Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, reflecting generally good compliance with regulations. The most recent report from July 25, 2025, related to a resident’s suicide, found no deficiencies connected to the incident. Some earlier reports identified isolated issues, including failure to update care plans after significant changes in condition, not submitting policy changes for approval regarding feeding assistance, and delays in providing resident records to authorized representatives. There were no fines or license actions listed in the available reports, and no immediate jeopardy findings beyond the isolated elopement incident in 2022. Overall, the facility’s recent inspections show improvement, with the latest annual inspection in April 2025 citing no deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
1.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
63% occupied
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 131
Capacity: 207
Deficiencies: 0
Date: Jul 25, 2025
Visit Reason
The inspection was conducted as an unannounced subsequent Case Management – Incident visit following a self-reported incident and subsequent incident death report regarding Resident #1 involving a fall and discovery of a firearm on 05/11/2025.
Complaint Details
The visit was complaint-related due to a self-reported incident and death involving Resident #1. The complaint was investigated through interviews, file reviews, physical plant tours, and police report review. The complaint was substantiated as the cause of death was suicide with no foul play.
Findings
The investigation found that Resident #1 was highly independent with no history of suicidal ideation and no indication of possessing a firearm. Police reported no evidence of foul play or suspicious activity, and the cause of death was ruled as suicide. No deficiencies were cited related to this incident.
Report Facts
Facility capacity: 207
Resident census: 131
Incident dates: 2
Staff interviewed: 6
Resident interviews conducted: 2
Resident interviews attempted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Remon Pagels | Executive Director | Met with during inspection and provided information about Resident #1 |
| Erica Mosley | Licensing Program Analyst | Conducted the unannounced subsequent Case Management – Incident visit and investigation |
| Kelly Dulek | Licensing Program Analyst | Assisted in conducting the initial and subsequent unannounced visits |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 207
Deficiencies: 0
Date: Jun 4, 2025
Visit Reason
The visit was an unannounced Case Management - Incident inspection triggered by a self-reported incident and subsequent incident death report regarding Resident #1 on 05/12/2025 and 05/13/2025.
Complaint Details
The visit was complaint-related based on a self-reported incident and incident death report concerning Resident #1. No substantiation status is provided in the report.
Findings
During the visit, Licensing Program Analysts conducted a physical plant tour to ensure no immediate health and safety concerns, interviewed the Executive Director, six staff members, and two residents, and reviewed pertinent documents related to the incident. Further investigation may be conducted if needed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Remon Pagels | Executive Director | Met with Licensing Program Analysts during the inspection and explained the reason for the visit. |
| Erica Mosley | Licensing Program Analyst | Conducted the inspection visit. |
| Kelly Dulek | Licensing Program Analyst | Conducted the inspection visit. |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 207
Deficiencies: 1
Date: May 22, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff are not assisting residents with feeding, specifically concerning residents in the memory care unit receiving hospice care.
Complaint Details
The complaint alleged that staff are not assisting residents with feeding. The allegation was substantiated based on interviews, record reviews, and policy analysis. It was found that staff are prohibited from feeding residents, and the facility's policies and Admission Agreement were not approved by the licensing agency. The facility delegates feeding assistance to private caregivers and family members, which is against policy and regulations.
Findings
The investigation substantiated that the facility staff do not assist residents with feeding as per facility policy, which requires residents to feed themselves or have private caregivers assist. The facility changed its Admission Agreement and policies without approval from the licensing agency, delegating feeding assistance to private aides or family members contrary to Title 22 regulations.
Deficiencies (1)
Failure to maintain a current, written definitive plan of operation and submit significant changes affecting resident services to the licensing agency for approval.
Report Facts
Capacity: 207
Census: 125
Plan of Correction Due Date: Jun 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Remon Pagels | Executive Director | Met with during investigation and provided information about facility policies |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 207
Deficiencies: 1
Date: May 22, 2025
Visit Reason
The inspection was a case management visit to continue the investigation into a self-reported incident/death involving a resident who died by suicide on 12/15/2024.
