Most inspections found no deficiencies, including the most recent annual inspection on October 23, 2025, which reported the facility operating safely and cleanly with no issues. Some earlier complaint investigations were substantiated, notably in April 2022 when staff gave medication not prescribed and failed to obtain timely refills, risking resident safety; a potential civil penalty was noted if corrections were not made. Another substantiated complaint in March 2022 involved resident falls and insufficient staffing, along with needed ceiling repairs, though other allegations in that investigation were unsubstantiated. Several other complaint investigations found no evidence to support allegations, including those related to medication administration, cleanliness, and resident care. The facility’s record shows improvement over time, with recent inspections consistently clean and no new deficiencies reported.
The visit was an unannounced required comprehensive annual inspection of the Residential Care Facility for Elderly (RCFE) to assess compliance with licensing requirements.
Findings
The facility was found to be operating within the approved capacity and in safe, clean conditions with no deficiencies cited. Resident rooms, physical plant, food service, and care supervision met regulatory standards, and medications were dispensed appropriately.
Report Facts
Resident files reviewed: 6Staff files reviewed: 4
Employees Mentioned
Name
Title
Context
Alondra Fuentes
Executive Director
Met with Licensing Program Analyst during inspection and received the report.
Paola Guerrero
Licensing Program Analyst
Conducted the unannounced annual inspection visit.
The visit was a case management inspection focusing on the physical plant and maintenance issues at the facility.
Findings
The facility was found to be clean and free from odors and clutter in common areas. An incident involving a water leak in a resident's bathroom on 08/13/2024 was promptly addressed with repairs completed within two hours and follow-up work done. No evidence of damage was visible during the visit.
An unannounced annual required visit was conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be operating within licensed capacity and maintaining safe physical conditions, adequate food supply, and competent staffing. No deficiencies were cited during the inspection.
Report Facts
Capacity: 145Census: 80
Employees Mentioned
Name
Title
Context
Javier Prieto
Licensing Program Analyst
Conducted the inspection and exit interview
Suby Kumar
Executive Director
Facility representative who met with the Licensing Program Analyst
An unannounced complaint investigation visit was conducted in response to allegations that staff were not adhering to a resident's doctor's orders and were not meeting the needs of the resident.
Findings
The investigation found the allegations to be unsubstantiated due to lack of preponderance of evidence. The facility did not retain the doctor's orders for intravenous therapy, and the resident refused hospital treatment due to COVID-19 restrictions. The facility did not have a registered nurse available to administer IV therapy.
Complaint Details
The complaint alleged that staff were not adhering to the resident's doctor's orders for intravenous therapy and were not meeting the resident's needs. The allegation was found unsubstantiated after investigation including interviews, observations, and record review.
Report Facts
Facility capacity: 145Resident census: 83
Employees Mentioned
Name
Title
Context
Nicole Stinson
Resident Service Director
Met with during the investigation and received the exit interview
Kathleen Banrasavong
Licensing Program Analyst
Conducted the complaint investigation
Subashani Kumar
Executive Director
Provided information regarding facility records and staffing
Licensing Program Analyst Javier Prieto conducted an unannounced Case Management visit to perform a Health & Safety check at the facility.
Findings
No imminent health and/or safety concerns or hazards were observed inside or outside the facility. The facility was found to have sufficient staff and the dining and kitchen areas were clean, sanitized, and neat. The needs of the residents appeared to be met during the inspection.
Employees Mentioned
Name
Title
Context
Javier Prieto
Licensing Program Analyst
Conducted the unannounced Case Management visit and inspection.
Suby Kumar
Executive Director
Met with Licensing Program Analyst during the visit.
The inspection was an unannounced complaint investigation regarding allegations of rodent infestation, unclean and unsanitary conditions, failure to provide necessary medical assistance, and failure to dispense medications as ordered.
Findings
The investigation found mouse droppings isolated to one resident's room, which was cleaned and treated, and the resident was relocated. The facility was otherwise clean, free from odors and clutter. Medical needs of the resident were addressed appropriately. Medication administration was verified as compliant. Therefore, all allegations were deemed unsubstantiated.
Complaint Details
The complaint was unsubstantiated based on the investigation findings. There was no sufficient evidence to support the allegations of rodent infestation, unsanitary conditions, failure to provide medical assistance, or failure to dispense medications.
