Inspection Report Summary
Most inspections found no deficiencies, with the facility generally maintaining a clean, safe, and well-managed environment. The most recent report from October 22, 2025, was perfect with no deficiencies cited. Past substantiated issues primarily involved medication mismanagement in March 2023 and violations of resident rights related to visitation and supervision between 2021 and 2022, but these were isolated and addressed. Several complaint investigations were unsubstantiated or unfounded, including allegations of abuse, improper eviction, and infection control failures. Overall, the facility’s compliance appears to have improved over time, with recent annual inspections showing no deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
71% occupied
Based on a October 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 230
Capacity: 325
Deficiencies: 0
Oct 22, 2025
Visit Reason
The inspection was a Required-1 Year unannounced visit conducted to ensure compliance with Title 22 regulations for the care home.
Findings
The inspection found the facility to be in compliance with all applicable regulations. No deficiencies were cited. The facility was observed to be properly maintained, with safe food storage, medication security, and operational safety equipment.
Report Facts
Bedrooms observed: 5
Bedrooms observed: 2
Bathrooms observed: 7
Hot water temperature: 112.7
Hot water temperature: 118.3
Hot water temperature: 110.5
Perishable food supply: 2
Non-perishable food supply: 7
Resident files reviewed: 6
Staff files reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dana Stansel | Executive Director | Met with Licensing Program Analyst during inspection |
| Angela Hood | Licensing Program Analyst | Conducted the Required-1 Year Inspection |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 229
Capacity: 325
Deficiencies: 0
Aug 21, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 03/19/2025 alleging that staff inappropriately handled a resident resulting in a fracture.
Findings
The investigation found insufficient evidence to substantiate the allegation that staff physically abused the resident. Interviews with staff, residents, and review of medical records indicated conflicting accounts, and the allegation was determined to be unsubstantiated. Additional unrelated allegations of verbal abuse and theft were also investigated but found to lack sufficient evidence.
Complaint Details
The complaint alleged that staff member (S1) grabbed and yanked resident (R1)'s arm causing a fracture. The allegation was unsubstantiated after investigation. Additional complaints of verbal abuse by staff (S3) and (S4) and theft of resident (R4)'s belongings were also investigated and found to have insufficient evidence.
Report Facts
Facility capacity: 325
Census: 229
Complaint received date: Mar 19, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Dana Stansel | Administrator | Facility administrator met during investigation and provided statements |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 201
Capacity: 325
Deficiencies: 0
May 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-10-10 regarding staff not according resident privacy and not safeguarding residents' mail packages.
Findings
The investigation found the allegation regarding resident privacy to be unsubstantiated, as evidence did not support the claim. The allegation about mail packages not being safeguarded was found to be unfounded, with no issues observed or reported.
Complaint Details
The complaint investigation was triggered by allegations that staff did not accord resident privacy and did not safeguard residents' mail packages. The privacy allegation was unsubstantiated, meaning there was insufficient evidence to prove the violation. The mail safeguarding allegation was unfounded, meaning it was false or without reasonable basis.
Report Facts
Capacity: 325
Census: 201
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Perez | Licensing Program Manager | Named in report as Licensing Program Manager |
| Natasha Georges | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 206
Capacity: 325
Deficiencies: 0
Apr 8, 2025
Visit Reason
The inspection was conducted as a case management follow-up on a recent incident report submitted regarding a resident who was not found in their apartment and was later found walking outside the community.
Findings
The resident was found safe after being missing for a short period, exhibited agitation and paranoia, but showed clear cognition upon evaluation. The resident was later admitted to the hospital for reasons unrelated to the incident. No citations were issued in this report.
Complaint Details
The visit was triggered by an incident report (LIC624) concerning a resident who was missing from their apartment on March 22, 2025. The resident was found walking outside and was evaluated by emergency medical services. The resident's responsible person provided 1:1 care and later reported hospital admission unrelated to the incident. The complaint was not substantiated with any citations.
Report Facts
Resident cognitive test score: 27
Incident report date: Mar 23, 2025
Resident move-in date: Mar 13, 2025
Resident hospital admission date: Mar 24, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Calzada | Licensing Program Analyst | Conducted the case management inspection |
| Dana Stansel | Administrator | Met with Licensing Program Analyst to discuss the incident |
Inspection Report
Complaint Investigation
Census: 208
Capacity: 325
Deficiencies: 0
Feb 6, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not mitigating the spread of infectious outbreaks in the facility.
Findings
The investigation included interviews with staff and residents and a review of records. It was found that staff followed infection control guidelines and there were no confirmed outbreaks or concerns. The allegation was determined to be unfounded.
Complaint Details
The complaint alleged that staff were not following infection control guidelines to mitigate the spread of outbreaks around Thanksgiving 2024. Interviews with three staff and three residents indicated proper infection control practices and appropriate care were provided. The allegation was found to be unfounded.
Report Facts
Residents sick with stomach bug: 3
Staff interviewed: 3
Residents interviewed: 3
Total residents sick: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Talwinder Bains | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Dana Stansel | Sr Executive Director | Met with Licensing Program Analyst during the investigation |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 191
Capacity: 325
Deficiencies: 0
Oct 30, 2024
Visit Reason
The visit was a case management follow-up conducted to review the closure of a death report visit related to an incident on 9/20/2024.
Findings
No deficiencies were observed during the visit. The Licensing Program Analyst and Executive Director discussed the closure of the death report, noting that the resident was found unresponsive during a meal check and had a POLST with 'do not resuscitate'.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Georges | Executive Director | Met with Licensing Program Analyst during the visit and discussed the closure of the death report. |
| Cassie Yang | Licensing Program Analyst | Conducted the case management follow-up visit. |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 191
Capacity: 325
Deficiencies: 0
Oct 30, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted to assess compliance with health and safety regulations at the facility.
Findings
The facility was found to be clean, sanitary, and maintained at a comfortable temperature. No deficiencies were cited during the inspection, though sharps were observed in one resident's room and the policy on residents storing detergents is under review.