Complaint Details
The visit was complaint-related, investigating a self-reported incident/death report involving a resident who died by suicide. The investigation included review of medical records, interviews with staff and family, and review of facility policies.
Findings
The investigation found that the resident had a change in condition including hospitalization, UTI, catheter insertion, medication changes, and increased anxiety/depression, but the facility failed to conduct a required reappraisal or update the care plan. The facility did not complete a reassessment or obtain a new physician's report following the change in condition. The investigation did not find sufficient evidence that lack of care or supervision led to the resident's death.
Deficiencies (1)
Failure to conduct a reappraisal following a significant change in condition including hospitalization, UTI, catheter, medication change, and increased anxiety/depression, which posed a potential health risk to persons in care.
Report Facts
Capacity: 207
Census: 125
Plan of Correction Due Date: Jun 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Remon Pagels | Executive Director | Met with Licensing Program Analyst during the visit and interviewed regarding the incident |
| Kelly Dulek | Licensing Program Analyst | Conducted the case management visit and investigation |
| Dennis Douglas | Investigator | Investigator assigned to the death investigation and conducted interviews and record reviews |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 207
Deficiencies: 0
Date: May 13, 2025
Visit Reason
The visit was conducted as an unannounced Case Management - Incident inspection following receipt of a self-reported incident and subsequent incident death report regarding Resident #1 on 05/12/2025 and 05/13/2025.
Complaint Details
The visit was triggered by a complaint incident involving Resident #1, with a referral made to the Community Care Licensing Division's Investigation Branch. The report does not state substantiation status.
Findings
During the visit, Licensing Program Analysts conducted a physical plant tour to ensure no immediate health and safety concerns, interviewed the Executive Director, reviewed Resident #1's file, and obtained pertinent documents related to the incident. Further investigation may be conducted if needed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Remon Pagels | Executive Director | Met with Licensing Program Analysts during the inspection and involved in the incident file review. |
| Erica Mosley | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 126
Capacity: 207
Deficiencies: 0
Date: Apr 24, 2025
Visit Reason
The Licensing Program Analyst conducted an unannounced required annual visit to evaluate the facility's compliance with Title 22 Regulations and ensure health and safety standards are met.
Findings
The facility was found to be in compliance with regulations, with no deficiencies cited. Observations included proper operation of elevators, functional fire safety equipment, well-maintained resident rooms, stocked restrooms, and compliant medication storage. Infection control and emergency disaster plans were up to date, and emergency drills were conducted as required.
Report Facts
Resident rooms toured: 12
Residents interviewed: 6
Staff interviewed: 3
Resident files reviewed: 5
Staff files reviewed: 5
Resident medications reviewed: 2
Water temperature range: 107.7 to 115.2
Last fire extinguisher service date: Jan 6, 2025
Last fire suppression system annual inspection: Jun 6, 2024
Last fire and life safety inspection: Jul 23, 2024
Last emergency disaster drill: Mar 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the annual inspection and authored the report |
| Remon Pagels | Executive Director | Met with Licensing Program Analyst during inspection |
| Hector Arjon | Maintenance Director | Accompanied Licensing Program Analyst during physical plant tour |
| Eden Tolentino | Administrator/Director | Facility Administrator named in report header |
Inspection Report
Complaint Investigation
Capacity: 207
Deficiencies: 0
Date: Apr 7, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-05-29 concerning resident confinement, financial safeguarding, attempted poisoning, and medication mismanagement at the facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included resident confinement by staff, failure to safeguard resident's funds, attempted poisoning, and medication mismanagement. Interviews and record reviews revealed no violations or supporting evidence for these claims.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Staff and residents denied mistreatment or confinement, no financial abuse was found, and medication refusal by the resident was documented with no evidence of staff mismanagement or poisoning attempts.
