Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised did not have supporting evidence. The most recent report from September 25, 2025, identified one minor deficiency involving a resident in memory care who had not received an annual medical assessment despite multiple requests. A prior complaint investigation on June 29, 2025, substantiated a medication administration issue where staff gave medications late without proper documentation, posing a health risk, but no fines or enforcement actions were noted. Other deficiencies over time were isolated and generally related to documentation or resident care processes, with no patterns of severe harm or license actions. The facility’s record shows improvement in recent inspections, with the latest annual inspection showing only a minor issue and no serious violations.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
0.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
80% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
33% occupied
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 89
Capacity: 266
Deficiencies: 1
Date: Sep 25, 2025
Visit Reason
An unannounced 1 year required annual inspection visit was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, safe, and in good standing with no citations issued. One resident in memory care had not received an annual medical assessment despite multiple requests. All other documentation and regulatory requirements were met.
Deficiencies (1)
One resident residing in memory care had not received an annual medical assessment despite multiple requests.
Report Facts
Residents receiving hospice services: 9
Residents receiving home health services: 61
Residents self-administering oxygen: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Boese | Assistant Executive Director | Met with Licensing Program Analyst during inspection and received exit interview |
| Monique Moreira | Administrator | Observed to have valid certification expiring 02/19/26 |
| Javina George | Licensing Program Analyst | Conducted the inspection visit |
| Carolyn Tuba | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 266
Deficiencies: 0
Date: Aug 3, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that a resident was sexually assaulted while in care.
Complaint Details
The complaint alleged that resident (R#1) was sexually assaulted by resident (R#2) while living at the facility. After investigation, including interviews and review of police and medical reports, the allegation was found to be unsubstantiated.
Findings
The investigation included interviews with staff, residents, and witnesses, and review of relevant documents and police reports. The evidence showed no signs of forceful interaction and indicated the incident was likely consensual. The allegation was found to be unsubstantiated due to insufficient evidence.
Report Facts
Facility capacity: 266
Census: 90
Caregivers present: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Teresa Ramirez | Community Business Director | Met with during the investigation and received the complaint report |
| Robert Barton | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 266
Deficiencies: 0
Date: Aug 2, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff were financially abusing a resident and not safeguarding the resident's personal belongings.
Complaint Details
The complaint alleged that facility staff were financially abusing resident (R#1) by taking their money and personal belongings. The investigation found that (R#1) had cognitive impairment and a Durable Power of Attorney was in place. Interviews with staff, residents, and the appointed agent revealed no observed financial abuse or theft by staff. The allegations were found to be unsubstantiated due to lack of evidence.
Findings
The investigation included interviews with staff, residents, and witnesses, as well as review of relevant documents. The Licensing Program Analyst found no sufficient evidence to support the allegations, and the complaint was determined to be unsubstantiated.
Report Facts
Residents interviewed: 9
Staff interviewed: 5
Residents stating no financial abuse: 9
Residents stating family manages finances: 6
Residents stating self-manage finances: 2
Staff stating no financial abuse: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
| Robert Stansbury | Administrator | Facility Administrator named in report |
| Claudia Herrera | Administrative Assistant | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 266
Deficiencies: 0
Date: Jul 13, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that a resident sustained unexplained bruises while in care.
Complaint Details
Allegation: Resident sustained unexplained bruises while in care. The resident and witnesses stated they did not know how the injury occurred and denied any assault by staff. The investigation found no sufficient evidence to support the allegation, resulting in an unsubstantiated finding.
Findings
The investigation included interviews with the resident, witnesses, staff, and review of relevant documents. The evidence did not support the allegation, and the complaint was found to be unsubstantiated due to lack of sufficient evidence.
Report Facts
Facility capacity: 266
Resident census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Robert Stansbury | Administrator | Facility administrator named in the report |
| Theresa Ramirez | Business Office Manager | Met with the investigator during the visit |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 266
Deficiencies: 0
Date: Jul 13, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff were charging residents for services not rendered and not providing residents with privacy.
Complaint Details
The complaint investigation was triggered by allegations that staff were charging a resident an additional $700 monthly for housekeeping services not provided, and that staff were asked to stay in a resident's apartment to watch over them, violating privacy. Interviews with staff and residents, and record reviews did not support these allegations, resulting in an unsubstantiated finding.
Findings
After interviews with staff and residents, review of records, and facility tour, there was insufficient evidence to substantiate the allegations. Staff and residents denied the allegations, and records showed residents were receiving the services as per their care plans. Therefore, the allegations were unsubstantiated.
Report Facts
Additional monthly charge: 700
Staff interviewed: 5
Residents interviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Ramirez | Business Office Director | Met with Licensing Program Analyst during investigation and exit interview |
| Elvira Gonzalez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 266
Deficiencies: 0
Date: Jul 13, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff were charging residents for services not rendered and not providing residents with privacy.
Complaint Details
The complaint investigation was triggered by allegations that staff were charging a resident $700 monthly for additional housekeeping services not provided, and that staff were asked to stay in a resident's apartment to watch over them, violating privacy. Interviews with staff and residents, and record reviews did not support these allegations, resulting in an unsubstantiated finding.