Report Facts
Residents on hospice services: 8
Resident records reviewed: 12
Personnel records reviewed: 10
Hospice waiver: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the inspection and met with the Executive Director |
| Natasha Georges | Executive Director | Met with Licensing Program Analyst during inspection and involved in facility tour |
| Anthony Perez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 189
Capacity: 325
Deficiencies: 0
Sep 20, 2024
Visit Reason
The visit was conducted as a case management visit regarding a death report the Department received on 09/19/2024.
Findings
Licensing Program Analysts met with the Executive Director and conducted a file review of the resident's records. The incident is still under review by the Department.
Complaint Details
The visit was triggered by a death report complaint received on 09/19/2024. The incident remains under review with no substantiation status provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Georges | Executive Director | Met with Licensing Program Analysts during the visit. |
| Cassie Yang | Licensing Program Analyst | Conducted the case management visit and file review. |
| Cassie Mikkelson | Licensing Program Analyst | Conducted the case management visit and file review. |
| Anthony Perez | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Capacity: 325
Deficiencies: 0
Aug 29, 2024
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that staff were not meeting the needs of the residents.
Findings
After extensive interviews and file reviews, the Licensing Program Analyst found the allegation to be unfounded, concluding that the allegation was false, could not have happened, and/or was without a reasonable basis.
Complaint Details
The complaint alleged that staff were not meeting the needs of the residents. Interviews with residents and the Executive Director, as well as file reviews, showed no evidence supporting the allegation. The Executive Director stated that a help signal training will be provided for residents. The allegation was determined to be unfounded.
Report Facts
Facility capacity: 325
Longest response time: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Natasha Georges | Administrator / Executive Director | Met with Licensing Program Analyst during the investigation and provided information |
Inspection Report
Monitoring
Capacity: 325
Deficiencies: 0
May 22, 2024
Visit Reason
The visit was an unannounced quarterly case management visit conducted in accordance with the Stipulation and Order effective from 06/01/2022 to 06/01/2024 to review compliance with the stipulation.
Findings
The Licensing Program Analyst observed the facility to be clean, safe, sanitary, and in good repair, with compliance to the Stipulation and Waiver and Order. Facility audits, emergency call responses, care records, incident reports, and staff training were reviewed and found satisfactory.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the quarterly case management visit and observed compliance. |
| Natasha Georges | Executive Director | Met with Licensing Program Analyst during the visit. |
| Cristina Ortiz | Administrator/Director | Named as facility administrator/director. |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 185
Capacity: 325
Deficiencies: 0
May 1, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations including illegal eviction and failure of staff to provide resident's responsible party with resident's records.
Findings
The investigation found both allegations to be unfounded. The illegal eviction allegation was disproven based on documentation of unpaid rent and legal eviction notices. The allegation regarding failure to provide records was unfounded as requested documents were provided multiple times to the responsible party.
Complaint Details
The complaint investigation was triggered by allegations of illegal eviction and failure to provide resident's records. The allegations were found to be unfounded after interviews and file reviews.
Report Facts
Facility capacity: 325
Resident census: 185
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Natasha Georges | Executive Director | Met with Licensing Program Analyst during the visit |
| Kimberly Hagen | Administrator | Facility Administrator named in report header |
Inspection Report
Monitoring
Census: 189
Capacity: 325
Deficiencies: 0
Mar 14, 2024
Visit Reason
The visit was an unannounced quarterly case management visit conducted in accordance with a Stipulation and Order effective from 06/01/2022 to 06/01/2024.
Findings
The facility was observed to be clean, safe, sanitary, and in good repair. The Licensing Program Analyst reviewed audits of staff hours, emergency call responses, incident reports, and staff training documentation. The facility was found to be in compliance with the Stipulation and Waiver and Order.
Report Facts
Total calls made: 883
Calls exceeding ten minutes: 3
Days with no response call exceeding ten minutes: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the inspection visit |
| Natasha Georges | Executive Director | Met with Licensing Program Analyst during the visit |
| Cristina Ortiz | Administrator | Facility Administrator |
| Anthony Perez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 189
Capacity: 325
Deficiencies: 0
Mar 14, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that the facility was not maintaining a comfortable temperature for a resident in care.
Findings
After extensive interviews, file reviews, and room inspections, the investigation found the allegation to be unfounded, meaning the complaint was false, could not have happened, or was without a reasonable basis. The facility was found to provide alternative heating and air conditioning accommodations as needed.
Complaint Details
The complaint alleged that the facility was not maintaining a comfortable temperature for a resident. The investigation included interviews with residents and the Executive Director, review of facility practices including provision of portable heating and air conditioning units, and documentation of a pending replacement request for the older HVAC system in the A wing. The complaint was found to be unfounded.
Report Facts
Capacity: 325
Census: 189
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Natasha Georges | Executive Director | Met with Licensing Program Analyst during the investigation |
| Kimberly Hagen | Administrator | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Census: 189
Capacity: 325
Deficiencies: 0
Mar 14, 2024
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation regarding an allegation that the facility was not allowing a resident to leave the facility.
Findings
The investigation included extensive interviews with residents and facility staff. The allegation was found to be unfounded, as the Executive Director required residents to sign out as a best practice protocol to ensure safe returning, and the resident in question chose not to leave after being informed they could leave.
Complaint Details
The complaint alleged that the facility was not allowing a resident to leave. Interviews revealed the Executive Director stopped the resident and asked them to sign out prior to leaving, which is standard protocol. The resident became upset and chose not to leave after being informed they could. The allegation was determined to be unfounded.
Report Facts
Capacity: 325
Census: 189
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Natasha Georges | Executive Director | Met with Licensing Program Analyst during investigation and involved in allegation |
Inspection Report
Complaint Investigation
Census: 189
Capacity: 325
Deficiencies: 0
Mar 13, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that facility staff were not keeping the facility at a comfortable temperature for residents and that the licensee did not ensure the facility AC unit was in working condition.
Findings
After extensive interviews, file reviews, and room inspections, the Department found the allegations to be unfounded, meaning the complaint was false or without reasonable basis. The facility staff conduct daily checks to ensure comfortable temperatures, provide portable heating and air conditioning units as needed, and have submitted a request to replace older HVAC units.
Complaint Details
The complaint was investigated and found to be unfounded. Allegations included failure to maintain comfortable temperature and non-working AC units. Interviews with residents and the Executive Director, along with document review, supported that the facility accommodates residents' heating and cooling needs.
