Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating the facility generally meets regulatory requirements. The most recent report from August 19, 2025, was clean with no deficiencies noted during a complaint investigation. An earlier complaint investigation on April 7, 2025, substantiated some issues related to hazardous passageways due to construction debris, elevator downtime, and lack of an accessible emergency evacuation plan, but these were isolated findings. Other complaints involving resident care, supervision, and staff conduct were not substantiated. The overall trend shows mostly compliance with occasional minor environmental and safety concerns that do not appear to be ongoing.
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-04-14 regarding allegations that the facility had no activities director, no administrator, and had not conducted emergency drills.
Findings
The investigation found all allegations to be unsubstantiated. The facility has an activities director since November 2024, a qualified designee acting as administrator when the Executive Director is absent, and conducts quarterly emergency drills as required. No health or safety hazards were noted during the visit.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included lack of activities director, lack of administrator, and failure to conduct emergency drills. Interviews, record reviews, and observations confirmed the facility met requirements in all areas.
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2025-04-01 regarding hazards in passageways, elevator maintenance, and lack of an evacuation plan.
Findings
The investigation substantiated that the facility had hazardous passageways due to ongoing construction debris, the elevator was non-operational for two days, and the emergency evacuation plan was not available to residents or their families upon request.
Complaint Details
The complaint was substantiated based on observations, staff and resident interviews confirming hazardous passageways, elevator downtime, and lack of accessible evacuation plan.
Severity Breakdown
Type B: 3
Deficiencies (3)
Description
Severity
Licensee did not ensure passageways were maintained free of hazards due to construction debris and exposed electrical wires.
Type B
Licensee did not ensure elevators were maintained in working condition; elevator was non-operational for two days.
Type B
Facility did not have an emergency evacuation plan available upon request to residents and their families.
Type B
Report Facts
Capacity: 85Census: 35Plan of Correction Due Date: Apr 21, 2025Plan of Correction Due Date: Apr 28, 2025
Employees Mentioned
Name
Title
Context
Gina Saucedo
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Troy Agard
Licensing Program Manager
Oversaw the complaint investigation
Katia Arriaga
Business Manager
Facility representative who met with the Licensing Program Analyst during the inspection
The inspection visit was conducted to investigate a complaint received on 2024-02-27 alleging financial abuse of a former resident, failure to adhere to the resident's Admissions Agreement, and inaccurate assessment of resident's needs.
Findings
The investigation found insufficient evidence to substantiate the allegations of financial abuse, failure to adhere to the Admissions Agreement, and inaccurate assessment of resident needs. Interviews with staff and residents, document reviews, and physical plant tours did not reveal any health or safety hazards or violations.
Complaint Details
The complaint involved allegations that the licensee financially abused a former resident by extracting funds unethically and billing discrepancies, did not adhere to the resident's Admissions Agreement, and failed to accurately assess the resident's needs. The allegations were unsubstantiated based on interviews, document reviews, and observations.
Report Facts
Complaint Control Number: 31Capacity: 85Census: 31Discount Offered: 50
Employees Mentioned
Name
Title
Context
Abeye Duguma
Licensing Program Analyst
Conducted the complaint investigation and interviews
Irma Arteaga
Administrator
Facility administrator named in the report header
Vartan Stepanian
Met with Licensing Program Analyst during the investigation
The visit was an unannounced complaint investigation triggered by allegations that a cluttered room created an unsafe environment and caused a resident to fall.
Findings
The investigation found no evidence of clutter or a fall incident during the relevant time period. Staff and residents interviewed did not confirm the allegations, and no health or safety hazards were observed. The allegations were determined to be unsubstantiated.
Complaint Details
The complaint was unsubstantiated after investigation. The allegations involved a cluttered room causing an unsafe environment and a resident fall, but no supporting evidence was found.
Report Facts
Capacity: 85Census: 31
Employees Mentioned
Name
Title
Context
Abeye Duguma
Licensing Program Analyst
Conducted the complaint investigation visit and report
Naira Margaryan
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
The visit was an unannounced case management visit conducted to ensure the safety and welfare of evacuees from the RCFE North Lake Villas facility due to the Eaton Fire.
Findings
The Licensing Program Analyst observed all residents in good condition; well kept, clean, and groomed. No immediate health or safety hazards were observed during the visit.
Employees Mentioned
Name
Title
Context
Antonia Alvizar-Ettima
Licensing Program Analyst
Conducted the unannounced case management visit and authored the report.
Joel Schochet
Vice President of Operations
Met with the Licensing Program Analyst during the visit.
The visit was an unannounced investigation of a complaint alleging that due to lack of supervision, a resident was restrained by another resident causing injuries.
Findings
Based on observations, interviews with administrative personnel and staff, and review of resident rosters, there was no evidence to support the allegation. The residents involved were not current facility residents but temporarily relocated due to a fire. The allegation was unsubstantiated.