Report Facts
Capacity: 207
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted investigation and authored report |
| Desaree Perera | Licensing Program Manager | Oversaw complaint investigation |
| Adam Syncheff | Administrator | Facility administrator during investigation |
| Gudalupe Ambriz | Community Business Director | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 207
Deficiencies: 0
Date: Mar 27, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-05-15 regarding allegations that the licensee did not issue an accurate refund and that staff did not provide care services as agreed upon.
Complaint Details
The complaint involved two allegations: 1) the facility failed to issue an accurate refund related to a New Resident Service Fee of $2,895.00, and 2) staff did not provide two-person transfer assistance as agreed upon. The investigation included interviews with residents, visitors, facility staff, and Resident 1's representative, as well as document reviews. Both allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that the facility issued an accurate refund to Resident 1 according to the admission agreement, and the allegation regarding the refund was unsubstantiated. Regarding care services, although Resident 1's representative reported staff dropped the resident during transfers and that two-person transfer assistance was not provided, there was insufficient evidence to prove the facility failed to provide care as stipulated, and the allegation was unsubstantiated.
Report Facts
New Resident Service Fee: 2895
Refund amount: 978.8
Capacity: 207
Census: 122
Care hours per week: 17.5
Late Fee: 120.38
Pro-rated rent: 309.47
December Level 5 Care: 350.14
December Med Level 1 Care: 57.21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the complaint investigation and issued final findings |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation |
| Adam Syncheff | Administrator | Facility administrator named in the report |
| Remon Pagels | Executive Director | Met with Licensing Program Analyst during initial complaint visit |
| Erika Miller | Licensing Program Analyst | Conducted additional document review and interviews |
| Gudalupe Ambriz | Community Business Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 207
Deficiencies: 1
Date: Nov 18, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not provide a resident's records to an authorized representative.
Complaint Details
The complaint was substantiated. The allegation was that staff did not provide resident's records to the authorized representative despite multiple requests from 3/22/2024 to 6/28/2024. Staff #2 confirmed the records request was forwarded to the Legal Department and records were eventually provided on 6/28/2024.
Findings
The allegation that staff failed to provide resident R1's records to the authorized records company for over two months was substantiated based on interviews and records review. The facility was found to have delayed providing records despite multiple requests.
Deficiencies (1)
Failure to provide resident's records promptly to authorized representative as required by regulation 87468.2(a)(19).
Report Facts
Deficiency Plan of Correction Due Date: Nov 22, 2024
Facility Capacity: 207
Facility Census: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Remon Pagels | Executive Director | Met with the investigator during the visit and acknowledged the findings |
| Adam Syncheff | Administrator | Named as facility administrator in report header |
| Staff #2 | Interviewed regarding records request and provided email confirmation | |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 207
Deficiencies: 0
Date: Oct 25, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations of neglect/lack of care towards Resident #1 (R1), including failure to provide adequate care resulting in sepsis, malnutrition, and dehydration during COVID-19 quarantine.
Complaint Details
The complaint alleged neglect/lack of care to Resident #1 (R1) resulting in sepsis from a urinary tract infection, malnutrition, and dehydration during COVID-19 quarantine. The investigation was unsubstantiated due to insufficient evidence supporting the allegations.
Findings
The investigation found insufficient evidence to substantiate the allegations of neglect or lack of care. Medical records, staff interviews, and resident representative statements indicated no concerns of neglect. The resident's health issues were attributed to comorbidities including COVID-19, and no citations were issued.
Report Facts
Capacity: 207
Census: 126
Complaint Control Number: 29-AS-20240524095925
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted subsequent complaint visit and investigation |
| Remon Pagels | Executive Director | Met with during investigation and interviewee |
| Guadalupe Ambriz | Business Director | Met with during investigation |
| Christine Ferris | Investigator | Conducted interviews and investigation |
| Zabel Chochian | Licensing Program Analyst | Conducted initial 10-day complaint visit |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 207
Deficiencies: 0
Date: Oct 21, 2024
Visit Reason
The visit was conducted as a complaint investigation following allegations received on 2024-02-05 regarding understaffing, neglect of incontinent residents, and unqualified staff attending residents.