Findings
Based on interviews with staff and residents, review of records, and observations, there was insufficient evidence to substantiate the allegations. Staff and residents denied the allegations, and records showed residents were receiving the services as per their care plans. Therefore, the allegations were unsubstantiated.
Report Facts
Additional monthly charge: 700
Staff interviewed: 5
Residents interviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvira Gonzalez | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Teresa Ramirez | Business Office Director | Met with Licensing Program Analyst during the investigation and participated in exit interview |
| Robert Stansbury | Administrator | Named as facility administrator |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 266
Deficiencies: 0
Date: Jul 12, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff were not ensuring residents' showering needs were met and were not providing adequate housekeeping services to residents.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not assisting residents with bathing needs and inadequate housekeeping services. Staff interviews denied the allegations, and residents reported satisfaction with services. Observations confirmed cleanliness and adequate care.
Findings
Based on interviews with staff and residents, observations, and records reviewed, there was insufficient evidence to substantiate the allegations regarding showering assistance and housekeeping services. The facility was found to be clean and in sanitary condition, and no deficiencies were observed during the visit.
Report Facts
Capacity: 266
Census: 90
Staff interviewed: 5
Residents interviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvira Gonzalez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Nathan Boese | Assistant Executive Director | Facility representative met during the investigation and exit interview |
| Stephanie Cifuentes | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 266
Deficiencies: 0
Date: Jul 12, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff do not provide residents with housekeeping services and that staff are not addressing pests at the facility.
Complaint Details
The complaint alleged that staff were not cleaning a resident's room and not addressing pest issues in the facility. After interviews, observations, and document reviews, the allegations were found to be unsubstantiated due to insufficient evidence.
Findings
The investigation found that the housekeeping department cleans residents' rooms weekly as per service agreements and schedules, and no evidence of pest issues was found. Interviews with residents, staff, and review of records supported that the allegations were unsubstantiated.
Report Facts
Residents interviewed: 9
Staff interviewed: 4
Rooms inspected: 6
Pest control invoices reviewed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Boese | Assistant Executive Director | Met with Licensing Program Analyst during the investigation and provided statements regarding housekeeping and pest control |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 181
Capacity: 266
Deficiencies: 1
Date: Jun 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff do not administer residents' medications as prescribed, staff dispense medications without prescriptions, and a resident wandered away due to lack of supervision.
Complaint Details
The complaint investigation was substantiated for the allegation that staff do not administer residents' medications as prescribed, specifically that medications were given late without explanation. The allegations that staff dispense medications without prescriptions and that a resident wandered away due to lack of supervision were unsubstantiated.
Findings
The investigation substantiated the allegation that staff provided medications late without documentation explaining the delays, posing a health and safety risk. The allegations that staff dispense medications without prescriptions and that a resident wandered away due to lack of supervision were unsubstantiated based on record reviews and observations.
Deficiencies (1)
Staff S2 provided residents their medication late, posing a health, safety, and personal rights risk to residents in care.
Report Facts
Residents present during inspection: 181
Total licensed capacity: 266
Residents reviewed for medication administration: 10
Residents with late medication administration: 7
Employee corrective actions: 2
Plan of Correction due date: Jul 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Teresa Ramirez | Business Office Director | Met with Licensing Program Analyst during the inspection and exit interview |
| Robert Stansbury | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 181
Capacity: 266
Deficiencies: 0
Date: Jun 29, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that the facility billed a resident for services not being provided.
Complaint Details
The complaint alleged that a resident was being charged for services not provided. The investigation reviewed physician reports, care plans, billing statements, and conducted interviews with staff and residents. One resident reported a charge for services not received, which was promptly removed by management. No evidence was found to support the allegation, resulting in an unsubstantiated finding.
Findings
The investigation found that billing statements were consistent with the level of care residents were receiving. Interviews with staff and residents indicated no evidence of residents being charged for services not provided. The allegation was unsubstantiated and no deficiencies were cited during the visit.
Report Facts
Residents interviewed: 9
Residents interviewed: 10
Residents reviewed: 3
Medication assistance frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation |
| Teresa Ramirez | Business Office Director | Met with Licensing Program Analyst during investigation and exit interview |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
| Robert Barton | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 181
Capacity: 266
Deficiencies: 0
Date: Jun 29, 2025
Visit Reason
Unannounced complaint investigation visit conducted in response to an allegation that a facility staff member forged a resident's signature to bill for a higher level of care.
Complaint Details
Allegation that a facility staff member forged a resident's signature to bill for a higher level of care. Interviews with residents and staff denied the allegation. The resident involved had passed away. Review of files showed no signatures on relevant assessments and no documentation of conservatorship or power of attorney. No corrective action documentation linked to the allegation was found.
Findings
The investigation included interviews with residents and staff, and a review of relevant files. Despite the allegation, there was no preponderance of evidence to substantiate the claim, and the allegation was determined to be unsubstantiated.
Report Facts
Facility capacity: 266
Resident census: 181
Number of residents interviewed: 10
Number of staff interviewed: 8
Care charge difference: 4500
Number of service plan assessments reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation and report |
| Teresa Ramirez | Community Business Director | Met with Licensing Program Analyst during investigation |
| Robert Barton | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 181
Capacity: 266
Deficiencies: 0
Date: Jun 29, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2023-05-05 alleging that staff did not provide authorized representative resident's records.