Complaint Details
The complaint alleged that resident #1 was tied up to a chair with a blanket by resident #2 due to lack of supervision, causing injuries. Investigation found no witnesses or evidence supporting this claim. Resident #1 was temporarily relocated and resident #2 was not on the facility roster. The allegation was unsubstantiated.
Report Facts
Facility capacity: 85Census: 59
Employees Mentioned
Name
Title
Context
Antonia Alvizar-Ettima
Licensing Program Analyst
Conducted the complaint investigation
Naira Margaryan
Licensing Program Manager
Named in report as Licensing Program Manager
Joel Schochet
Vice President of Operations
Met with Licensing Program Analyst during investigation
The visit was an unannounced complaint investigation conducted to investigate an allegation that staff did not prevent a resident from causing injuries to another resident in care.
Findings
The investigation found that the alleged residents with injuries were not present at the facility and were likely temporarily relocated due to a fire. Interviews, observations, and record reviews did not verify the complaint, and no health or safety hazards were noted. The allegation was unsubstantiated.
Complaint Details
The complaint alleged that staff failed to prevent resident #2 from causing injuries to resident #1, who was seen with a cut and multiple bruises. The investigation concluded the allegation was unsubstantiated as the residents were not at the facility and no evidence supported the claim.
Report Facts
Facility capacity: 85Census: 59
Employees Mentioned
Name
Title
Context
Antonia Alvizar-Ettima
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Naira Margaryan
Licensing Program Manager
Oversaw the complaint investigation
Joel Schochet
Vice President of Operations
Met with the Licensing Program Analyst during the investigation
The visit was an unannounced Case Management visit conducted to ensure the safety and welfare of evacuees from the Eaton Fire who were temporarily relocated to the facility.
Findings
The visit included interviews with staff and residents, and a physical plant inspection. No immediate health or safety hazards were observed, and all residents were reported to be in good condition and feeling safe.
The inspection was a required one-year unannounced visit to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be clean, well-maintained, and compliant with safety and health standards. No health and safety hazards were noted, and medication and toxins were properly secured.
Report Facts
Facility capacity: 85Resident census: 32Fire extinguisher last inspection date: Dec 19, 2023Hot water temperature: 110.6Liability insurance expiration date: Jan 1, 2025
Employees Mentioned
Name
Title
Context
Abeye Duguma
Licensing Program Analyst
Conducted the inspection and noted findings
Katia Arriaga
Business Office Manager
Met with the Licensing Program Analyst during the inspection
The visit was an unannounced complaint investigation triggered by an allegation that staff did not seek timely medical attention for a resident.
Findings
The investigation found insufficient evidence to support the allegation. Interviews and record reviews showed that 911 was contacted and the resident was taken to the hospital in a timely manner. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff did not seek timely medical attention for a resident. The investigation included interviews with staff and residents, review of medical and transport documents, and found that the resident initially refused hospital transport but was taken to the hospital the following day when symptoms worsened. The allegation was unsubstantiated.
Report Facts
Capacity: 85Census: 34
Employees Mentioned
Name
Title
Context
Abeye Duguma
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Tihesha Smith
Licensing Program Analyst
Conducted the initial unannounced complaint visit and interviews
The visit was an unannounced complaint investigation conducted in response to allegations received on 2024-04-17 regarding staff speaking inappropriately to residents, staff hitting a resident, and inadequate food services.
Findings
The investigation found no substantiation for the allegations of staff speaking inappropriately or hitting residents, as observations and interviews indicated residents were treated with dignity and respect. The allegation of inadequate food services was also unsubstantiated, with observations confirming fresh, nutritious, and well-balanced meals were served.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff speaking inappropriately to residents, staff hitting a resident, and inadequate food services. Interviews with staff and residents, physical plant tours, and menu reviews did not verify the allegations.
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff refused to accept a resident back into the facility.
Findings
The investigation found that the resident was not refused admission back to the facility; the resident arrived without notice from the hospital and was allowed to return. The allegation was deemed unsubstantiated due to insufficient information to support it, and no immediate health and safety risks were observed.
Complaint Details
The complaint alleged that staff refused to accept Resident #1 back into the facility. The investigation included interviews and document reviews. It was found that Resident #1 passed away on 2023-09-26 and was never refused admission. The facility was not notified by the hospital of the resident's discharge and return, and the administrator was not afforded time to conduct a reassessment prior to discharge. The allegation was unsubstantiated.
Report Facts
Facility capacity: 85Resident census: 42
Employees Mentioned
Name
Title
Context
Tihesha Smith
Licensing Program Analyst
Conducted the complaint investigation and made the unannounced visit
Irma Arteaga
Administrator
Facility administrator present during the investigation
Sonia Nault
Executive Director
Met with the Licensing Program Analyst during the visit
An unannounced required 1-year inspection was conducted to ensure compliance with Title 22 Regulations and to check for health and safety hazards at the facility.
