility was found to be clean and orderly with no Covid-19 cases. Reports were timely and well-written, staff training on medication management was adequate, and no deficiencies or citations were found during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jake Bruno | Resident Services Director | Met with Licensing Program Analyst during the Case Management visit and participated in the exit interview. |
Inspection Report
Census: 144
Capacity: 210
Deficiencies: 0
Date: Aug 26, 2022
Visit Reason
The inspection was conducted to check on the new Medication Administration Record (MAR) system and Memory Care at the facility.
Findings
The facility was found to be clean, orderly, and in good repair with all amenities operational. Staff and residents were interactive and engaged, and no deficiencies or citations were found during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jake Bruno | Resident Services Director | Met with the Licensing Program Analyst and showed the facility during the inspection. |
Inspection Report
Annual Inspection
Census: 149
Capacity: 210
Deficiencies: 0
Date: Jul 7, 2022
Visit Reason
The inspection was a required 1-year unannounced visit focused on infection control procedures and practices at the facility.
Findings
The facility was found to be clean, orderly, and compliant with infection control protocols, including visitor and staff screening, proper storage of medications and toxins, sufficient supplies of hygiene products and PPE, and approved plans for dementia care and hospice waiver. No deficiencies or citations were issued during the inspection.
Report Facts
Residents in care: 149
Facility capacity: 210
Hospice waiver residents: 9
Fire clearance capacity: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Venegas | Administrator | Met with Licensing Program Analyst during inspection |
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection |
| Kimberley Mota | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Capacity: 210
Deficiencies: 0
Date: Jun 16, 2022
Visit Reason
The inspection was conducted as a case management visit following an incident report submitted on 05/24/2022 regarding a medication error.
Complaint Details
The visit was complaint-related due to a medication error incident report. The error had no ill effects, and corrective actions including retraining and testing were initiated.
Findings
No deficiencies were cited during the inspection. The facility implemented re-training and corrective action for the employee involved, and plans were made for further training and testing of all Medication Technicians.
Report Facts
Passing grade requirement: 90
Facility capacity: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Venegas | Administrator | Met during inspection and involved in corrective action and training related to medication error |
| Jake Bruno | Resident Services Director, LVN | Met during inspection and responsible for conducting training and evaluation of Medication Technicians |
Inspection Report
Follow-Up
Census: 143
Capacity: 210
Deficiencies: 1
Date: May 24, 2022
Visit Reason
The visit was an unannounced follow-up on a self-reported incident involving a medication error that occurred on 2022-05-03.
Findings
The facility failed to ensure that resident R1 received medication as prescribed, resulting in a medication error that posed an immediate health and safety risk. The resident was taken to the hospital for observation and returned with no adverse reactions. Deficiencies were cited related to medication administration.
Deficiencies (1)
87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. The facility failed to ensure R1's medication was given as prescribed by doctor which poses an immediate health and safety risk to resident in care.
Report Facts
Census: 143
Total Capacity: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Venegas | Administrator | Met with Licensing Program Analyst during inspection and involved in medication error incident |
| Jill Nakagawa | Licensing Program Analyst | Conducted the unannounced follow-up inspection |
| Kimberley Mota | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 138
Capacity: 210
Deficiencies: 0
Date: Mar 29, 2022
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2021-12-16 regarding insufficient staffing and uncomfortable facility temperature.
Complaint Details
Complaint alleged insufficient staffing resulting in care needs not being met and that the facility was not a comfortable temperature. The allegations were found to be unsubstantiated based on observations, interviews, and record reviews.
Findings
The investigation found that most call lights were answered within 3-8 minutes, with some taking 12-15 minutes, indicating adequate staffing. The facility temperature was found to be between 74-76 degrees Fahrenheit, comfortable for most individuals. Both allegations were unsubstantiated and no deficiencies were cited.
Report Facts
Facility capacity: 210
Census: 138
Call light response time: 3
Call light response time: 12
Facility temperature: 74
Facility temperature: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation |
| Emily Venegas | Executive Director | Facility administrator met during investigation |
| Kimberley Mota | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 133
Capacity: 210
Deficiencies: 0
Date: Nov 19, 2021
Visit Reason
The inspection was an unannounced Case Management Health Check regarding resident R1, focusing on ongoing pressure ulcer concerns.
Findings
The pressure ulcer for resident R1 was reported as no longer open as of 11/17/2021, with skin assessment within normal range. No new concerns were identified and no deficiencies were cited during the inspection.