Complaint Details
The complaint alleged that staff did not provide copies of resident and business files upon request. Interviews with residents and staff mostly denied the allegation, and no records request documentation was found in the reviewed files. The allegation was unsubstantiated.
Findings
The investigation included interviews with residents and staff, review of resident files, and a facility tour. The allegation was found to be unsubstantiated due to lack of preponderance of evidence to prove the alleged violation occurred.
Report Facts
Capacity: 266
Census: 181
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Teresa Ramirez | Community Business Director | Met with Licensing Program Analyst during the investigation |
| Robert Barton | Administrator | Facility administrator named in the report |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 181
Capacity: 266
Deficiencies: 0
Date: Jun 22, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not assisting a resident with their care needs.
Complaint Details
The complaint alleged that staff were not assisting Resident #1, who is visually impaired, with care needs including making outpatient treatment appointments. The investigation included interviews with residents, staff, and the resident's power of attorney, and review of relevant records. The allegation was found to be unsubstantiated.
Findings
The investigation found insufficient evidence to support the allegation. Interviews with residents, staff, and the resident's power of attorney, as well as record reviews, indicated that the resident was independent in scheduling medical appointments and received appropriate care and assistance as needed. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 266
Census: 181
Number of residents interviewed: 10
Number of staff interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Roldan | Resident Service Director | Met with Licensing Program Analyst during investigation and exit interview |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 181
Capacity: 266
Deficiencies: 0
Date: Jun 22, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not prevent a resident from harming other residents in care.
Complaint Details
The complaint alleged that staff did not prevent Resident #2 from harming Resident #1. Interviews with staff, residents, and a witness, along with record reviews, found no evidence of physical assault or injury. Both residents were companions with verbal disagreements but no violence. Resident #1 had passed away in September 2023, and Resident #2 was unattainable. The allegation was unsubstantiated due to insufficient evidence.
Findings
The investigation included interviews, record reviews, and facility tour. The allegation was found to be unsubstantiated as staff and resident interviews, as well as record reviews, showed no evidence of physical assault or injury between the residents involved. The facility was found to be well-supervised with adequate staffing and surveillance.
Report Facts
Capacity: 266
Census: 181
Medications with side effects: 11
Total prescribed medications: 14
Staff interviewed: 6
Residents interviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Roldan | Resident Service Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 181
Capacity: 266
Deficiencies: 0
Date: Jun 22, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 10/04/2021 regarding inadequate staff services and facility disrepair.
Complaint Details
The complaint alleged that staff were not providing adequate services and that the facility was in disrepair. The investigation included observations, record reviews, and interviews with staff and residents. Despite the allegations, no violations were found and the complaint was unsubstantiated.
Findings
The investigation found no evidence to support the allegations. Staff levels were adequate to meet resident needs, and the facility was observed to be clean and in good repair. Interviews with staff and residents confirmed these findings, resulting in the allegations being unsubstantiated.
Report Facts
Caregivers on AM shift: 7
Medication Technicians on AM shift: 4
Caregivers on PM shift: 6
Medication Technicians on PM shift: 3
Caregivers on Night shift: 4
Medication Technicians on Night shift: 2
Residents interviewed: 10
Staff interviewed: 5
Work order completion timeframe: 24
Maximum repair timeframe: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit and report |
| Stephanie Roldan | Resident Service Director | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Robert Barton | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 181
Capacity: 266
Deficiencies: 0
Date: Jun 22, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that the facility was without an administrator.
Complaint Details
The complaint alleged that the facility was without an administrator since April 2022. The investigation included interviews with staff and residents, and review of administrator documentation. The allegation was found unsubstantiated as evidence showed the facility had an administrator during the investigation.
Findings
The investigation found that although the former administrator left in April 2022, the facility currently has an administrator covering the role. Interviews with staff and residents confirmed the presence of an administrator, and no deficiencies were observed or cited. The allegation was unsubstantiated due to lack of evidence.
Report Facts
Facility capacity: 266
Resident census: 181
Staff interviewed: 5
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation |
| Stephanie Roland | Resident Service Director | Met with Licensing Program Analyst during the visit and exit interview |
| Robert Barton | Administrator | Named as the facility administrator in the report |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 169
Capacity: 266
Deficiencies: 0
Date: May 8, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-04-29 regarding staff actions and resident care at the facility.
Complaint Details
The complaint included allegations that staff did not allow a resident to make or receive phone calls, failed to seek timely medical attention, a resident developed a pressure injury, personal property was not secured, and staff engaged in inappropriate conversations. The investigation found that the resident in question never resided at the facility, and all allegations were unfounded.
Findings
Based on record review and interviews conducted, all allegations were found to be unfounded, meaning the complaint was false, could not have happened, or was without reasonable basis.
Report Facts
Capacity: 266
Census: 169
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Palacios | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Monique Moreira | Executive Director | Met with Licensing Program Analyst during the investigation and provided information |
| Robert Stansbury | Administrator | Named as facility administrator |
| Rikesha Stamps | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 266
Deficiencies: 0
Date: Apr 27, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that a resident was being held at the facility against their will.
Complaint Details
The complaint alleged that a resident (R#1) was held against their will at the facility. The investigation found that (R#1) had a Durable Power of Attorney designating (W#1) as decision-maker, and multiple interviews confirmed the resident was not held against their will. The allegation was unsubstantiated.