Complaint Details
The complaint included allegations that the facility was understaffed, incontinent residents were left in soiled diapers for extended periods due to staff neglect, and unqualified staff were attending residents. The investigation deemed all allegations unsubstantiated based on record reviews, staff and resident interviews, and observations.
Findings
The investigation found insufficient evidence to substantiate the allegations of understaffing, unqualified staff, and neglect of incontinent residents. Staff schedules and interviews confirmed adequate staffing and proper training, and residents reported timely assistance.
Report Facts
Capacity: 207
Census: 126
Staff count in memory care unit: 2
Staff count in memory care unit: 3
Staff interviews: 4
Staff interviews: 3
Resident interviews: 6
Family member interviews: 1
Incontinent resident changing frequency: 2
Incontinent resident changing frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation visits and authored the report |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Guadalupe Ambriz | Business Office Manager | Met with the Licensing Program Analyst during the inspection visit |
| Adam Syncheff | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 207
Deficiencies: 0
Date: Oct 15, 2024
Visit Reason
Unannounced complaint investigation visit conducted to address allegations that facility staff were not meeting the incontinence needs of residents and that staff had inadequate training.
Complaint Details
The complaint was unsubstantiated. Allegations included failure to meet residents' incontinence needs and inadequate staff training. Interviews and record reviews showed care needs were met and training was documented and sufficient.
Findings
The investigation found insufficient evidence to support the allegations. Residents and staff interviews, record reviews, and facility tours indicated that incontinence care needs were being met and staff training was adequate. No violations or citations were issued.
Report Facts
Capacity: 207
Census: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation visit and reviewed records |
| Remon Pagels | Executive Director/Administrator | Met with Licensing Program Analyst during inspection |
| Adam Syncheff | Administrator | Named as facility administrator in report header |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 207
Deficiencies: 0
Date: Oct 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-11-15 regarding resident care concerns including soiled clothing, room odor, and hygiene maintenance.
Complaint Details
The complaint alleged that staff left a resident in soiled clothing and diapers, did not keep the resident's room free from odor, and did not maintain residents' hygiene. After investigation, all allegations were deemed unsubstantiated due to lack of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. Observations and interviews indicated residents were clean, properly groomed, and rooms were odor-free. Staff reported regular care and cleaning practices were in place.
Report Facts
Capacity: 207
Census: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Remon Pagels | Executive Director/Administrator | Met with Licensing Program Analyst during the inspection |
| Adam Syncheff | Administrator | Named as facility administrator in report header |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 207
Deficiencies: 0
Date: May 31, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations received on 11/07/2022 regarding medication distribution, hydration, monitoring of resident condition, and dietary needs at Atria Hillcrest facility.
Complaint Details
The complaint included allegations that staff did not distribute resident's medication as prescribed, did not ensure hydration, did not monitor for change in condition, and did not meet dietary needs. The investigation included file reviews, staff and resident interviews, and observations. The resident was found to be independent in medication management and not on the medication program. Staff provided water and food options appropriately. No violations were substantiated.
Findings
The investigation found insufficient evidence to support the allegations that staff failed to distribute medication as prescribed, ensure hydration, monitor changes in resident condition, or meet dietary needs. All allegations were deemed unsubstantiated based on interviews, record reviews, and observations.
Report Facts
Capacity: 207
Census: 116
Complaint received date: Nov 7, 2022
Inspection start time: 1010
Inspection end time: 1330
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian A Larios | Senior Executive Director | Met during inspection and provided information regarding resident assessments and facility operations |
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kasandra Lopez | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 207
Deficiencies: 0
Date: May 2, 2024
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 2023-11-06 regarding plumbing issues in a resident's room.
