Inspection Report Summary
Most inspections found no deficiencies, including the most recent report on October 23, 2025, which was perfect and found the complaint about staffing unsubstantiated. Earlier reports were also mostly clean, with no issues cited during annual inspections in 2024 and 2025, as well as follow-up visits. One complaint investigation in February 2023 found a substantiated deficiency for a delay of over three hours in seeking medical attention after a resident fall, resulting in a $500 civil penalty. Other complaint investigations, including allegations of illegal eviction and resident injury, were unsubstantiated. The facility appears to have improved since the 2023 penalty, with no deficiencies noted in subsequent inspections.
Deficiencies per Year
4
3
2
1
0
High
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 120
Capacity: 155
Deficiencies: 0
Oct 23, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-08-27 alleging that the facility lacks staffing and resident needs are not being met.
Findings
Based on interviews with residents and staff, including the Executive Director, the allegation that the facility lacks sufficient staffing to meet resident needs was determined to be unsubstantiated. Staff reported adequate response times and training, and no deficiencies were cited.
Complaint Details
The complaint alleged insufficient staffing resulting in unmet resident needs. The investigation included interviews with 6 residents and 5 caregiving staff, all stating needs were met and timely responses were provided. The allegation was found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Residents interviewed: 6
Caregiving staff interviewed: 5
Caregivers scheduled AM and PM shifts: 3
Med-techs scheduled AM and PM shifts: 1
Caregivers scheduled overnight: 2
Med-techs scheduled overnight: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Mendivil | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jeremy Gilmore | Executive Director | Interviewed regarding staffing levels and care plans |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 122
Capacity: 155
Deficiencies: 0
Apr 24, 2025
Visit Reason
An unannounced required annual inspection was conducted by Licensing Program Analysts to evaluate compliance with licensing requirements.
Findings
The facility was toured and inspected including physical plant, food supply, medication storage, and resident activities. No deficiencies were cited during this visit.
Report Facts
Licensed capacity: 155
Current census: 122
Staff records reviewed: 6
Resident records reviewed: 8
Hot water temperature range: 110-118
Last fire drill date: Mar 12, 2025
Administrator certificate expiration: Jul 28, 2026
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James D. Craddock | Executive Director | Met with Licensing Program Analysts during inspection and involved in facility tour |
| Andrea Mendivil | Licensing Program Analyst | Conducted facility tour, medication review, and other inspection activities |
| Fred Arias | Licensing Program Analyst | Reviewed staff and resident records during inspection |
Inspection Report
Annual Inspection
Census: 106
Capacity: 155
Deficiencies: 0
Jul 16, 2024
Visit Reason
The visit was an unannounced required comprehensive annual inspection conducted by the Licensing Program Analyst Mary Rico to evaluate the facility's compliance with regulatory standards.
Findings
The facility was found to be operating within its approved capacity and maintained in safe, clean, and good repair conditions. No deficiencies were cited during the inspection.
Report Facts
Client files reviewed: 8
Medications audited: 8
Staff files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Rico | Licensing Program Analyst | Conducted the inspection and audit |
| Dorice Redman | Executive Director | Facility representative met during inspection |
| James D. Craddock | Administrator/Director | Named as facility administrator/director |
| Efren Malagon | Licensing Program Manager | Named in report signature section |
Inspection Report
Follow-Up
Census: 102
Capacity: 155
Deficiencies: 0
Jun 10, 2024
Visit Reason
The visit was a case management follow-up on an incident where a resident eloped from the facility on May 24, 2024, and was found on facility property by staff.
Findings
Staff responded promptly and appropriately to the incident, resident was safe and monitored closely, and no deficiencies were cited as a result of this visit.
Report Facts
Capacity: 155
Census: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Tea | Licensing Program Analyst | Conducted the case management visit |
| Dori Redman | Executive Director | Facility representative met during inspection and exit interview |
| Elaheh Mobadifar | Resident Service Director | Submitted the incident report |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 155
Deficiencies: 0
Apr 26, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 12/15/2020 alleging that a resident sustained an injury from a fall while in care.
Findings
The investigation included interviews with the Executive Director, staff, and residents, as well as a review of relevant records. The facility was found to have conducted appropriate nightly checks, and there was insufficient evidence to prove that the alleged injury resulted from facility negligence. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that a resident sustained an injury from a fall while in care, resulting in hospitalization for major blunt trauma. The alleged victim had passed away in December 2020. The investigation found insufficient evidence to substantiate the allegation.
Report Facts
Complaint Control Number: 22-AS-20201215112452
Capacity: 155
Census: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dwayne L Mason | Licensing Program Analyst | Conducted the complaint investigation |
| Dorice Redman | Executive Director | Interviewed during investigation and participated in exit interview |
| Armando J Lucero | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 155
Deficiencies: 0
Mar 15, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation of illegal eviction at the facility.
Findings
The investigation found that the facility served a thirty-day notice to a resident for violation of house rules regarding alcohol abuse, supported by multiple incident reports and documented public intoxication episodes. The department determined the eviction was legal and the allegation was unfounded.
Complaint Details
The complaint alleged illegal eviction. The investigation revealed the eviction was legal due to documented violations of house rules related to alcohol abuse. The allegation was deemed unfounded.
Report Facts
Incident reports reviewed: 6
Public intoxication instances documented: 10
Facility capacity: 155
Census: 101
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Dori Redman | Executive Director | Met with investigator and provided information during investigation |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 155
Deficiencies: 1
Feb 16, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including a resident pushing another resident causing injury due to neglect and staff not seeking timely medical attention for a resident who fell.
Findings
The allegation that a resident pushed another causing injury due to neglect was unsubstantiated. However, the allegation that staff did not seek timely medical attention for the resident who fell was substantiated, resulting in a delay of over three hours before medical care was obtained and a civil penalty was assessed.
Complaint Details
The complaint investigation was triggered by allegations that a resident pushed another causing injury due to neglect and that staff failed to seek timely medical attention for a resident who fell. The first allegation was unsubstantiated, but the second was substantiated with evidence of a three and a half hour delay in medical care. A civil penalty of $500 was assessed.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee failed to seek immediate medical attention following R1's fall, violating CCR 87465(g) requiring immediate 911 call for imminent threats to resident health. | Type A |
Report Facts
Civil penalty amount: 500
Delay in medical services (hours): 3.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James D. Craddock | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Andrea Mendivil | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 104
Capacity: 155
Deficiencies: 0
Dec 13, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on an incident report dated 12/08/2022 involving a resident who took an incorrect medication dosage.
Findings
No deficiencies were noted during the visit. The Licensing Program Analyst reviewed relevant documents and conducted an exit interview, leaving a copy of the report at the facility.
Report Facts
Incident date: Dec 8, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James D. Craddock | Executive Director | Met with Licensing Program Analyst during the visit |
| Andrea Mendivil | Licensing Program Analyst | Conducted the unannounced case management visit |
| Alisa Ortiz | Licensing Program Manager | Named in the report |
Report
February 16, 2023
File
report_6_306000752_inx5_2023-02-16.pdf
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