Findings
The investigation included interviews with staff, residents, witnesses, and review of relevant documents including Durable Power of Attorney and admission agreements. The evidence did not support the allegation, and the complaint was found to be unsubstantiated.
Report Facts
Capacity: 266
Census: 70
Number of staff interviewed: 4
Number of residents interviewed: 8
Number of witnesses interviewed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Stephanie Roldan | Resident Services Director | Met with Licensing Program Analyst during investigation and received the complaint report |
| Robert Barton | Administrator | Provided interview and information regarding the resident and facility |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 266
Deficiencies: 0
Date: Apr 27, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations regarding staff mismanaging residents' medications, not ensuring residents are showered, and not meeting residents' diapering needs.
Complaint Details
The complaint investigation was triggered by allegations that staff mismanaged medications for residents #1-#4, failed to ensure residents were showered regularly, and did not meet residents' diapering needs due to staffing shortages. After interviews with staff, residents, family representatives, hospice representatives, and review of records, the allegations were found unsubstantiated due to lack of evidence.
Findings
The investigation included interviews, record reviews, and facility tours. The Department found no sufficient evidence to support the allegations. Staff and residents consistently denied the allegations, and documentation and observations supported proper medication management, personal care, and incontinence care. The allegations were determined unsubstantiated.
Report Facts
Staff per shift: 16
Staff per shift: 12
Staff per shift: 13
Staff per shift: 2
Resident interviews: 7
Staff interviews: 6
Witness interviews: 7
Family representatives interviewed: 4
Hospice representatives interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Roldan | Resident Services Director | Met with Licensing Program Analyst during the investigation and participated in exit interview |
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 266
Deficiencies: 0
Date: Apr 26, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-07-17 alleging overcharging residents, failure to prevent wandering, failure to keep the facility free from scabies, and unlawful eviction of residents.
Complaint Details
The complaint alleged that staff overcharged residents (R#1 and R#2) for services not received, failed to prevent residents from wandering, did not keep the facility free from scabies, and unlawfully evicted residents. The investigation found no evidence to substantiate these allegations. Interviews with staff, residents, and review of records including admissions agreements, physicians reports, incident reports, and infection control plans supported the unsubstantiated findings.
Findings
The investigation included interviews with staff, residents, and review of records. The allegations were found to be unsubstantiated as there was insufficient evidence to support claims of overcharging, wandering, scabies infection, or unlawful eviction. Staff and residents consistently denied the allegations, and records supported these findings.
Report Facts
Capacity: 266
Census: 70
Number of allegations: 4
Number of residents interviewed: 9
Number of staff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Boese | Assistant Executive Director | Met with Licensing Program Analyst during the investigation and received a copy of the complaint report |
| Robert Stansbury | Administrator | Interviewed regarding allegations and facility practices |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 266
Deficiencies: 0
Date: Apr 26, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations that staff were not providing adequate food service to residents, including claims of staff licking their fingers and touching food served to residents.
Complaint Details
The complaint alleged inadequate food service by staff, specifically that staff were licking their fingers and touching food served to residents. Interviews with six staff members, eight residents, and four family representatives found no corroboration of these claims. Observations during the inspection confirmed proper food handling and safety practices. The allegation was unsubstantiated due to insufficient evidence.
Findings
The investigation included interviews with staff, residents, and witnesses, a review of records, and a facility tour. No evidence was found to substantiate the allegations, and all interviewed parties denied any misconduct or issues with food service. The allegation was determined to be unsubstantiated.
Report Facts
Staff interviewed: 6
Residents interviewed: 8
Witnesses interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Nathan Boese | Assistant Executive Director | Met with Licensing Program Analyst during inspection and exit interview |
| Claudia Herrera | Assistant Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 168
Capacity: 266
Deficiencies: 0
Date: Nov 1, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that staff threatened a resident and conducted an illegal eviction.
Complaint Details
The complaint alleged staff threatened a resident during an eviction process and that an illegal eviction occurred. The investigation included interviews with residents and staff, file reviews, and observations. The threat allegation was unsubstantiated, and the illegal eviction allegation was unfounded.
Findings
The investigation found the allegation that staff threatened a resident was unsubstantiated due to lack of evidence. The allegation of illegal eviction was found to be unfounded as the resident was still residing at the facility and had paid their balance, with the unlawful detainer dismissed.
Report Facts
Capacity: 266
Census: 168
Eviction notice date: Feb 2, 2024
Eviction effective date: Mar 1, 2024
Unlawful Detainer served date: May 14, 2024
Staff interviews conducted: 4
Resident interviews conducted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janira Arreola | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Robert Stansbury | Administrator | Facility administrator named in the report |
| Claudia Herrera | Executive Assistant | Met with Licensing Program Analyst during the investigation |
| Monique Moreia | Executive Director | Spoke with Licensing Program Analyst by phone during the investigation |
| S1 | Staff member alleged to have threatened Resident #1, denied allegations |
Inspection Report
Annual Inspection
Census: 168
Capacity: 266
Deficiencies: 0
Date: Sep 16, 2024
Visit Reason
The inspection was an unannounced one-year required visit to evaluate compliance with licensing regulations and facility standards.
