Most inspections found no deficiencies, with the facility consistently clean, well-maintained, and compliant with licensing requirements. Several complaint investigations were unsubstantiated, including allegations related to resident care, dignity, and supervision. One substantiated complaint in May 2023 involved a staff member accepting money from a resident, resulting in a minor deficiency for not safeguarding the resident’s checkbook; no fines or enforcement actions were listed in the available reports. Another minor deficiency was cited in January 2023 for a personnel record issue involving the interim administrator. The most recent report from September 29, 2025, was perfect, showing improvement and continued compliance over time.
Deficiencies (last 6 years)
Deficiencies (over 6 years)0.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
93% better than California average
California average: 4 deficiencies/year
Deficiencies per year
43210
2020
2021
2022
2023
2024
2025
Census
Latest occupancy rate80% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
The inspection was an unannounced annual inspection conducted by Licensing Program Analysts to assess compliance with regulatory requirements.
Findings
The facility was found to be in compliance with all reviewed areas including resident records, physical plant safety, food service, employee records, and fire safety regulations. No deficiencies were cited during this inspection.
Report Facts
Food supply duration: 7Food supply duration: 2Water temperature: 109Fire extinguisher last tested: Dec 8, 2023Last disaster drill: Sep 18, 2024Resident records reviewed: 6Employee records reviewed: 6
An unannounced complaint investigation visit was conducted in response to an allegation that staff would not change a resident's diaper.
Findings
The investigation found that staff do check and assist the resident with diaper changes as needed, and the allegation was deemed unsubstantiated based on interviews and record review.
Complaint Details
The allegation was that staff would not change Resident One's diaper. Interviews with the resident and staff, as well as record review, showed that staff regularly check and assist with diaper changes. The allegation was unsubstantiated.
Report Facts
Capacity: 142Census: 124
Employees Mentioned
Name
Title
Context
Sara Martinez
Licensing Program Analyst
Conducted the complaint investigation
Monique Moreira
Executive Director
Met with the Licensing Program Analyst during the investigation
Jillian Ryan
Resident Service Coordinator
Provided information regarding resident care and diaper changes
The visit was an unannounced case management visit to obtain signatures for an amended case management report deficiency page dated 1/12/23.
Findings
No other citations or deficiencies were noted during this visit. An exit interview was conducted and a copy of the report and amended deficiency page was provided to the Executive Director.
Employees Mentioned
Name
Title
Context
Monique Moreira
Executive Director
Met with Licensing Program Analyst during the case management visit and exit interview.
The inspection was an unannounced annual inspection conducted to evaluate compliance with state regulations and facility standards.
Findings
The facility was found to be clean, well-maintained, and in compliance with all applicable regulations. No deficiencies were observed during the inspection.
Report Facts
Staff members present: 26Client records reviewed: 5Employee records reviewed: 5Food supply duration: 1Food supply duration: 2Water temperature: 108Fire extinguishers: 19
Employees Mentioned
Name
Title
Context
Monique Moreira
Administrator
Conducted the facility tour during the inspection
Sandra Zendejas
Business Director
Completed the facility tour and received a copy of the report
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff were financially abusing a resident.
Findings
The investigation substantiated that a staff member accepted money from a resident in violation of facility policy, specifically involving cashed checks. Two other allegations regarding medication administration and resident dignity were found unsubstantiated.
Complaint Details
The complaint alleged financial abuse by facility staff involving resident #1's bank account. The allegation was substantiated based on evidence that staff member S1 received a $150 check from the resident, violating facility policy. Other allegations about medication and dignity were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Facility did not ensure that resident #1's checkbook was safeguarded from staff #1, posing a potential health, safety, and personal rights violation.
An unannounced complaint investigation was conducted in response to allegations received on 2023-05-05 regarding lack of supervision resulting in resident injuries from falls, failure to provide planned activities, and unmet care needs.
Findings
The investigation found insufficient evidence to substantiate the allegations. Resident One (R1) sustained two falls but no injuries were observed, and R1 declined interviews. Staff reported encouraging R1 to participate in activities and assisting with care needs, though R1 sometimes refused assistance.
Complaint Details
The complaint was unsubstantiated due to insufficient evidence to prove the alleged violations occurred. Allegations included lack of supervision causing falls, failure to provide planned activities, and unmet care needs for Resident One (R1).
Report Facts
Facility capacity: 142Resident census: 114
Employees Mentioned
Name
Title
Context
Monique Moreira
Executive Director
Met with Licensing Program Analyst during investigation
The visit was an unannounced case management visit regarding an eviction process taking place at the facility.
Findings
During the visit, staff and a resident were interviewed, and resident and facility records were reviewed to ensure the eviction process complied with Title 22, California Code of Regulations. No deficiencies were noted at the time of the visit.
An office meeting was held to discuss the current management team in place at Gladwell Rancho Mirage and to confirm the managing members identified on the Administrative Organization form submitted in 2019 are still current.