Report Facts
Capacity: 145Census: 88
Employees Mentioned
Name
Title
Context
Javier Prieto
Licensing Program Analyst
Conducted the complaint investigation
Suby Kumar
Executive Director
Met with Licensing Program Analyst during investigation
Licensing Program Analyst Javier Prieto made an unannounced visit to conduct an annual inspection with an emphasis on infection control.
Findings
The facility was observed to have proper infection control measures including signage, hand hygiene supplies, PPE use, and cleaning protocols. No deficiencies were cited during this inspection.
Employees Mentioned
Name
Title
Context
Suby Kumar
Executive Director
Met with Licensing Program Analyst during the inspection.
An unannounced complaint investigation visit was conducted in response to allegations that staff gave medication not prescribed to a resident and did not obtain timely medication refill for a resident.
Findings
The complaint was substantiated based on evidence that staff gave medication not prescribed to Resident #1 and failed to obtain a timely medication refill, posing a potential health and safety risk. A civil penalty may be assessed if deficiencies are not corrected by the plan of correction date.
Complaint Details
The complaint was substantiated. Staff gave medication not prescribed to Resident #1 and failed to obtain timely medication refill. A civil penalty of $100 per day retroactively for the first 15 days may be assessed if deficiencies are not corrected by the plan of correction date.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Basic services including assistance with taking prescribed medications were not provided as required; staff admitted medication was not administered as prescribed and was not refilled in a timely manner.
Type B
Report Facts
Capacity: 145Census: 86Civil penalty amount: 100Penalty duration days: 15Plan of Correction due date: Apr 29, 2022
Employees Mentioned
Name
Title
Context
Rohit Lama
Licensing Program Analyst
Conducted the complaint investigation and exit interview
An unannounced complaint investigation visit was conducted in response to allegations including resident falls, injuries, failure to notify authorized representatives, ceiling disrepair, and lack of laundry services.
Findings
The investigation substantiated that Resident 1 fell on 11/23/21 resulting in injuries and that the facility contacted the responsible party. The facility was unaware of a September fall. Ceiling repairs were completed after water damage. Laundry services were provided weekly. Some allegations were unsubstantiated due to lack of evidence.
Complaint Details
The complaint investigation was substantiated for allegations that Resident 1 fell on 11/23/21 causing injuries and that the facility contacted the responsible party. Other allegations such as failure to notify representatives for other incidents, ceiling disrepair, and lack of laundry services were unsubstantiated due to insufficient evidence.
Severity Breakdown
Type B: 4
Deficiencies (4)
Description
Severity
Facility personnel were not sufficient in numbers and competent to provide necessary services to meet resident needs.
Type B
Resident sustained falls on 9/24/21 and 11/23/21 resulting in minor injuries, posing a potential health and safety risk.
Type B
Residents must be accorded safe, healthful, and comfortable accommodations; ceiling was in disrepair due to water damage.
Type B
Resident sustained injuries after falls on 9/24/21 and 11/23/21, posing a potential health and safety risk.
Type B
Report Facts
Capacity: 145Census: 81Deficiencies cited: 4Plan of Correction Due Date: Mar 18, 2022
Employees Mentioned
Name
Title
Context
Shaunte Henry
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Nedra Brown
Licensing Program Manager
Oversaw the complaint investigation
Erick Romero
Director of Culinary Services
Met with Licensing Program Analyst during the investigation
Samuel DeGuzman
Administrator
Provided information regarding resident falls and facility conditions
An unannounced annual inspection was conducted with an emphasis on infection control to assess compliance with regulatory requirements.
Findings
No deficiencies were observed or cited during the inspection. The facility demonstrated adequate infection control measures, including sufficient PPE supplies, COVID-19 mitigation plans, and proper signage recommendations.
Employees Mentioned
Name
Title
Context
Samuel Deguzman
Executive Director
Met with Licensing Program Analyst during inspection and discussed report findings.
A case management visit was conducted to deliver an amended complaint investigation report regarding complaint number 18-AS-20210525135840.
Findings
The amended complaint investigation report was reviewed with and provided to the Executive Director Samuel DeGuzman. Nothing further was needed at this time.