Findings
The inspection found no immediate violations or concerns. The facility was observed to be well-maintained with proper safety measures, sufficient supplies, and compliance with infection control and staff credentialing requirements.
Report Facts
Perishable food supply duration: 2
Non-perishable food supply duration: 7
Water temperature: 113.5
Facility temperature: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monique Moreria | Executive Director | Met with during inspection and provided information about the facility |
| Valerie Flores | Licensing Program Analyst | Conducted the inspection |
| Abdoulaye Zerbo | Licensing Program Analyst | Conducted the inspection |
| Rikesha Stamps | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 163
Capacity: 266
Deficiencies: 0
Date: Jul 25, 2024
Visit Reason
An unannounced complaint investigation was conducted to investigate the allegation that staff were denying authorized representative access to the facility.
Complaint Details
The complaint alleged that staff denied access to Resident 1 and Resident 2's Power of Attorney agents. The investigation revealed no POA forms on file, residents were self-responsible, and family members became hostile over a billing dispute, resulting in trespass orders issued by law enforcement. The complaint was determined to be unfounded.
Findings
The investigation found that the allegation was unfounded. The Licensing Program Analyst reviewed records and interviewed staff and a resident witness, concluding that the complaint was false and without reasonable basis.
Report Facts
Trespass Arrest Authorizations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janette Romero | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Monique Moreira | Administrator | Interviewed during investigation and involved in incident with family members |
| Tricia Danielson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 168
Capacity: 266
Deficiencies: 0
Date: Oct 6, 2023
Visit Reason
The visit was an unannounced case management visit conducted in conjunction with complaint 18-AS-20231003091855 to check on the health, safety, and welfare of residents in care.
Complaint Details
The visit was related to complaint 18-AS-20231003091855; no deficiencies were cited, indicating no substantiated issues during this visit.
Findings
During the visit, no health or safety hazards were observed, and no deficiencies were cited. Staff and residents were interviewed, and resident #2's file was reviewed.
Report Facts
Capacity: 266
Census: 168
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chinwe Nwogene | Licensing Program Analyst | Conducted the case management visit and inspection |
| April Princesa | Assistant Executive Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 159
Capacity: 266
Deficiencies: 0
Date: Sep 18, 2023
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that residents were being illegally evicted from the facility.
Complaint Details
The complaint alleged that residents were being illegally evicted. The allegation was unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found insufficient evidence to substantiate the allegation of illegal eviction. Interviews with staff and a resident, as well as a review of the resident's file, indicated that the resident was issued a 30-day eviction notice due to an unstageable pressure wound and need for a higher level of care, but the eviction was not deemed illegal.
Report Facts
Capacity: 266
Census: 159
Eviction notice period: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chinwe Nwogene | Licensing Program Analyst | Conducted the complaint investigation |
| Robert Stansbury | Senior Executive Director | Met with investigator during the visit |
| April Princesa | Assistant Executive Director | Met with investigator during the visit |
Inspection Report
Annual Inspection
Census: 159
Capacity: 266
Deficiencies: 0
Date: Sep 13, 2023
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate the facility's compliance with regulatory requirements.
Findings
The facility was found to be clean, well-maintained, and in good repair with no deficiencies observed. Food service, physical plant, safety, infection control, medication management, and fire safety were all compliant with regulations.
Report Facts
Staff present: 96
Records reviewed: 5
Employee records reviewed: 5
Food supply: 1
Food supply: 2
Water temperature: 108
Facility temperature: 78
Fire inspection date: Mar 14, 2023
Fire extinguisher service date: Mar 14, 2023
Deficiencies observed: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Stansbury | Senior Resident Director | Met with Licensing Program Analyst and completed facility tour |
| April Princesa | Assistant Executive Director | Conducted the facility tour during inspection |
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the annual inspection |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 157
Capacity: 266
Deficiencies: 0
Date: May 12, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to multiple allegations received on 2023-04-18 regarding resident care, eviction, care plan adherence, bullying, and staff response times.
Complaint Details
The complaint investigation addressed allegations including failure to notify responsible party of condition changes, illegal eviction, non-adherence to authorized care plan, bullying of resident, and delayed staff response to calls. All allegations were found to be unfounded or unsubstantiated after interviews and record reviews.
Findings
The investigation found all allegations to be either unfounded or unsubstantiated. Specifically, the facility staff did notify the resident directly of condition changes, no eviction notice was served, care plans were followed as the resident is responsible for themselves, no bullying occurred, and staff response times to call buttons were reported as timely by residents.
Report Facts
Residents interviewed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Danielson | Licensing Program Analyst | Conducted the complaint investigation |
| Janette Romero | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Robert Stansbury | Executive Director | Met with investigators during the complaint investigation |
| April Princessa | Assistant Executive Director | Met with investigators during the complaint investigation |
| Jazmond D Harris | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 211
Capacity: 266
Deficiencies: 0
Date: Jan 23, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 07/24/2020 regarding resident medication theft and staff neglect resulting in a resident fall.
Complaint Details
The complaint involved two allegations: 1) Resident medication was stolen, and 2) Staff neglect resulted in resident falling and sustaining unknown injury. Both allegations were investigated and found to be unsubstantiated.