Report Facts
Capacity: 325
Census: 189
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Natasha Georges | Executive Director | Met with Licensing Program Analyst during investigation and provided information |
| Kimberly Hagen | Administrator | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Capacity: 325
Deficiencies: 0
Jan 5, 2024
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that staff did not follow proper eviction procedures.
Findings
The investigation found that the allegation was unfounded. Documentation showed that the eviction letter was served in compliance with Title 22 Eviction Procedures, including required notices and referral services. Interviews confirmed the resident and Power of Attorney were aware of the rent arrears and eviction process.
Complaint Details
Allegation: Staff did not follow proper eviction procedures. The allegation was found to be unfounded, meaning it was false, could not have happened, or was without reasonable basis.
Report Facts
Capacity: 325
Eviction notice period: 30
Missed rent payments: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Cristina Ortiz | Executive Director | Facility Administrator interviewed during investigation |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Capacity: 325
Deficiencies: 0
Nov 30, 2023
Visit Reason
The visit was an unannounced case management visit conducted due to a voicemail received from the Executive Director regarding facility matters.
Findings
No deficiencies were observed during the visit. A family visitation dispute was discussed and the facility was advised to document and report any future incidents.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Hagen | Executive Director | Named as the Executive Director who is relocating and whose exit date was reported. |
| Cristina Ortez | Assistant Executive Director | Met with Licensing Program Analyst and discussed visitation dispute. |
| Cassie Yang | Licensing Program Analyst | Conducted the case management visit. |
| Anthony Perez | Licensing Program Manager | Named in the report header. |
Inspection Report
Census: 192
Capacity: 325
Deficiencies: 0
Oct 20, 2023
Visit Reason
Unannounced case management visit conducted regarding incident reports received by the Department on October 17, 2023.
Findings
LPAs discussed serious/unusual incident reports related to emotional distress and medication storage incidents. The facility was reminded of timely reporting requirements and medication protocols. A death report was reviewed, with cause of death unknown as the resident had not been at the facility for weeks. No deficiencies were cited during this visit.
Report Facts
Incident report dates: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Hagen | Executive Director | Met with LPAs and discussed incident reports and facility protocols |
| Cassie Yang | Licensing Program Analyst | Conducted case management visit |
| Cheyenne Ratajczak | Licensing Program Analyst | Conducted case management visit |
| Anthony Perez | Licensing Program Manager | Named in report header and signature |
Inspection Report
Census: 192
Capacity: 325
Deficiencies: 0
Oct 20, 2023
Visit Reason
The visit was an unannounced quarterly case management visit conducted in accordance with a Stipulation and Order effective from 06/01/2022 to 05/31/2024.
Findings
The facility was observed to be clean, safe, sanitary, and in good repair. The Stipulation and Waiver and Order were posted conspicuously, and documentation including daily emergency call audits, monthly staff training, resident care task audits, and incident reports were reviewed. The facility was found to be in compliance with the Stipulation and Waiver and Order.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Hagen | Executive Director | Met with Licensing Program Analysts during the visit and named in the report. |
| Cassie Yang | Licensing Program Analyst | Conducted the inspection and received incident reports. |
| Cheyenne Ratajczak | Licensing Program Analyst | Conducted the inspection. |
| Anthony Perez | Licensing Program Manager | Named in the report. |
Inspection Report
Annual Inspection
Census: 192
Capacity: 325
Deficiencies: 0
Oct 20, 2023
Visit Reason
Licensing Program Analysts arrived unannounced to conduct a required 1-year annual inspection of the facility.
Findings
The facility was toured and observed to be in compliance with no violations of health, safety, or personal rights. The CARE tool was completed and no deficiencies were found.
Report Facts
Hospice waiver residents: 20
Residents on hospice services: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Hagen | Senior Executive Director | Met with Licensing Program Analysts during inspection; Administrator Certificate status discussed |
| Cassie Yang | Licensing Program Analyst | Conducted inspection and confirmed Administrator Certificate status |
| Cheyenne Ratajczak | Licensing Program Analyst | Conducted inspection |
| Anthony Perez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 197
Capacity: 325
Deficiencies: 0
Aug 11, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2023-01-31 regarding unsanitary conditions, pest presence, moldy food, and improper hand washing procedures at the facility.
Findings
The investigation included interviews, observations, and records review. The Licensing Program Analyst found no preponderance of evidence to substantiate the allegations. The facility was found to be clean, free from pests, and compliant with Title 22 regulations. Allegations were determined to be either unfounded or unsubstantiated.
Complaint Details
The complaint investigation was triggered by allegations that the facility was unsanitary, staff did not ensure the facility was free from pests, staff served residents moldy food, and staff did not follow proper hand washing procedures. The findings were that the allegations were either unfounded or unsubstantiated based on interviews, observations, and records review.
Report Facts
Capacity: 325
Census: 197
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Hagen | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 188
Capacity: 325
Deficiencies: 0
May 4, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of illegal eviction and rough handling of a resident.
Findings
The investigation found the facility to be in compliance with eviction procedures and the allegation of illegal eviction was unfounded. The allegation that staff handled a resident in a rough manner was also found to be unfounded based on records review and interviews.
Complaint Details
The complaint alleged illegal eviction and rough handling of a resident. The investigation included records review and interviews, including with the resident involved (R1). The resident admitted to being disrespectful to staff. The allegations were determined to be unfounded.
Report Facts
Capacity: 325
Census: 188
Complaint Control Number: 25-AS-20230207101842
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kimberly Hagen | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 188
Capacity: 325
Deficiencies: 0
May 4, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-03-07 regarding interference with residents' packages/mail and financial abuse of a resident.
Findings
The investigation found the allegation of interference with residents' packages/mail to be unfounded based on records and interviews, including a signed waiver by the resident. The allegation of financial abuse was found to be unsubstantiated as there was insufficient evidence to prove the violation occurred.
Complaint Details
Two allegations were investigated: 1) Facility interfering with residents' packages/mail, which was found to be unfounded. 2) Facility financially abused a resident, which was found to be unsubstantiated.
Report Facts
Capacity: 325
Census: 188
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kimberly Hagen | Executive Director | Met with Licensing Program Analyst during investigation |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 188
Capacity: 325
Deficiencies: 0
May 4, 2023
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation regarding an allegation that the facility tampered with a resident's records.