Complaint Details
The complaint alleged that staff did not prevent plumbing issues in Resident #1's room, which occurred three times in six months during 2023. The allegation was investigated through interviews and document review and was found to be unsubstantiated.
Findings
The investigation found that the facility did experience plumbing issues in 2023, but services were performed to fix the problems and the resident was moved to a new unit. The allegation was deemed unsubstantiated based on the review of interviews and documents.
Report Facts
Complaint Control Number: 29
Number of plumbing issues: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Remon Pagels | Executive Director | Met with Licensing Program Analyst during the investigation |
| Adam Syncheff | Administrator | Facility Administrator named in the report |
| Cassandra Sadowsky | Memory Care Director | Interviewed during initial 10-day complaint visit |
Inspection Report
Annual Inspection
Census: 108
Capacity: 207
Deficiencies: 0
Date: Apr 17, 2024
Visit Reason
The inspection was an unannounced required annual visit to evaluate the facility's compliance with Title 22 Regulations and ensure there are no health and safety hazards.
Findings
The facility was found to be in compliance with no deficiencies cited at the time of the visit. Resident rooms, common areas, kitchen, restrooms, and outside areas were all observed to be well maintained and safe. Interviews with residents revealed no concerns.
Report Facts
Number of resident rooms toured: 8
Number of residents interviewed: 5
Water temperature range: 114
Water temperature range: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the inspection and signed the report |
| Remon Pagels | Executive Director | Met with Licensing Program Analyst during inspection |
| Hector Arjon | Maintenance Director | Participated in the physical plant tour during inspection |
| Desaree Perera | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 207
Deficiencies: 0
Date: Nov 28, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding an allegation that the facility was trying to persuade residents or their responsible parties to change physicians or home health agencies to those preferred by the administration.
Complaint Details
The complaint alleged that the facility was persuading residents or their responsible parties to change physicians or home health agencies for financial gain. The investigation included interviews with staff, residents, and review of documents. It was confirmed that residents have freedom of choice and the facility provides a list of agencies without coercion. The complaint was unsubstantiated.
Findings
The investigation found insufficient evidence to support the allegation. Staff and residents confirmed that choices regarding physicians and home health agencies were made by residents and their responsible parties without undue influence from the facility. The allegation was determined to be unsubstantiated and no deficiencies were observed.
Report Facts
Capacity: 207
Census: 111
Number of home health agencies: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elsie Campos | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Executive Director | Met with Licensing Program Analyst during investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 207
Deficiencies: 0
Date: Oct 12, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations received on 2023-10-06 regarding charging for services not provided, failure to provide special diets as prescribed, and staff lacking criminal record clearance.
Complaint Details
The complaint investigation addressed three allegations: 1) Facility charging for services not provided; 2) Facility not providing special diets as prescribed; 3) Facility staff lacking criminal record clearance. All allegations were deemed unsubstantiated based on observations, interviews, and record reviews.
Findings
The investigation included interviews, observations, and record reviews. All allegations were found to be unsubstantiated due to insufficient evidence. The facility was observed providing housekeeping and cleaning services, residents confirmed receipt of special diet options, and staff records confirmed criminal background clearances.
Report Facts
Facility capacity: 207
Census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elsie Campos | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Administrator | Met with Licensing Program Analyst during investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 207
Deficiencies: 0
Date: Oct 12, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff force residents to do activities of daily living.
Complaint Details
The complaint alleged that staff force residents to do activities of daily living. After interviews and record reviews, the allegation was found unsubstantiated.
Findings
Interviews with staff and residents denied the allegation that residents were forced to participate in activities of daily living. Residents confirmed they make their own decisions and participate at their leisure. The allegation was deemed unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 207
Census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elsie Campos | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Adam Syncheff | Administrator | Met with Licensing Program Analyst during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 207
Deficiencies: 0
Date: Aug 29, 2023
Visit Reason
The visit was conducted to investigate a complaint alleging that staff were not present to administer medication to residents during certain hours.