Findings
The investigation found that the resident medication theft allegation was resolved and the resident was self-responsible for medication administration. The staff neglect allegation related to a resident fall was confirmed to have been properly handled with emergency services called. Both allegations were deemed unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited during the visit.
Report Facts
Complaint control number: 18-AS-20200724114424
Facility capacity: 266
Census: 211
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Gardner | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Yorlenis Cota | Billing Director | Met with Licensing Program Analyst during the visit and received report |
| Robert Barton | Administrator | Facility Administrator named in the report |
Inspection Report
Census: 144
Capacity: 266
Deficiencies: 0
Date: Nov 17, 2022
Visit Reason
The visit was an unannounced Case Management Health and Safety visit conducted to assess the facility's compliance and overall safety conditions.
Findings
No imminent health or safety concerns were observed during the visit. The facility had sufficient staff, adequate food and medication supplies, and residents in independent care units received three status checks per day.
Report Facts
Facility staff count: 80
Resident status checks: 3
Food supply duration: 2
Food supply duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Tucker | Senior Executive Director | Met with Licensing Program Analyst and provided information during the visit |
| Venus Mixson | Licensing Program Analyst | Conducted the Case Management Health and Safety visit |
| Jazmond D Harris | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 143
Capacity: 266
Deficiencies: 0
Date: Sep 23, 2022
Visit Reason
The Licensing Program Analyst arrived unannounced to complete the facility's Annual Inspection, focusing on infection control and the facility's Mitigation Plan related to COVID-19.
Findings
The inspection confirmed that infection control practices were being observed, including availability of hand sanitizer, PPE supplies sufficient for 30 days, staff training on COVID-19 protocols, and ongoing screening of residents, staff, and visitors for COVID-19 symptoms.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Tucker | Administrator/Executive Director | Met with Licensing Program Analyst and confirmed infection control practices and staff training. |
| Tammy Eddy | Business Office Manager | Participated in exit interview and received a copy of the report. |
| Crystal Colvin | Licensing Program Analyst | Conducted the annual inspection and infection control review. |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 266
Deficiencies: 0
Date: Jul 14, 2022
Visit Reason
The inspection visit was an unannounced complaint investigation into an allegation of physical abuse of a resident at the facility.
Complaint Details
The complaint alleged physical abuse of a resident. The allegation was found to be unsubstantiated after investigation, as there was insufficient evidence to prove the violation occurred.
Findings
The investigation found that the resident had bruises which did not require medical attention and no discomfort was expressed. Interviews with staff and witnesses revealed no abuse was observed or reported. The injuries may have occurred during transferring the resident. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Number of individuals interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Danielson | Licensing Program Analyst | Conducted the complaint investigation |
| Mariana Torres | Assistant Business Office Manager | Met with investigator during the visit and participated in exit interview |
| Robert Barton | Administrator | Named as facility administrator |
| Deborah Mullen | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 148
Capacity: 266
Deficiencies: 2
Date: May 10, 2022
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by allegations that the facility neglected a resident by not seeking medical attention in a timely manner and did not follow the resident's care plan.
Complaint Details
The complaint investigation was substantiated. The allegations included neglect by not seeking timely medical attention and failure to follow the resident's care plan. The investigation found evidence supporting these allegations.
Findings
The investigation substantiated that Resident #1 experienced a fall on July 18, 2020, but was not sent to the hospital until the following day, resulting in a hip fracture requiring surgery. Additionally, the facility failed to provide escorting services as required by the resident's care plan, which contributed to the fall.
Deficiencies (2)
The licensee did not ensure 9-1-1 was called immediately following Resident #1's fall on 7/18/2020, resulting in delayed medical evaluation and a hip fracture requiring surgery.
The licensee did not ensure Resident #1 was provided proper care and supervision during ambulation following a visit, failing to provide escorting services as required by the care plan.
Report Facts
Capacity: 266
Census: 148
Deficiencies cited: 2
Plan of Correction Due Date: May 11, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Danielson | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sarah Wolfe | Community Business Director | Met with Licensing Program Analyst during the investigation |
| Robert Barton | Administrator | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 266
Deficiencies: 0
Date: Apr 19, 2022
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations that a resident sustained injuries due to neglect and that staff did not respond to the resident's call button in a timely manner.
Complaint Details
The complaint involved two allegations: 1) Resident sustained injuries while in care due to neglect, and 2) Staff did not respond to resident's call button in a timely manner. Both allegations were investigated and found unsubstantiated due to insufficient evidence.
Findings
Both allegations were found to be unsubstantiated. The resident's fall was unwitnessed but staff responded appropriately and completed required status checks. Conflicting information and lack of evidence prevented substantiation of delayed staff response to call button.
Report Facts
Capacity: 266
Census: 141
Call response times: 3
Call response time: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Crystal Colvin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Monique Moreira | Assistant Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Joel Esquivel | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 266
Deficiencies: 0
Date: Nov 3, 2021
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that staff did not prevent scabies from spreading.
Complaint Details
The complaint alleged that staff did not prevent scabies from spreading. The investigation found that although some residents had symptoms, these were unrelated to the alleged incident, and no scabies were reported during status checks on 10/21/2021. Therefore, the allegation was unsubstantiated.
Findings
The investigation included interviews with residents and staff and a review of records. The allegation was found to be unsubstantiated as there was no preponderance of evidence that the alleged violation occurred.
