Inspection Report Summary
Most inspections found no deficiencies, with the facility consistently meeting health, safety, and regulatory standards over time. The most recent report from September 4, 2025, was perfect, showing no deficiencies during the annual inspection. Several complaint investigations were conducted, including allegations of questionable death, fractures, inappropriate staff contact, insufficient staffing, medication mishandling, unsanitary kitchen conditions, and refund disputes; all were found unsubstantiated after thorough reviews. The facility has maintained a clean record without any fines, enforcement actions, or severe findings noted in the available reports. This pattern suggests stable compliance and no emerging concerns in resident care, environment, or staffing.
Deficiencies per Year
4
3
2
1
0
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 87
Capacity: 116
Deficiencies: 0
Sep 4, 2025
Visit Reason
The inspection was an unannounced Required-1 Year Inspection 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, with no deficiencies cited. The facility was observed to be properly maintained, with safe food storage, medication security, and operational safety equipment.
Report Facts
Food supply: 2
Food supply: 7
Bedrooms observed: 4
Bedrooms observed: 2
Bathrooms observed: 8
Hot water temperature: 109.5
Resident files reviewed: 4
Staff files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joanna Lehman | Executive Director | Met with Licensing Program Analyst during inspection |
| Angela Hood | Licensing Program Analyst | Conducted the inspection |
| Phoebie Carcot | Administrator | Named as facility administrator |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 116
Deficiencies: 0
Sep 4, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including questionable death, resident fractures due to lack of care, inappropriate staff contact, and insufficient staffing.
Findings
All four allegations investigated were found to be unsubstantiated after interviews, facility tour, and documentation review. There was no preponderance of evidence to prove the alleged violations occurred.
Complaint Details
The complaint investigation addressed four allegations: questionable death, resident sustained multiple fractures due to lack of care, staff touched resident inappropriately, and insufficient staffing to meet residents' needs. All allegations were found unsubstantiated.
Report Facts
Capacity: 116
Census: 87
Staff interviews: 3
Resident interviews: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Graham Gunby | Licensed Program Analyst | Conducted the complaint investigation and delivered findings |
| Joanna Lehman | Administrator | Met with the investigator during the unannounced visit |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 96
Capacity: 116
Deficiencies: 0
Aug 27, 2024
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate compliance with regulatory requirements and ensure the health and safety of residents.
Findings
The facility was found compliant with all reviewed areas including resident and staff files, fire drills, emergency preparedness, and safety equipment. No health or safety violations were observed and no deficiencies were cited.
Report Facts
Resident files reviewed: 9
Staff files reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Parks | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Phoebie Carcot | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 116
Deficiencies: 0
Jan 2, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding an allegation that the facility kitchen is unsanitary.
Findings
The investigation found the dining room and kitchen to be clean, well-organized, and following current regulations. Interviews and review of cleaning schedules and staff certifications showed compliance, and the allegation was found to be unfounded.
Complaint Details
The complaint alleged that the facility kitchen was unsanitary. After investigation, the allegation was found to be unfounded based on evidence including observations, interviews, and an internal audit showing 100% compliance.
Report Facts
Capacity: 116
Census: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Parks | Licensing Program Analyst | Conducted the complaint investigation |
| Natasha Georges | Administrator | Met with Licensing Program Analyst during investigation |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 77
Capacity: 116
Deficiencies: 0
Jul 31, 2023
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate compliance with regulatory requirements and ensure the health and safety of residents.
Findings
The facility was found to be compliant with all reviewed requirements including resident and staff files, fire drills, elopement drills, and environmental safety. No health or safety violations or deficiencies were observed or cited during the inspection.
Report Facts
Resident files reviewed: 8
Staff files reviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Parks | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Natasha Georges | Administrator | Facility administrator met during inspection |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 116
Deficiencies: 0
Jun 19, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff mishandled a resident's medication while in care.
Findings
The investigation found that the resident managed their own medication and that the missing medication was later found. There was no preponderance of evidence to prove the alleged violation occurred, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged staff mishandled a resident's medication. The investigation included interviews with staff, residents, and healthcare providers, and review of medication records and police reports. The allegation was found unsubstantiated.
Report Facts
Capacity: 116
Census: 81
Estimated Days of Completion: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Parks | Licensing Program Analyst | Conducted the complaint investigation |
| Maribeth Senty | Licensing Program Manager | Oversaw the complaint investigation |
| Dana Stansel | Administrator | Facility administrator involved in the investigation |
Inspection Report
Annual Inspection
Census: 89
Capacity: 116
Deficiencies: 0
Aug 8, 2022
Visit Reason
The inspection was conducted as a required annual unannounced visit to evaluate the facility's compliance with health and safety regulations.
Findings
The facility was found to be in substantial compliance with no deficiencies cited. No immediate health, safety, or personal rights violations were observed during the tour of the facility.
Report Facts
PPE supply duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha A Georges | Administrator | Met with Licensing Program Analyst during inspection and completed infection control domain. |
Inspection Report
Annual Inspection
Census: 88
Capacity: 116
Deficiencies: 0
Aug 19, 2021
Visit Reason
The inspection was conducted as a required unannounced annual inspection to evaluate the health and safety compliance of the facility.
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 this inspection.
Report Facts
PPE supply duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha A Georges | Administrator | Met with Licensing Program Analyst during the inspection and toured the facility. |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 116
Deficiencies: 0
Apr 23, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was not refunding community fees per agreement.
Findings
Based on interviews and documentation review, the allegation was found to be unfounded as the preponderance of evidence standards were not met. The complaint was determined to be false or without reasonable basis.
Complaint Details
The complaint alleged that the facility was not refunding community fees per agreement. The investigation concluded the allegation was unfounded.
Report Facts
Estimated Days of Completion: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Lusby | Licensing Program Analyst | Conducted the complaint investigation and contacted the facility |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Natasha Georges | Administrator | Facility Administrator involved in the investigation |
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