Findings
The investigation included interviews and record reviews related to the allegation. The evidence did not meet the preponderance of evidence standard, and the allegation was found to be unsubstantiated.
Complaint Details
The complaint alleged that the facility tampered with resident R1's records to increase R1's rent. Interviews and record reviews showed multiple LIC 602 forms from October 2022 to January 2023, and authorization for medical information release was in place. The allegation was unsubstantiated based on the evidence.
Report Facts
LIC 602 forms: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kimberly Hagen | Executive Director | Met with Licensing Program Analyst during investigation |
| Anthony Perez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 178
Capacity: 325
Deficiencies: 1
Mar 24, 2023
Visit Reason
The visit was a case management inspection conducted to review compliance with regulations related to changes in level of care and associated notifications.
Findings
The facility failed to provide a written notice within two days to resident R1 regarding a change in level of care and the implementation of new private duty personnel services, which is a violation of Health and Safety Code §1569.657(a).
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide resident R1 with a written notice within two business days after implementing new private duty personnel services due to a change in level of care. | Type B |
Report Facts
Deficiency due date: Apr 8, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Hagen | Executive Director | Met during the case management visit and named in the findings |
| Michael Hood | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Anthony Perez | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 178
Capacity: 325
Deficiencies: 0
Mar 24, 2023
Visit Reason
The inspection visit was a Case Management Legal visit conducted unannounced in accordance with a Stipulation and Order effective from 6/1/2022 to 5/31/2024.
Findings
The Licensing Program Analyst observed that the facility was clean and in good repair, alert button logs were documented and responded to timely, resident care task audits and staff numbers were sufficient, and monthly staff training was conducted. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Hood | Licensing Program Analyst | Conducted the Case Management Legal visit and observed compliance with stipulations. |
| Kimberly Hagen | Executive Director | Met with Licensing Program Analyst during the visit. |
| Anthony Perez | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 178
Capacity: 325
Deficiencies: 0
Mar 24, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was overcharging a resident in care.
Findings
The investigation found the allegation to be unsubstantiated as there was not a preponderance of evidence to prove the alleged violation occurred. Charges for level of care and pre-admission fees were consistent with the signed admission agreement, and a disputed charge for medication services was credited back. Additional charges for private duty personnel were implemented by the facility due to a safety incident, but the resident did not agree to these services.
Complaint Details
The complaint alleged that the facility was overcharging a resident. The investigation included interviews with staff and residents, review of admission agreements, invoices, and physician reports. The allegation was found to be unsubstantiated.
Report Facts
Charge amount: 530
Charge amount: 4012.5
Complaint control number: 25
Complaint control number suffix: 20221209100006
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Hood | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kimberly Hagen | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 178
Capacity: 325
Deficiencies: 0
Mar 24, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-12-16 alleging that the facility did not issue a refund to a resident.
Findings
The investigation found that the allegation was unfounded. Documentation and interviews showed that the resident was charged appropriately according to the signed admission agreement, and a $530 charge for medication services was credited back when it was determined the resident was not receiving those services.
Complaint Details
The complaint alleged the facility did not issue a refund to a resident for unnecessary charges. The allegation was found to be unfounded after review of admission agreements, invoices, staff interviews, and relevant regulations.
Report Facts
Refund amount credited: 530
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Hood | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kimberly Hagen | Executive Director | Facility representative met during investigation and exit interview |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 178
Capacity: 325
Deficiencies: 1
Mar 24, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2023-01-12, including mismanagement of residents' medications, staff threatening residents, failure to release records, lack of dignity in treatment, failure to provide proper documentation to physicians, and false claims.
Findings
The investigation substantiated the allegation that the facility mismanaged residents' medications, specifically that resident R8 was not receiving medications as prescribed, posing an immediate health and safety risk. All other allegations, including staff threatening residents, failure to release records, lack of dignity, failure to provide documentation to physicians, and false claims, were found to be unsubstantiated based on interviews and documentation review.
Complaint Details
The complaint investigation was substantiated for the allegation of medication mismanagement but unsubstantiated for allegations of staff threatening residents, failure to release records, lack of dignity, failure to provide proper documentation to physicians, and false claims.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not ensure that resident R8 was receiving medications as prescribed, posing an immediate health, safety, and personal rights risk. | Type A |
Report Facts
Capacity: 325
Census: 178
Deficiencies cited: 1
Plan of Correction Due Date: Mar 25, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Hood | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kimberly Hagen | Executive Director | Facility representative met during investigation and exit interview |
| Anthony Perez | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 179
Capacity: 325
Deficiencies: 0
Mar 2, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff inappropriately interfered with a resident's sleep.
Findings
Interviews with residents and staff indicated that while some residents initially experienced sleep interruptions, after communicating their preferences, the interruptions ceased. The investigation found no preponderance of evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Complaint Details
The allegation that staff inappropriately interfered with resident's sleep was investigated and found to be unsubstantiated based on interviews and evidence collected.
Report Facts
Capacity: 325
Census: 179
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Hood | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kimberly Hagen | Executive Director | Facility representative met during investigation and exit interview |
| Anthony Perez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 179
Capacity: 325
Deficiencies: 0
Mar 2, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-11-10 regarding staff not taking precautions for COVID-19 and the facility not conducting response testing due to a COVID-19 outbreak.
Findings
The investigation found the allegation that staff were not taking COVID-19 precautions to be unsubstantiated, as staff were observed wearing masks and visitors were redirected to screening points. The allegation that the facility was not conducting response testing during a COVID-19 outbreak was found to be unfounded, with documentation and interviews confirming testing was conducted and reported appropriately.
Complaint Details
The complaint involved two main allegations: 1) staff not taking precautions for COVID-19, and 2) the facility not conducting response testing due to a COVID-19 outbreak. Both allegations were investigated through interviews with residents, staff, and the Executive Director, observations, and review of documentation. The first allegation was unsubstantiated and the second was unfounded.
Report Facts
Capacity: 325
Census: 179
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Hood | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kimberly Hagen | Executive Director | Facility representative met during investigation and exit interview |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 180
Capacity: 325
Deficiencies: 0
Feb 8, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-01-30 regarding interference with residents receiving mail and unsafe food service.