Report Facts
Facility capacity: 210
Resident census: 133
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Giam Alviedo | Resident Service Director | Met during inspection and involved in follow-up of resident's progress |
| Jill Nakagawa | Licensing Program Analyst | Conducted the unannounced Case Management Health Check |
| Kimberley Mota | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 133
Capacity: 210
Deficiencies: 0
Date: Nov 19, 2021
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that the facility bathroom was not kept clean.
Complaint Details
The complaint alleged that the facility bathroom was not kept clean. The investigation found no evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Findings
The inspection of two facility restrooms found them clean with no offensive odors and adequate toiletry supplies. Trash cans were not empty but not overflowing. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 210
Census: 133
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Venegas | Administrator | Met with during inspection and mentioned in findings |
| Jill Nakagawa | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Kimberley Mota | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 210
Deficiencies: 1
Date: Sep 30, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the facility did not adhere to the admissions agreement.
Complaint Details
The complaint was substantiated. The allegation was that the facility did not adhere to the admissions agreement, specifically regarding termination on death and visitor access. The investigation included interviews, documentation review, and observations conducted on 5/19/2021 and 6/10/2021, with findings supporting the complaint.
Findings
The investigation found that the facility did not comply with the admissions agreement regarding termination on death and visitor policies, specifically related to a resident who had passed away and the handling of personal property and visitation. The allegation was substantiated based on documentation review, interviews, and observations.
Deficiencies (1)
87507(f) Admissions Agreement. Facility did not comply with the admissions agreement in 1 out of 1 resident admissions agreement, posing a potential health, safety or personal rights risk to persons in care.
Report Facts
Capacity: 210
Census: 134
Plan of Correction Due Date: Oct 14, 2021
Resident admissions agreements not complied: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carla Fernandes-Goes | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bethany Moellers | Licensing Program Manager | Oversaw the complaint investigation |
| Emily Venegas | Executive Director | Met with Licensing Program Analyst during the investigation |
| Ashlee Sloan | Former Executive Director | Interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 210
Deficiencies: 0
Date: Sep 30, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that the facility failed to provide residents with food of good quality and that the Administrator did not treat residents with dignity and respect.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred. Allegations included poor food quality and lack of dignity and respect from the Administrator.
Findings
The investigation included interviews, documentation review, and facility observations. The allegations regarding food quality and administrator treatment were found to be unsubstantiated due to insufficient evidence to prove or disprove the claims. No deficiencies were cited during this inspection.
Report Facts
Capacity: 210
Census: 134
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carla Fernandes-Goes | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
| Ashlee Sloan | Former Executive Director | Named in relation to allegations about administrator treatment of residents |
| Emily Venegas | Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Census: 133
Capacity: 210
Deficiencies: 0
Date: Jul 27, 2021
Visit Reason
An unannounced Annual Inspection focusing on Infection Control was conducted to evaluate the facility's compliance with health and safety standards.
Findings
The facility was observed to be clean, well-maintained, and compliant with infection control protocols including COVID-19 vaccination and mask usage among staff. No deficiencies were cited during this inspection.
Report Facts
Vaccination rate: 100
Inspection duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashlee Sloan | Administrator | Met during inspection and provided facility tour |
| Giam Alviedo | Resident Services Director | Met during inspection, oversees training and surveillance testing |
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Census: 131
Capacity: 210
Deficiencies: 1
Date: May 25, 2021
Visit Reason
The visit was an unannounced Case Management visit conducted to follow up on medication destruction practices and compliance with facility policies.
Findings
The facility failed to destroy medications of two residents who had moved out months earlier, posing a potential health and safety risk. The administrator subsequently destroyed the medications and agreed to submit a self-certification. Deficiencies were cited related to medication destruction policy compliance.
Deficiencies (1)
Facility did not comply with the section cited. LPA observed that the facility did not destroy 2 residents medications, which poses/posed a potential health, safety or personal rights risk to persons in care.
Report Facts
Deficiency due date: Jun 1, 2021
Residents with undestroyed medications: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katrina Walters | Licensing Program Analyst | Conducted the inspection and authored the report |
| Ashlee Sloan | Executive Director | Facility administrator involved in medication destruction issue |
| Hope DeBenedetti | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Capacity: 210
Deficiencies: 0
Date: May 25, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 09/15/2020 regarding improper medication storage, failure to report to licensing agency, and insufficient staffing at the facility.