Complaint Details
The complaint alleged that no medtech was available from 10am to 6am, causing residents to wait 30 minutes to an hour for medication. The allegation was deemed unsubstantiated based on interviews and schedule reviews.
Findings
The investigation found insufficient evidence to support the allegation. Interviews with residents and staff, as well as a review of staffing schedules, confirmed that a medtech was available during the night shift to administer pain medication as needed.
Report Facts
Capacity: 207
Census: 107
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Executive Director | Met with Licensing Program Analyst during investigation |
| Brian A Larios | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 207
Deficiencies: 0
Date: Mar 14, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2022-12-08 regarding staff not following resident's admissions agreement, not providing an itemized list of fees, and not providing rent increase notice within 60 days.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not following resident admissions agreements, not providing itemized fee lists, and failing to provide rent increase notices within 60 days. Interviews and record reviews did not support these claims.
Findings
The investigation found insufficient evidence to support any of the allegations. Residents reported activities are offered but would like more frequent options; bills are itemized and communicated; and rent increase notices were sent timely except for a few new residents. All allegations were deemed unsubstantiated.
Report Facts
Facility capacity: 207
Census: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation and visits |
| Adam Syncheff | Executive Director | Met with Licensing Program Analyst during investigation |
| Brian A Larios | Administrator | Facility administrator named in report header |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 207
Deficiencies: 0
Date: Feb 28, 2023
Visit Reason
The visit was conducted to conclude an investigation regarding an incident that occurred on 08/24/2022 involving a physical altercation between a resident and a staff member.
Complaint Details
The complaint involved an incident where Resident #1 reportedly kicked Staff #1, who later alleged being punched by the resident. Interviews and inspections found no evidence of abuse. The complaint was not substantiated and no further follow-up was required.
Findings
The investigation found conflicting statements about the incident, with no physical evidence of injury on the resident. The staff member denied abuse, and although fault was not determined, the staff member was terminated to avoid future issues. No deficiencies were cited.
Report Facts
Incident date: Aug 24, 2022
Investigation start date: Sep 6, 2022
Telephonic interview date: Feb 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Executive Director | Met with Licensing Program Analyst during the investigation |
| Martha Arroyo | Licensing Program Analyst | Conducted the unannounced Case Management – Incident visit and investigation |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 105
Capacity: 207
Deficiencies: 2
Date: Feb 10, 2023
Visit Reason
The Licensing Program Analyst Elsie Campos arrived unannounced to conduct a required annual visit to ensure compliance with Title 22 Regulations and to check for health and safety hazards.
Findings
The facility was generally clean, well maintained, and in compliance with infection control and safety regulations. However, some maintenance issues were noted including broken cabinets in the memory care unit and a broken sugar bin in the kitchen. One staff member was found not properly associated with the facility, resulting in a civil penalty.
Deficiencies (2)
One staff member was not associated to the facility, posing an immediate health and safety risk.
Kitchen drawer in the memory care unit, cabinet under the aquarium in memory care unit, broken towel rack in room #242 shower, and broken sugar bin in main kitchen were in disrepair, posing potential health and safety risks.
Report Facts
Civil penalty amount: 500
Water temperature range: 117.8
Water temperature range: 119.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elsie Campos | Licensing Program Analyst | Conducted the inspection and authored the report |
| Brian Larios | Executive Director | Met with Licensing Program Analyst during inspection |
| Adam Syncheff | Administrator | Facility Administrator named in report header |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 207
Deficiencies: 1
Date: Nov 10, 2022
Visit Reason
An unannounced Case Management - Deficiencies visit was conducted due to a deficiency discovered during a complaint investigation related to a COVID-19 outbreak that was not reported to Community Care Licensing.
Complaint Details
The visit was triggered by a complaint investigation. The deficiency was substantiated as the Administrator failed to report the COVID-19 outbreak to Community Care Licensing.