Findings
The investigation found the allegations to be unfounded, meaning the claims were false, could not have happened, or lacked a reasonable basis. The Executive Director confirmed residents have mailboxes and packages are delivered to the front desk without being opened by staff.
Complaint Details
The complaint involved allegations that the facility was interfering with residents receiving mail and that food was not served in a safe or healthful manner. The reporting party did not provide further information and the allegations were found to be unfounded.
Report Facts
Capacity: 325
Census: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Hagen | Executive Director | Interviewed during complaint investigation |
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Perez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 183
Capacity: 325
Deficiencies: 0
Oct 29, 2022
Visit Reason
The inspection was a Required-1 Year unannounced visit to evaluate infection control compliance at the facility.
Findings
The facility was found to be in substantial compliance with infection control requirements. No immediate health, safety, or personal rights violations were observed and no deficiencies were cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Hagen | Senior Executive Director | Met with Licensing Program Analyst during inspection and involved in infection control domain completion. |
| Michael Hood | Licensing Program Analyst | Conducted the Required-1 Year Inspection and infection control domain evaluation. |
Inspection Report
Census: 183
Capacity: 325
Deficiencies: 0
Oct 29, 2022
Visit Reason
The inspection visit was a Case Management Legal visit conducted unannounced in accordance with a Stipulation and Order effective from 6/1/2022 to 5/31/2024.
Findings
The Licensing Program Analyst observed that the facility was clean and in good repair, alert button logs were documented and responded to timely, resident care tasks and staff numbers were sufficient, and monthly staff training was conducted with attendance documented. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Hood | Licensing Program Analyst | Conducted the inspection and observed compliance with stipulations. |
| Kimberly Hagen | Senior Executive Director | Met with the Licensing Program Analyst during the inspection. |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 169
Capacity: 325
Deficiencies: 1
Aug 24, 2022
Visit Reason
The inspection visit was conducted unannounced to deliver complaint findings and issue a citation for a deficiency discovered during a recent complaint investigation related to a secured environment addendum not signed by the resident.
Findings
The facility was cited for failing to ensure that a resident signed the 'Secured Environment Addendum' dated 2/25/22, as it was signed by the resident's Power of Attorney instead, posing a potential personal rights violation. This deficiency was previously cited in 2018 for the same issue.
Complaint Details
The visit was related to complaint #25-AS-20220426122233. The complaint was substantiated as the facility failed to obtain the resident's signature on the secured environment document, which was signed by the resident's Power of Attorney instead.
Deficiencies (1)
| Description |
|---|
| Failure to ensure that resident signed the 'Secured Environment Addendum' dated 2/25/22; document was signed by resident's Power of Attorney instead. |
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Aug 25, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Calzada | Licensing Program Analyst | Conducted the inspection and issued the citation |
| Kimberly Hagen | Administrator | Facility administrator met during inspection and discussed findings |
| Maribeth Senty | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 169
Capacity: 325
Deficiencies: 1
Aug 24, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-04-26 regarding alleged violations of resident visitation rights, Covid-19 precautionary protocols, and resident placement appropriateness.
Findings
The investigation substantiated that resident visitation rights were violated when visitors were denied indoor visits and required to wear masks outdoors, based on family authorization rather than resident consent. The allegation that the facility was not following Covid-19 protocols was unsubstantiated as the facility consistently offered outdoor visits with mask requirements. The allegation that a resident was inappropriately placed was found to be unfounded based on medical documentation and care plans.
Complaint Details
The complaint alleged violations of resident visitation rights, failure to follow Covid-19 precautionary protocols, and inappropriate resident placement. The visitation rights allegation was substantiated, Covid-19 protocol allegation was unsubstantiated, and placement allegation was unfounded.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure resident was able to visit with visitors who requested to visit on 4/29/2022 and 5/6/2022, violating personal rights. | Type B |
Report Facts
Facility capacity: 325
Census: 169
Plan of Correction due date: Sep 6, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kimberly Hagen | Administrator | Facility Administrator involved in the investigation |
| Deborah Ahrens | Business Office Director | Met with Licensing Program Analyst during investigation |
| Ingrid Weber | Memory Care Director | Met with Licensing Program Analyst and involved in visitation decisions |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 325
Deficiencies: 0
Jun 16, 2022
Visit Reason
The inspection was an unannounced case management visit conducted following the receipt of several incident reports involving multiple residents.
Findings
The inspection reviewed incidents involving four residents who experienced falls or behavioral issues. No deficiencies were cited during the inspection.
Complaint Details
The visit was triggered by multiple incident reports (LIC624) concerning resident falls and behavioral concerns. The incidents were discussed individually, and no deficiencies were found.
Report Facts
Resident falls: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Hagen | Administrator | Met with Licensing Program Analyst during inspection and involved in incident discussions. |
| Sabrina Calzada | Licensing Program Analyst | Conducted the unannounced case management inspection. |
| Sharika Montenegro | Resident Services Coordinator | Met with Licensing Program Analyst during inspection. |
| Ingrid Weber | Memory Care Director | Met with Licensing Program Analyst during inspection. |
Inspection Report
Complaint Investigation
Capacity: 325
Deficiencies: 0
Jun 16, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-03-14 alleging that the facility was not allowing a resident to manage his own medications.
Findings
The investigation found that the resident was not allowed to manage his own medications because he was unable to identify the majority of his medications, their purposes, and side effects. The resident's physician's assistant rescinded prior authorization for self-management. The allegation was found to be unfounded.
Complaint Details
The complaint alleged that the facility was not allowing the resident to manage his own medications despite the resident's request and physician indication that he could. The investigation included interviews with the administrator, regional nurses, the resident, and the resident's representative, and review of relevant documentation. The allegation was determined to be unfounded.
Report Facts
Facility capacity: 325
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kimberly Hagen | Administrator | Facility administrator interviewed during the investigation |
| Alisa Salluce | Regional Nurse | Interviewed during the investigation regarding resident's medication management |
| Cindy Barnes | Regional Nurse | Interviewed during the investigation regarding resident's medication management |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Capacity: 325
Deficiencies: 0
Jun 8, 2022
Visit Reason
The visit was a Case Management - Legal/Non-compliance meeting held to review the stipulation adopted on 06/01/2022 and discuss next steps regarding the facility's probationary status.