Complaint Details
The visit was related to complaint number 18-AS-20210525135840. The report was amended and delivered during this visit.
Employees Mentioned
Name
Title
Context
Samuel DeGuzman
Executive Director
Facility representative met during the case management visit and recipient of the amended complaint investigation report.
Pauline Beschorner
Licensing Program Analyst
Conducted the case management visit and delivered the amended complaint investigation report.
An unannounced complaint investigation was conducted in response to allegations that staff were not providing adequate care and supervision to a resident and were not addressing a resident's change in level of care.
Findings
The investigation found that the resident was independent in activities of daily living and medication administration, and reassessments showed no change in care needed. The complaint was determined to be unfounded and dismissed.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, and were without reasonable basis.
Report Facts
Facility capacity: 145
Employees Mentioned
Name
Title
Context
Pauline Beschorner
Licensing Program Analyst
Conducted the complaint investigation
Samuel DeGuzman
Executive Director
Met with Licensing Program Analyst during investigation
An unannounced complaint investigation was conducted in response to multiple allegations received on 05/25/2021 regarding the facility's dietary services, cleanliness, disposal of needles and syringes, medical appointment arrangements, and reporting of resident condition changes.
Findings
The investigation found the allegations unsubstantiated or unfounded. The facility was observed to be clean, safe, and sanitary. The resident was able to self-manage medical appointments and diet, and there was no evidence that staff failed to report changes in condition. Needle disposal practices were noted but lacked sufficient evidence to confirm violations.
Complaint Details
The complaint investigation was unannounced and addressed multiple allegations including failure to meet dietary needs, cleanliness issues, improper disposal of needles, failure to arrange medical appointments, and failure to report changes in resident condition. The complaint was ultimately found to be unsubstantiated or unfounded after interviews and record reviews.
Report Facts
Capacity: 145Census: 85Number of used insulin needles observed: 5
Employees Mentioned
Name
Title
Context
Samuel DeGuzman
Executive Director
Met with Licensing Program Analyst during complaint investigation and named in findings
The visit was an unannounced complaint investigation triggered by allegations that the facility had bed bugs and that a resident's room was not maintained clean.
Findings
The allegation of bed bugs was found to be unfounded as the facility promptly engaged pest control and took appropriate measures. The allegation regarding the resident's room cleanliness was unsubstantiated due to insufficient evidence to prove the violation.
Complaint Details
The complaint investigation was conducted following a complaint received on 06/11/2021. The bed bug allegation was unfounded, and the resident room cleanliness allegation was unsubstantiated.
Report Facts
Capacity: 145Census: 85
Employees Mentioned
Name
Title
Context
Samuel DeGuzman
Executive Director
Met with Licensing Program Analyst during inspection and named in findings
The Licensing Program Analyst contacted the facility via telephone due to COVID-19 to amend complaint findings issued on 11/18/2020 for complaint #18-AS-20200623090020.
Findings
The report documents a telephone contact with the Executive Director to inform him of the purpose of amending prior complaint findings related to a previous complaint investigation.
Complaint Details
The visit was related to amending complaint findings from complaint #18-AS-20200623090020 issued on 11/18/2020.
Employees Mentioned
Name
Title
Context
Samuel De Guzman
Executive Director
Spoke with Licensing Program Analyst regarding amendment of complaint findings.
Stephanie Torres
Licensing Program Analyst
Contacted the facility via telephone to amend complaint findings.
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility failed to meet a resident's hygiene needs.
Findings
The investigation found that Resident One was checked regularly by staff and was being assisted with hygiene needs when soiled. Emergency medical personnel observed the resident covered in excrement but noted no neglect and that staff had cleaned the resident prior to hospital transport. The allegation was deemed unfounded.
Complaint Details
The complaint alleged the facility failed to meet Resident One's hygiene needs, specifically that the resident was found covered in their own excrement upon hospital arrival. The allegation was investigated and determined to be unfounded.
Report Facts
Facility capacity: 145Census: 85
Employees Mentioned
Name
Title
Context
Samuel De Guzman
Executive Director
Met with during investigation and named in findings discussion
Stephanie Torres
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Reyna Lacey
Licensing Program Manager
Named as Licensing Program Manager on report
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