Findings
The facility failed to report a COVID-19 outbreak in August 2022 affecting approximately nine residents and one staff member to Community Care Licensing, which poses a potential health, safety, and personal rights risk to residents in care.
Deficiencies (1)
Failure to report a COVID-19 outbreak to Community Care Licensing as required by reporting regulations.
Report Facts
Residents affected by COVID-19 outbreak: 9
Staff affected by COVID-19 outbreak: 1
Census: 108
Total Capacity: 207
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian A Larios | Administrator | Named in relation to the failure to report the COVID-19 outbreak |
| Kasandra Lopez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Desaree Perera | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 207
Deficiencies: 0
Date: Sep 20, 2022
Visit Reason
The visit was conducted as a complaint investigation regarding an allegation that a resident was fed food against their religious beliefs.
Complaint Details
The allegation was that Resident #1 was intentionally tricked into eating pork against their religion. The investigation included interviews, record reviews, and observations, concluding there was insufficient evidence to substantiate the claim.
Findings
The investigation found that the resident in question had moved out over two years ago, and residents choose their meals daily with accommodations made if they are unhappy. Staff continuously check with residents about their food preferences, and no evidence was found to support the allegation. The complaint was deemed unsubstantiated.
Report Facts
Facility capacity: 207
Resident census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Denise Wadkins | Memory Care Director | Met with Licensing Program Analyst during the visit |
| Sarah Dodd | Administrator | Facility administrator named in the report |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 117
Capacity: 207
Deficiencies: 0
Date: Sep 6, 2022
Visit Reason
The visit was conducted to investigate an incident reported by the facility regarding Resident #1, alleging that Staff #1 punched them in the right calf area of their leg.
Complaint Details
The visit was complaint-related, investigating an incident of alleged physical abuse by staff against a resident. Substantiation status is not stated.
Findings
The Licensing Program Analyst conducted an unannounced case management incident visit including interviews, a plant tour, and a resident file review. Further investigation is required prior to issuing findings.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Dodd | Executive Director | Met with Licensing Program Analyst during investigation of incident involving Resident #1. |
| Martha Arroyo | Licensing Program Analyst | Conducted the unannounced case management incident visit and investigation. |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Capacity: 207
Deficiencies: 1
Date: Jul 29, 2022
Visit Reason
The visit was an unannounced case management incident investigation conducted to investigate an elopement incident involving Resident #1 that occurred on 2022-07-17.
Complaint Details
The visit was complaint-related, investigating an elopement incident of Resident #1 on 2022-07-17. The facility reported the incident the following day. Resident #1 was found outside the facility unassisted, contrary to the physician's report stating the resident cannot leave unassisted.
Findings
The investigation found that Resident #1 eloped from the facility unassisted on 2022-07-17, despite the presence of a front desk clerk and memory care staff training on elopement protocols. The facility failed to supervise the resident, posing an immediate health and safety risk.
Deficiencies (1)
87464 Basic services (f)(1)(c) 'Care and supervision' means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as Resident #1 left the facility unassisted which poses an immediate health and safety risk to persons in care.
Report Facts
Facility capacity: 207
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Dodd | Executive Director | Met with Licensing Program Analyst during investigation |
| Martha Arroyo | Licensing Program Analyst | Conducted the unannounced case management incident visit and investigation |
| Desaree Perera | Licensing Program Manager | Supervisor and named in the report |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 207
Deficiencies: 0
Date: Apr 1, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2021-09-17 regarding multiple concerns about resident care and staff conduct at the facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff causing a resident to expose himself, staff hitting a resident, failure to accord privacy, multiple falls, staff leaving a resident on the floor, delayed response to call buttons, and failure to assist with medical appointments. Investigations included interviews with staff, residents, and review of records. No citations were issued.
Findings
The investigation found insufficient evidence to substantiate any of the allegations, including staff causing a resident to expose himself, staff hitting a resident, failure to accord privacy, multiple falls, delayed response to call buttons, and failure to assist with medical appointments. All allegations were deemed unsubstantiated.