Findings
No violations were cited during this visit. The stipulation contents, probation terms, monitoring, and license conditions were reviewed and acknowledged by facility representatives and licensing officials.
Report Facts
Facility licensed capacity: 325
Hospice residents allowed: 20
Probation period: 06/01/2022 to 06/01/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager involved in the meeting and report |
| Cassie Yang | Licensing Program Analyst | Named as Licensing Program Analyst involved in the meeting and report |
| Jason Thomas | Facility representative met during the visit | |
| Kimberly Hagen | Administrator | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Census: 172
Capacity: 325
Deficiencies: 1
May 17, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to a complaint received on 2021-10-20 regarding a resident leaving the facility without staff knowledge.
Findings
The investigation substantiated that the facility failed to ensure a resident with dementia did not leave unaccompanied, posing an immediate health and safety risk. Other allegations regarding rate increases, family notification, and emergency services call were found unsubstantiated.
Complaint Details
Complaint involved allegations that a resident left the facility without staff knowledge. The investigation found the allegation substantiated based on evidence including interviews, documentation, video surveillance, and law enforcement reports.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure that resident (R1) did not leave the facility, on 10/16/2021, accompanied in a group, as directed by resident's physician, which posed an immediate health and safety risk to residents in care. | Type A |
Report Facts
Capacity: 325
Census: 172
Deficiencies cited: 1
Status checks required: 10
Care needs points: 210
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberly Hagen | Senior Executive Director / Administrator | Interviewed during investigation |
| Barbara Fleck | Assistant Executive Director | Interviewed during investigation |
| Deborah Ahrens | Business Office Director | Interviewed during investigation and involved in incident |
Inspection Report
Complaint Investigation
Census: 172
Capacity: 325
Deficiencies: 0
May 17, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to a complaint received on 2022-01-18 alleging inadequate supervision and inadequate food service to residents.
Findings
The investigation included interviews with facility staff and residents, and review of documentation. Both allegations—lack of adequate supervision and inadequate food service—were found to be unsubstantiated due to insufficient evidence to prove the alleged violations occurred.
Complaint Details
Complaint involved two main allegations: 1) Facility does not have adequate supervision, including concerns about insufficient staffing affecting paperwork and resident care such as showers; 2) Staff did not provide adequate food service, including complaints about food quality, staffing shortages in the kitchen, and lack of vegetable servings. The investigation found these allegations unsubstantiated.
Report Facts
Facility capacity: 325
Census: 172
Staff names provided: 5
Med-Techs interviewed: 3
Residents interviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Hagen | Senior Executive Director / Administrator | Met with Licensing Program Analyst during investigation and provided information |
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation |
| Maribeth Senty | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 172
Capacity: 325
Deficiencies: 0
May 17, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-01-07 alleging that staff were not assisting residents with showering as often as needed and not assisting residents with ambulating to the restroom in a timely manner.
Findings
The investigation included interviews with staff and residents and review of documentation such as shower schedules and pendant response times. The allegations were found to be unsubstantiated as there was insufficient evidence to prove the alleged violations occurred. The facility demonstrated compliance with their policy goal for pendant response times, and residents reported receiving assistance as needed.
Complaint Details
The complaint alleged that staff were not assisting residents with showering as often as needed and not assisting residents with ambulating to the restroom in a timely manner, resulting in poor hygiene and accidents. Interviews with Med-Techs and residents, as well as review of pendant response times and shower schedules, showed that while some delays occurred, the facility met its policy goals and residents generally received timely assistance. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 325
Census: 172
Average pendant response time: 13.1
Median pendant response time: 10.67
Average pendant response time: 8.99
Average pendant response time: 3.43
Average pendant response time: 1.51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberly Hagen | Administrator | Met with Licensing Program Analyst during investigation |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 180
Capacity: 325
Deficiencies: 0
Apr 20, 2022
Visit Reason
Unannounced complaint investigation conducted due to an allegation that the facility was not abiding by the admission agreement.
Findings
The investigation found the allegation to be unfounded after reviewing resident documentation, interviews with facility staff, and billing statements. The resident's level of care change and associated costs were properly documented and communicated.
Complaint Details
The complaint alleged that the facility was not abiding by the admission agreement. The investigation concluded the allegation was unfounded, meaning it was false or without reasonable basis.
Report Facts
Facility capacity: 325
Resident census: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberly Hagen | Administrator | Met with Licensing Program Analyst during investigation |
| Ingrid Weber | Memory Care Director | Interviewed regarding resident care level |
| Deborah Ahrens | Business Office Director | Interviewed and provided billing documentation |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 184
Capacity: 325
Deficiencies: 0
Mar 30, 2022
Visit Reason
Unannounced complaint investigation conducted in response to an allegation that the facility was not in good repair, specifically regarding water leaks in a resident's apartment.
Findings
The investigation found that the facility promptly addressed the water leak issue through internal remediation and external vendor services. The allegation was determined to be unsubstantiated due to insufficient evidence to prove the violation occurred.
Complaint Details
The complaint alleged the facility was not in good repair due to water leaks in a resident's apartment. The investigation included interviews with staff and residents, review of work orders dating back to 2013, and contractor invoices. The facility took corrective actions including gutter cleaning and sealing overflow to prevent leaks. The allegation was found unsubstantiated.
Report Facts
Facility capacity: 325
Census: 184
Dates of work orders: Sep 21, 2013
Dates of work orders: Nov 1, 2015
Date of leak report: Dec 23, 2021
Date of contractor invoice: Jan 1, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kimberly Hagen | Administrator | Met with Licensing Program Analyst during investigation |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 184
Capacity: 325
Deficiencies: 0
Mar 11, 2022
Visit Reason
The inspection was an unannounced case management follow-up visit triggered by an incident report received on 03/09/2022 regarding a medication incident on 03/04/2022.
Findings
The medication technician misinterpreted a medication order and prepared two vials instead of one, but the resident refused the medication, so it was not administered. No deficiencies were cited from this case management inspection.