Findings
The facility's common areas were observed to be sanitary and appropriately furnished. The physical plant was toured with no health or safety hazards noted. The required annual inspection was not fully completed due to time constraints and will be completed later.
Report Facts
Number of bedrooms: 73Number of public restrooms: 4
Employees Mentioned
Name
Title
Context
Tihesha Smith
Licensing Program Analyst
Conducted the unannounced required 1-year inspection
The visit was an unannounced complaint investigation triggered by an allegation that staff did not provide the authorized representative with the resident's 30-day notice of eviction.
Findings
The investigation found that the resident was self-responsible and did not have a Power of Attorney on file. The eviction notice was served directly to the resident in accordance with the admissions agreement. There was insufficient evidence to support the allegation, and the complaint was unsubstantiated.
Complaint Details
The complaint alleged failure to provide the authorized representative with a 30-day eviction notice. The allegation was found to be unsubstantiated based on document review and interviews.
Report Facts
Facility capacity: 85Census: 48Dates of eviction notices: Eviction notices were issued on 09/22/2022 and 02/24/2023Resident move-out date: Resident moved out on 02/15/2024 with outstanding balance
Employees Mentioned
Name
Title
Context
Tihesha Smith
Evaluator / Licensing Program Analyst
Conducted the complaint investigation visit and interviews
Nicholas Reed
Licensing Program Analyst
Delivered amended document and signed report
Irma Arteaga
Administrator
Facility administrator who disclosed resident's overdue balance
The visit was a One (1) Year Required - Infection Control inspection conducted to evaluate compliance with infection control and facility standards.
Findings
The facility was found to have appropriate infection control measures in place, including PPE availability, staff mask usage, proper signage, clean and well-maintained physical plant, adequate food storage, and safety equipment operational. No deficiencies or violations were noted in the report.
Report Facts
Bedrooms: 73Public restrooms: 4Fire clearance capacity: 85Hospice waiver capacity: 8Residents present: 64Food stock duration: 2Food stock duration: 7Fire extinguisher last inspection date: Jan 10, 2022Hot water temperature: 115.9Facility temperature: 73
Employees Mentioned
Name
Title
Context
Abeye Duguma
Licensing Program Analyst
Conducted the inspection and met with facility representative
Irma Arteaga
Administrator
Facility administrator named in the report
Julio Lara
Facility representative designated to sign and accept the report
Ivan Saa
Executive Director
Designated Julio Lara to sign and accept the report
The visit was conducted as an unannounced Case Management investigation following an incident report received on 10/18/2022 regarding a resident's concern about being treated roughly during showering.
Findings
Interviews and file review revealed that the resident did not suspect sexual violation but alleged rough treatment during showering. The Executive Director filed a police report but no crime was found. The caregiver no longer assists the resident with showering, and in-service training was provided to staff. No health or safety hazards were noted.
Complaint Details
The complaint involved resident #1 feeling violated during showering. The investigation found no evidence of a crime, and the complaint was effectively addressed with staff training and changes in caregiving assignments.
Report Facts
Facility capacity: 85Resident census: 60
Employees Mentioned
Name
Title
Context
Ivan Saa
Executive Director
Interviewed during the investigation and provided information about the incident and staff training
Abeye Duguma
Licensing Program Analyst
Conducted the unannounced Case Management visit and investigation
The visit was a required one-year unannounced infection control inspection of the facility.
Findings
The facility was found to have appropriate COVID-19 prevention protocols in place, including screening, PPE availability, and signage. The physical plant was clean and well-maintained, with proper food storage, fire safety equipment, and medication security. Residents' rooms and common areas were adequately furnished and maintained.
Report Facts
Bedrooms: 73Public restrooms: 4Non-ambulatory residents: 41Ambulatory residents: 4Fire extinguisher last inspection date: Nov 1, 2021Hot water temperature: 119.2Facility temperature: 73Perishable food stock: 2Non-perishable food stock: 7
Employees Mentioned
Name
Title
Context
Abeye Duguma
Licensing Program Analyst
Conducted the inspection and met with the Executive Director
The visit was conducted in response to an incident report received regarding a resident fall on 08/01/2021.
Findings
The resident was inspected with no reported injury, and the facility had documented the fall internally but did not submit an incident report initially. An unusual incident report was submitted timely after the resident reported pain. No deficiencies were cited during this visit.
Complaint Details
The visit was triggered by a complaint/incident report about a resident fall. The complaint was investigated and found to have no deficiencies.
Report Facts
Facility capacity: 85
Employees Mentioned
Name
Title
Context
Patrick Shanahan
Licensing Program Analyst
Arrived at the facility in response to the incident report and conducted the inspection
Irina Konyavko
Resident Service Director
Met with the Licensing Program Analyst during the visit
Irma Arteaga
Administrator
Facility administrator named in the report header
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