Report Facts
Facility capacity: 207
Census: 111
Number of allegations: 8
Staff interviews: 5
Resident interviews: 4
Resident interviews: 3
Routine checks on high fall risk resident: 3
Notification interval: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Guzman-Chavez | Licensing Program Analyst | Conducted the complaint investigation and visits |
| Sarah Dodd | Executive Director | Facility administrator met during investigation |
| Elijah Soltan | Med-Tech | Interviewed during investigation |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 111
Capacity: 207
Deficiencies: 0
Date: Mar 24, 2022
Visit Reason
The Licensing Program Analyst arrived unannounced to conduct a required annual visit with a specific emphasis on infection control practices and procedures.
Findings
No deficiencies were observed during the inspection. The facility was found to be in compliance with Title 22 regulations, infection control practices, and visitation requirements. Adequate supplies of food, PPE, and properly maintained safety equipment were noted.
Report Facts
Water temperature: 109.4
Water temperature: 111.4
Facility capacity: 207
Census: 111
Fire extinguisher last serviced: Mar 22, 2022
Date of last positive COVID case: Mar 2, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Dodd | Administrator | Met with Licensing Program Analyst during inspection |
| Martha Guzman Chavez | Licensing Program Analyst | Conducted the inspection |
| Desaree Perera | Licensing Program Manager | Named in report header |
| Lupe Ambriz | Signed the report during exit interview |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 207
Deficiencies: 0
Date: Dec 13, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not appropriately care for a resident.
Complaint Details
The complaint alleged that staff did not appropriately care for Resident #1. Interviews with the resident, responsible party, other residents, and staff did not substantiate the claim. The allegation was deemed unsubstantiated.
Findings
The investigation found insufficient evidence to support the allegation that staff failed to appropriately care for Resident #1. Resident and responsible party interviews did not corroborate the claims, and residents reported feeling comfortable and well cared for. No deficiencies were cited.
Report Facts
Capacity: 207
Census: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Sarah Dodd | Executive Director | Met with Licensing Program Analyst during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 114
Capacity: 207
Deficiencies: 0
Date: Aug 26, 2021
Visit Reason
An unannounced required 1-year inspection was conducted focusing on infection control and compliance with Title 22 regulations.
Findings
The inspection found no deficiencies. The facility was in compliance with health and safety regulations, infection control practices were observed, and safety equipment was operational. The facility had adequate PPE supplies and housekeeping was actively maintaining cleanliness.
Report Facts
Resident files reviewed: 8
Staff records reviewed: 3
Fire extinguisher last serviced: Jan 22, 2021
Water temperature range (degrees F): 109.4-111.2
COVID-19 positive cases: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Dodd | Administrator | Met with Licensing Program Analyst during inspection |
| Martha Guzman Chavez | Licensing Program Analyst | Conducted the inspection |
| Desaree Perera | Licensing Program Manager | Named in report header |
Inspection Report
Census: 114
Capacity: 207
Deficiencies: 1
Date: Aug 26, 2021
Visit Reason
An unannounced Case Management - Other visit was conducted to discuss the serious illness/injury reporting requirement as per regulation 87211(a)(1)(D).
Findings
The facility failed to submit unusual incident/injury reports within the required seven days on multiple occasions, posing a potential health and safety risk to residents.
Deficiencies (1)
Failure to submit incident reports of four residents within seven days of occurrence as required by regulation 87211(a)(1)(D).
Report Facts
Incident reports late: 4
POC Due Date: Aug 30, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Dodd | Administrator | Met during visit and named in relation to failure to ensure timely incident reporting. |
| Martha Guzman Chavez | Licensing Program Analyst | Conducted the inspection visit and authored the report. |
| Desaree Perera | Licensing Program Manager | Supervisor named in the report. |
| Carthel Mercado | Resident Services Coordinator | Met during visit to discuss reporting requirements. |
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