Report Facts
Incident report date: Mar 4, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management inspection |
| Kimberly Hagen | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Follow-Up
Census: 181
Capacity: 325
Deficiencies: 0
Feb 24, 2022
Visit Reason
The inspection was conducted as a case management follow-up visit after receiving a SOC 341 on 02/22/2022 to verify resident status and facility compliance.
Findings
The facility made appropriate follow-ups regarding the resident discussed in the SOC 341 and confirmed the resident still resides at the facility. No deficiencies were cited during this case management inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Hagen | Administrator | Met with Licensing Program Analysts during the inspection. |
| Allison Perkes | Assistant Executive Director | Met with Licensing Program Analysts during the inspection. |
| Deborah Ahrens | Senior Community Business Director | Met with Licensing Program Analysts and discussed SOC 341 regarding a resident. |
| Sabrina Calzada | Licensing Program Analyst | Conducted the case management inspection. |
| Talwinder Bains | Licensing Program Analyst | Conducted the case management inspection. |
Inspection Report
Census: 200
Capacity: 325
Deficiencies: 0
Nov 23, 2021
Visit Reason
The visit was an unannounced case management visit to discuss a recent eviction notification received by Community Care Licensing for resident R1 and a recent fall by resident R2.
Findings
No deficiencies were cited during this visit. The facility staff is working with residents and responsible parties to address health condition changes and update care plans accordingly.
Report Facts
Capacity: 325
Census: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and explained the purpose of the visit |
| Alycia Berryman | Regional Manager | Accompanied the Licensing Program Analyst during the visit |
| Alicia Rist | Administrator | Facility administrator who provided information about residents and facility operations |
Inspection Report
Census: 201
Capacity: 325
Deficiencies: 0
Nov 4, 2021
Visit Reason
The visit was a case management visit regarding an incident report received by the Community Care Licensing Division on 10/22/2021 involving a resident who left the facility unassisted and did not return the same day as expected.
Findings
The facility reported no deficiencies during the visit. The resident returned safely the following day with no adverse reactions to missed medication doses. The facility plans to obtain contact phone numbers for residents when they leave with escorts or visitors.
Report Facts
Incident report date: Oct 22, 2021
Incident date: Oct 16, 2021
Resident return date: Oct 17, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Hagen | Senior Executive Director | Met with during the visit and involved in discussing the incident with the resident |
| Angela Hood | Licensing Program Analyst | Conducted the case management visit |
| Michael Hood | Licensing Program Analyst | Conducted the case management visit |
Inspection Report
Census: 206
Capacity: 325
Deficiencies: 0
Oct 29, 2021
Visit Reason
The visit was an unannounced office Non-Compliance Conference conducted to discuss the history of citations issued since 2016, substantiated complaints, and a civil penalty issued in August 2021.
Findings
No deficiencies were cited during this visit. The report summarizes past citations including 8 Type A and 15 Type B citations since 2016, with 1 Type A and 3 Type B violations in 2021. The facility agreed to submit a compliance plan addressing resident care and staffing issues.
Complaint Details
The report discussed substantiated complaints filed against the facility, including those on August 6, 2021 and April 8, 2020, as well as a summary of complaints since 2016.
Report Facts
Civil penalty amount: 15000
Total Type A citations since 2016: 8
Total Type B citations since 2016: 15
Type A citations in 2021: 1
Type B citations in 2021: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Rist | Administrator | Facility Administrator named in report header |
| Aron Alexander | Met with during visit and exit interview conducted | |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager in report |
| Kevin Mknelly | Licensing Program Analyst | Named as Licensing Program Analyst in report |
Inspection Report
Complaint Investigation
Census: 205
Capacity: 325
Deficiencies: 0
Oct 27, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of unlawful eviction received on 09/09/2021.
Findings
The investigation found the allegation of unlawful eviction to be unfounded. The facility issued a 30-day termination notice to a resident for failure to comply with community policies, specifically unsafe operation of a motorized scooter, but the allegation was determined to be false or without reasonable basis after review of records and interviews.
Complaint Details
The complaint alleged unlawful eviction of a resident. The investigation included interviews with staff and review of facility policies and notices. The allegation was found to be unfounded.
Report Facts
Capacity: 325
Census: 205
Days notice: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Hood | Licensing Program Analyst | Conducted the complaint investigation |
| Michael Hood | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberly Hagen | Senior Executive Director | Met with investigators during the visit |
| Maribeth Senty | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 205
Capacity: 325
Deficiencies: 0
Oct 27, 2021
Visit Reason
The inspection was a Required-1 Year unannounced visit to conduct an annual inspection utilizing the infection control domain.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Fleck | Assistant Executive Director | Met with Licensing Program Analysts during the inspection. |
Inspection Report
Census: 205
Capacity: 325
Deficiencies: 1
Oct 27, 2021
Visit Reason
The visit was a case management visit conducted to review compliance related to deficiencies, specifically regarding the submission of a 30-day written notice to terminate a resident's stay.
Findings
The facility failed to submit the required 30-day written notice to terminate a resident (R1) to the licensing agency, which poses a potential health, safety, and personal rights risk to residents in care.
Deficiencies (1)
| Description |
|---|
| Failure to submit the 30-day written notice to terminate resident R1 to the licensing agency within five days as required by eviction procedures. |
Report Facts
Deficiency Type: 1
Capacity: 325
Census: 205
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Hood | Licensing Program Analyst | Conducted the case management visit and authored the report. |
| Barbara Fleck | Assistant Executive Director | Facility representative met during the inspection. |
| Maribeth Senty | Licensing Program Manager | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 218
Capacity: 325
Deficiencies: 1
Aug 30, 2021
Visit Reason
The visit was conducted as a Case Management - Other unannounced visit to deliver additional civil penalties regarding substantiated findings from a complaint investigation concluded on April 8, 2020, related to failure to respond timely to a resident's call button.
Findings
The investigation substantiated that on December 22, 2019, staff failed to respond to resident R1's emergency call device for approximately 40 minutes, contributing to the resident's death. Staffing shortages and staff duties contributed to delayed response times. A civil penalty of $14,500 was issued related to this violation.
Complaint Details
The complaint investigation substantiated that the facility staff failed to respond timely to resident R1's emergency calls on December 22, 2019, resulting in the resident's death. The allegation was substantiated and cited under CCR Title 22, § 87468.2(a)(8).