Report Facts
Capacity: 266
Census: 158
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Crystal Colvin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Robert Barton | Administrator | Facility administrator met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 155
Capacity: 266
Deficiencies: 0
Date: Oct 25, 2021
Visit Reason
An unannounced complaint investigation was conducted based on allegations that residents were not provided with properly washed linens as needed and that facility surfaces were not properly sanitized by staff.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found both allegations to be unsubstantiated. Interviews and observations confirmed that linens were properly washed and provided as needed, and that facility surfaces were cleaned daily with approved sanitizing chemicals, with no concerns noted.
Report Facts
Capacity: 266
Census: 155
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Barton | Administrator | Met with during investigation and exit interview |
| Crystal Colvin | Licensing Program Analyst | Conducted the complaint investigation |
| Joel Esquivel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 154
Capacity: 266
Deficiencies: 0
Date: Oct 18, 2021
Visit Reason
This case management visit was conducted to address possible additional information regarding a prior complaint investigation (control number 18-AS-20200602112630).
Complaint Details
The visit was related to complaint investigation control number 18-AS-20200602112630. The Licensing Program Analyst concluded that the additional information reviewed did not change the outcome of the investigation findings.
Findings
Based on further record review and interview with the Executive Director, the Licensing Program Analyst found that the review of the information will not change the outcome of the delivered findings of the prior complaint investigation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Barton | Executive Director | Met with Licensing Program Analyst during the visit and discussed hygiene assistance and documentation procedures. |
| Amy Goldenberg | Licensing Program Analyst | Conducted the case management visit and reviewed records. |
| Nedra Brown | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 153
Capacity: 266
Deficiencies: 0
Date: Sep 15, 2021
Visit Reason
An unannounced annual inspection was conducted with an emphasis on infection control to evaluate the facility's compliance with Community Care Licensing guidelines.
Findings
The inspection found incomplete proper signage, minimum hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. The facility has an infection control lead and plans in place for COVID-19 testing, isolation, and monitoring. No deficiencies were cited.
Report Facts
Staff present: 56
Residents fully vaccinated: 151
Staff fully vaccinated percentage: 100
COVID-19 cases: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Barton | Administrator | Met with Licensing Program Analyst during inspection |
| Yolanda Delgado | Licensing Program Analyst | Conducted the inspection |
| Efren Malagon | Licensing Program Manager | Named in report header |
Inspection Report
Capacity: 266
Deficiencies: 0
Date: Jul 2, 2021
Visit Reason
A case management visit was conducted to deliver an amended complaint investigation report regarding complaint number 18-AS-20200602112630.
Complaint Details
The visit was related to complaint number 18-AS-20200602112630. The report was amended and delivered during this visit.
Findings
The amended complaint investigation report was reviewed with and provided to the Assistant Executive Director. Nothing further was needed at the time of the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pauline Beschorner | Licensing Program Analyst | Conducted the case management visit and delivered the amended complaint investigation report. |
| Robert Barton | Administrator | Met with Licensing Program Analyst during the visit. |
| Victoria Mata | Assistant Executive Director | Received and reviewed the amended complaint investigation report. |
Inspection Report
Complaint Investigation
Capacity: 266
Deficiencies: 0
Date: Jul 2, 2021
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that, due to neglect, a resident sustained a fall resulting in a broken arm.
Complaint Details
The complaint alleged neglect resulting in a resident's fall causing a broken arm. The investigation included interviews with staff and review of resident records. The resident was found on the floor with a chin laceration but no broken arm, as corroborated by the resident's responsible party. The allegation was determined to be unfounded.
Findings
Based on interviews and record review, the allegation was found to be unfounded, meaning the allegations were false, could not have happened, and/or were without a reasonable basis.
Report Facts
Facility capacity: 266
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pauline Beschorner | Licensing Program Analyst | Conducted the complaint investigation visit |
| Victoria Mata | Assistant Executive Director | Interviewed during the investigation and received report and appeal rights |
| Robert Barton | Administrator | Named as facility administrator |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 132
Capacity: 266
Deficiencies: 0
Date: Jun 25, 2021
Visit Reason
This was an unannounced complaint investigation visit conducted in response to allegations including neglect, lack of required emergency call button, and failure to follow a resident's doctor's orders.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff interviews and record reviews indicated that the resident received appropriate care, call button was maintained within reach, and doctor's orders were generally followed despite some resident refusals.
Report Facts
Capacity: 266
Census: 132
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pauline Beschorner | Licensing Program Analyst | Conducted the complaint investigation |
| Victoria Mata | Assistant Executive Director | Met with Licensing Program Analyst during investigation |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
| Robert Barton | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 266
Deficiencies: 0
Date: Jun 18, 2021
Visit Reason
An unannounced visit was conducted to investigate complaints alleging psychological abuse by facility staff, failure to administer medications as ordered, and lack of assistance with activities of daily living (ADLs).
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or were without reasonable basis.
Findings
The investigation found that the allegations were unfounded. Resident 1 was verbally and physically abusive to staff, medication administration records showed medications were given as ordered, and Resident 1 was independent with ADLs and did not require assistance.