Complaint Details
The complaint alleged that staff were not properly storing medication, the facility failed to report incidents to the licensing agency, and there was insufficient staffing to meet residents' needs. After investigation, all allegations were found to be unsubstantiated or unfounded.
Findings
The investigation found all allegations to be unsubstantiated after reviewing records, interviewing staff and residents, and making observations. No deficiencies were cited during the inspection.
Report Facts
Facility capacity: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katrina Walters | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Ashlee Sloan | Administrator / Executive Director | Met with Licensing Program Analyst during the investigation |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Capacity: 210
Deficiencies: 0
Date: May 10, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident's personal rights were violated due to denial of in-person visitation despite a potential end-of-life condition.
Complaint Details
The complaint alleged violation of personal rights when a resident's family was not allowed in-person visitation despite the resident's potential end-of-life condition. The allegation was found unsubstantiated and the complaint was dismissed.
Findings
The investigation found that the facility was following county and state public health guidelines accurately and allowed visitation based on the resident's medical documentation. The complaint allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katrina Walters | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Ashlee Sloan | Administrator | Facility Administrator mentioned in relation to the investigation |
| Emily Venegas | Community Business Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Capacity: 210
Deficiencies: 0
Date: Mar 16, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility issued an unlawful rate increase.
Complaint Details
The complaint alleged that the facility issued an unlawful rate increase and that rate increases were not consistent for all residents. The allegation was found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that residents were notified of the rate increase more than 60 days prior to its effective date, with explanations for the increase due to operating expenses. Rate increases varied based on room market value and personal care needs. The allegation was unsubstantiated and no deficiencies were cited.
Report Facts
Capacity: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katrina Walters | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Ashlee Sloan | Administrator | Facility administrator interviewed during the investigation |
| Hope DeBenedetti | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Capacity: 210
Deficiencies: 0
Date: Mar 16, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that staff were not properly trained, specifically regarding lifting and transferring residents.
Complaint Details
The complaint alleged that staff were not trained properly, resulting in improper lifting and transferring of residents. The allegation was unsubstantiated after review of training records, interviews, and additional complaint visit.
Findings
The investigation found that staff training records were consistent with the facility's Program Plan and that staff received training upon onboarding. Annual transfer training was not conducted routinely but as needed. Staff interviews indicated knowledge of proper transfer techniques. The complaint allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katrina Walters | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Ashlee Sloan | Administrator | Facility administrator interviewed during investigation |
| Hope DeBenedetti | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 210
Deficiencies: 0
Date: Dec 3, 2020
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2020-02-19 regarding overcharging a resident and illegal eviction.
Complaint Details
The complaint involved allegations that the facility was overcharging a resident and unlawfully evicting the resident. The investigation concluded these allegations were unsubstantiated.
Findings
The investigation found that the resident required a higher level of care and that the facility issued a valid eviction notice due to non-payment, which was later resolved. The allegations of overcharging and illegal eviction were determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katrina Walters | Licensing Program Analyst | Conducted the complaint investigation |
| Ashlee Sloan | Administrator met during investigation and provided information | |
| Brooke Hanson | Facility Nurse | Provided statements regarding resident care |
| Hope DeBenedetti | Licensing Program Manager | Named in report header and signature |
| Kelly Fredrickson | Administrator | Named in facility information |
Inspection Report
Complaint Investigation
Capacity: 210
Deficiencies: 1
Date: Dec 3, 2020
Visit Reason
The visit was conducted as a case management complaint investigation by phone due to COVID-19 precautions, to review concerns regarding medication administration by a private caregiver.
Complaint Details
The complaint was substantiated as the private caregiver was providing care and supervision, including medication assistance, which violates the Health and Safety Code.
Findings
The investigation found that a resident's private caregiver was crushing medication for the resident, which is not allowed as the caregiver is not employed by the facility. This posed a potential health, safety, or personal rights risk to the resident.
Deficiencies (1)
Private caregiver assisted resident with medication, which is not allowed and poses a potential health, safety, or personal rights risk.
Report Facts
Total licensed capacity: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashlee Sloan | Executive Director | Contacted by Licensing Program Analyst during complaint investigation |
| Katrina Walters | Licensing Program Analyst | Conducted the complaint investigation |
| Hope DeBenedetti | Licensing Program Manager | Supervisor overseeing the investigation |
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