Deficiencies (1)
| Description |
|---|
| Failure to respond to resident's call button in a timely manner resulting in neglect and death of resident R1. |
Report Facts
Civil penalty amount: 14500
Immediate civil penalty amount: 500
Resident emergency call delay: 40
Staff scheduled but absent: 2
Staff present during incident: 4
Residents in care: 242
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Rist | Administrator | Met with Licensing Program Analysts during visit and received civil penalty documentation. |
| Melana Llopis | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Census: 220
Capacity: 325
Deficiencies: 0
Aug 19, 2021
Visit Reason
The visit was an unannounced case management inspection to ensure the facility's compliance with Health and Safety Code 1569.38 regarding the posting of licensing reports and disclosure to new residents following the department serving an Accusation on 08/03/2021.
Findings
The inspection found that the facility was in compliance with the posting requirements and disclosure to residents. The administrator showed the posted notice containing the required elements, and all 220 residents or their representatives were informed via written notice. No deficiencies were cited during this visit.
Report Facts
Residents informed via written notice: 220
Facility capacity: 325
Facility census: 220
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Rist | Administrator | Met with Licensing Program Analysts during the inspection and responsible for posting notices |
| Melana Llopis | Licensing Program Analyst | Conducted the case management inspection |
| Sabrina Calzada | Licensing Program Analyst | Conducted the case management inspection |
| Maribeth Senty | Licensing Program Manager | Designated contact person for the Community Care Licensing Division |
Inspection Report
Census: 222
Capacity: 325
Deficiencies: 0
Aug 11, 2021
Visit Reason
Licensing Program Analyst Melana Llopis arrived unannounced to deliver a letter of immediate exclusion for staff (S1) and to conduct a case management visit.
Findings
The Licensing Program Analyst completed required COVID-19 protocols, conducted interviews with residents, and delivered the exclusion letter to the administrator. An exit interview was conducted and a copy of the report was provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Rist | Administrator | Met with Licensing Program Analyst during visit and received the letter of immediate exclusion. |
| Melana Llopis | Licensing Program Analyst | Conducted the unannounced visit, delivered exclusion letter, and completed interviews and COVID-19 protocols. |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 224
Capacity: 325
Deficiencies: 1
Aug 6, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 08/05/2021 alleging residents were not treated with dignity and respect, including being showered with cold water and verbally abused by an employee.
Findings
The investigation substantiated the complaint, finding that staff member Carmencita Phelps admitted to giving residents cold showers and verbally threatening them, posing an immediate health, safety, and personal rights risk. The facility terminated the staff member and conducted in-service training on elder abuse.
Complaint Details
The complaint was substantiated. Staff member Carmencita Phelps admitted to abuse involving cold showers and verbal threats to residents R1, R2, and R3.
Deficiencies (1)
| Description |
|---|
| Staff member admitted to giving residents cold showers and verbally threatening residents in care, violating personal rights. |
Report Facts
Capacity: 325
Census: 224
Deficiency Type: 1
Plan of Correction Due Date: Aug 7, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carmencita Phelps | Staff member who admitted to abusing residents by giving cold showers and verbal threats | |
| Melana Llopis | Licensing Program Analyst | Conducted the complaint investigation |
| Alicia Rist | Administrator | Facility administrator met during investigation and acknowledged abuse |
| Deborah Ahrens | Business Director | Interviewed during investigation and acknowledged abuse |
| Ingrid Weber | Life Guidance Director | Interviewed during investigation and acknowledged abuse |
Inspection Report
Complaint Investigation
Census: 224
Capacity: 325
Deficiencies: 3
Jul 26, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-03-22 regarding allegations of inadequate resident care including failure to shower a resident, denial of smoking rights, and lack of supervision during smoking.
Findings
The investigation substantiated three allegations: staff did not assist the resident with scheduled showers, staff did not allow the resident to smoke as requested, and staff did not supervise the resident during smoking, which led to a fall. Two other allegations related to missed doctor appointments and being charged for services not provided were found unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not shower the resident as scheduled, did not allow the resident to smoke, and did not supervise the resident during smoking. The allegations that staff did not ensure the resident was taken to doctor appointments and that the resident was charged for services not provided were unsubstantiated.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Licensee did not ensure resident was assisted with weekly showers per care plan, posing a potential health and safety risk. | Type B |
| Licensee did not ensure resident was allowed a smoke break on 3/6/2021, posing a potential personal rights violation. | Type B |
| Licensee did not ensure resident received supervision during a smoke break on 1/20/2021, resulting in resident falling and posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 325
Census: 224
Deficiencies cited: 3
Plan of Correction Due Date: Aug 9, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Rist | Executive Director | Met with Licensing Program Analyst during investigation and involved in findings |
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation |
| Maribeth Senty | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 325
Deficiencies: 0
Jun 18, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-03-08 regarding staff making a resident feel uncomfortable.
Findings
The investigation included interviews with staff, the Ombudsman, and review of resident documentation. The allegation was found to be unsubstantiated due to lack of preponderance of evidence, though the facility conducted in-service training on appropriate resident interaction.
Complaint Details
The complaint involved a resident (R1) who felt uncomfortable with a male staff member (S1) escorting her. The resident did not report abuse. The facility removed the staff from providing care to the resident and conducted an internal investigation. The Ombudsman also investigated and did not substantiate the allegation. The facility provided in-service training on appropriate interactions with residents.
Report Facts
Complaint received date: Mar 8, 2021
Facility capacity: 325
Census: 84
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Alicia Rist | Administrator | Facility administrator involved in investigation |
| Shannon Yeoman | Assistant Administrator | Met with Licensing Program Analyst during inspection |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 225
Capacity: 325
Deficiencies: 0
Apr 23, 2021
Visit Reason
The visit was a Case Management call conducted via telephone due to Covid-19 and precautionary measures, to address concerns received regarding the facility's visitation policies.
Findings
No deficiencies were cited during the call. The facility's visitation plan was reviewed along with relevant CCLD guidelines, and a follow-up was planned.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Rist | Administrator | Spoke with Licensing Program Analyst regarding visitation policies and provided the facility visitation plan. |
| Melana Llopis | Licensing Program Analyst | Contacted the facility for the Case Management call and reviewed visitation plan with Administrator. |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on the report. |
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