Findings
The meeting confirmed the current management team and requested submission of a current Personnel Report by January 27, 2023. Contact information for the assigned Licensing Program Analyst was provided, and an exit interview was conducted with the Regional Vice President.
Employees Mentioned
Name
Title
Context
Deborah Mullen
Licensing Program Manager
Participated in the office meeting regarding management team discussion.
Jesse Gardner
Licensing Program Analyst
Participated in the office meeting regarding management team discussion.
Nicole Wentworth
Regional Vice President
Met during the office meeting and received the report.
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2020-07-06 alleging inadequate staff response to resident pull cords, insufficient staffing, poor food quality and quantity, and improper staff training.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Staff responded to pull cords within 15 minutes, staffing levels were adequate, food quality and quantity met standards, and staff were properly trained.
Complaint Details
The complaint included allegations that staff do not respond to residents' pull cords in a timely manner, the facility lacks adequate staffing, food quality and quantity are inadequate, and staff are not properly trained. All allegations were found unsubstantiated due to insufficient evidence.
Report Facts
Facility capacity: 142Census: 111
Employees Mentioned
Name
Title
Context
Rayshaun Nickolas
Licensing Program Analyst
Conducted the complaint investigation and made findings
The Licensing Program Analyst conducted an unannounced case management visit to follow up on information needed by the Department.
Findings
A deficiency was cited because the Assistant Executive Director (Interim Administrator), April Princesa, was not properly associated with the facility in the clearance roster, posing a potential health and safety risk. No other citations were noted during the visit.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Assistant Executive Director (Interim Administrator) April Princesa was not associated to Gladwell Rancho Mirage in the clearance roster, violating personnel requirements related to criminal record review.
Type B
Report Facts
Capacity: 142Census: 108Plan of Correction Due Date: Jan 13, 2023
Employees Mentioned
Name
Title
Context
April Princesa
Assistant Executive Director (Interim Administrator)
Named in deficiency for not being associated with the facility in clearance roster
Sandra Zendejas
Business Director
Met with Licensing Program Analyst during the visit
The inspection was an unannounced annual inspection limited to infection control due to an active COVID-19 outbreak at the facility.
Findings
The inspection focused on COVID-19 infection control practices, confirming availability of hand sanitizer, PPE supplies, staff training on infection control, symptom screening of residents, staff, and visitors, and adherence to COVID-19 mitigation protocols.
Employees Mentioned
Name
Title
Context
Sandra Zendeias
Community Business Director
Met with Licensing Program Analyst during inspection and confirmed infection control practices.
Monique Moreira
Administrator
Participated via telephone during inspection and confirmed infection control practices.
Crystal Colvin
Licensing Program Analyst
Conducted the annual inspection focused on infection control.
An unannounced annual inspection was conducted with an emphasis on infection control.
Findings
The inspection found sufficient hand hygiene supplies, cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead responsible for tracking COVID-19 cases and ensuring adequate PPE and staff training.
Report Facts
Staff present: 48
Employees Mentioned
Name
Title
Context
Jonathan Karp
Executive Director
Met with Licensing Program Analyst during inspection and discussed infection control practices
An unannounced complaint investigation visit was conducted in response to a complaint received on 2021-03-01 regarding allegations of staff not speaking to residents with dignity, failure to provide incontinent care, and unclean dementia unit patio and living room.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Observations and interviews indicated that the dementia unit areas were clean, and the incontinent care allegation was not supported by evidence. No deficiencies were cited.
Complaint Details
The complaint was unsubstantiated. Allegations included staff not speaking to residents with dignity, failure to provide incontinent care to a resident, and unclean dementia unit patio and living room. Interviews and observations did not support these allegations.
Report Facts
Capacity: 142Census: 81
Employees Mentioned
Name
Title
Context
Anna Bueno
Evaluator / Licensing Program Analyst
Conducted the complaint investigation
Amy Goldenberg
Licensing Program Analyst
Assisted in conducting the complaint investigation
This unannounced visit was conducted to investigate a complaint alleging that a resident fell while in care and sustained scrapes and bruises on his knees.
Findings
The investigation found insufficient evidence to corroborate or refute the allegation. Resident notes, incident reports, and employee interviews did not confirm that the resident had a fall or injury while in care. The complaint was determined to be unsubstantiated.
Complaint Details
Complaint allegation was unsubstantiated due to lack of preponderance of evidence to prove the alleged violation occurred.
Report Facts
Facility capacity: 142Census: 81
Employees Mentioned
Name
Title
Context
Jonathan Karp
Executive Director
Met with during investigation and furnished report copy
Amy Goldenberg
Licensing Program Analyst
Conducted the complaint investigation
Anna Bueno
Licensing Program Analyst
Assisted in conducting the complaint investigation
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 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.
Leslie Mendiveles
Licensing Program Manager
Named as Licensing Program Manager on the report.
Juliet Ugalde
Community Business Manager
Facility representative who participated in the visit.
Vicki Mariger
Administrator
Facility administrator who stated understanding of background check process.
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