Report Facts
Capacity: 266
Census: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shaunte Henry | Licensing Program Analyst | Conducted the complaint investigation |
| Nedra Brown | Licensing Program Manager | Named in report as Licensing Program Manager |
| Manny Salazar | Resident Services Coordinator | Met with during investigation |
| Theresa Ramirez | Activities Director | Met with during investigation |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 266
Deficiencies: 1
Date: Jun 10, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that facility staff handled a resident roughly causing bruising and that staff spoke inappropriately to a resident.
Complaint Details
The complaint investigation was triggered by allegations received on 03/27/2020. One allegation regarding rough handling causing bruising was unsubstantiated. Another allegation regarding inappropriate speech by staff to a resident was substantiated.
Findings
The investigation found the allegation of rough handling causing bruising to be unsubstantiated, as there was no evidence staff caused the resident to fall. However, the allegation that staff spoke inappropriately to a resident was substantiated, posing a potential risk to residents in care.
Deficiencies (1)
Failure to ensure that resident R2 was accorded dignity in their personal relationship with staff S2, as evidenced by an inappropriate comment made by staff to the resident.
Report Facts
Capacity: 266
Census: 126
Plan of Correction Due Date: Jun 18, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Gayoso | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Tara Gonzalez | Resident Services Director | Met with Licensing Program Analyst during the investigation |
| Robert Barton | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 266
Deficiencies: 0
Date: Jun 10, 2021
Visit Reason
An unannounced case management visit was conducted to deliver findings related to complaint number 18-AS-20200327111832.
Complaint Details
Visit was related to complaint number 18-AS-20200327111832; no substantiation status stated.
Findings
Licensing Program Analysts Natalie Gayoso and Anna Bueno met with Tara Gonzalez, Resident Services Director, and conducted an exit interview. A copy of the report was provided to the facility representative.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Gonzalez | Resident Services Director | Met with Licensing Program Analysts during the visit and exit interview. |
| Natalie Gayoso | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Anna Bueno | Licensing Program Analyst | Conducted the unannounced case management visit and signed the report. |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 266
Deficiencies: 0
Date: Mar 2, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of unlawful eviction received on 2021-02-04.
Complaint Details
The complaint alleged unlawful eviction of Resident #1. The complaint was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
Findings
The investigation found that the allegation of unlawful eviction was unfounded. Records showed that the resident had signed an admission agreement with house rules and had violated these rules multiple times. The facility provided reminders after each violation, and the complaint was determined to be without reasonable basis.
Report Facts
Complaint control number: 18
Capacity: 266
Census: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Danielson | Licensing Program Analyst | Conducted the complaint investigation and contacted the facility |
| Robert Barton | Executive Director | Facility representative met during investigation |
| Reyna Lacey | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 139
Capacity: 266
Deficiencies: 0
Date: Feb 11, 2021
Visit Reason
The visit was a case management call conducted via telephone to confirm the removal of an individual named William Winegar, who was previously the subject of an Immediate Action Required letter regarding employment at the facility.
Findings
The Community Business Director confirmed that William Winegar was never hired, is not present, employed, or residing at the facility, and the facility did not request an exemption for him. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Danielson | Licensing Program Analyst | Conducted the case management visit and verification of removal. |
| Sarah Wolfe | Community Business Director | Facility representative who provided information during the visit. |
| Robert Barton | Administrator | Named as facility administrator. |
Inspection Report
Census: 158
Capacity: 266
Deficiencies: 0
Date: Dec 7, 2020
Visit Reason
The visit was a case management telephone call conducted due to COVID-19 precautionary measures and to verify the removal of an individual named Alexander Burmudez from employment at the facility following an Immediate Action Required letter.
Findings
No deficiencies were cited during this visit. Verification confirmed that the individual named in the Immediate Action Required letter was no longer present, employed, or residing at the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Wolfe | Community Business Director | Met with during the case management visit and provided information about the removal of the employee. |
| Tricia Danielson | Licensing Program Analyst | Conducted the case management visit and verified removal of the individual. |
| Reyna Lacey | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 266
Deficiencies: 0
Date: Dec 7, 2020
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that facility staff were not properly trained, specifically regarding the lifting of a resident who suffered bruising.
Complaint Details
The complaint alleged that Resident #1 suffered bruising due to staff not being properly trained to lift them. The complaint was found to be unfounded, meaning the allegation was false or without reasonable basis.
Findings
The investigation found that the complaint was unfounded. Staff training records and interviews confirmed proper training in lifting and transferring residents, and observations by hospice staff showed no issues with resident handling.
Report Facts
Capacity: 266
Census: 158
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Danielson | Licensing Program Analyst | Conducted the complaint investigation |
| Cheree Escandel | Assistant Executive Director | Facility representative interviewed during the investigation |
| Robert Barton | Administrator | Facility administrator named in the report |
Inspection Report
Capacity: 266
Deficiencies: 0
Date: Nov 16, 2020
Visit Reason
The visit was a case management telephone call conducted due to COVID-19 to verify that an individual named in a Confirmation of Removal letter was not present, employed, or residing at the facility.
Findings
The Licensing Program Analyst verified that the individual named in the Confirmation of Removal letter was not present, employed, or residing at the facility. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Wiggins | Licensing Program Analyst | Conducted the case management visit and verified removal of individual. |
| Sarah Woofe | Community Business Director | Spoke with Licensing Program Analyst during the visit and provided information about the individual. |
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