Inspection Report Summary
Most inspections found no deficiencies, with the facility generally clean, well-maintained, and compliant with regulations. Several complaint investigations were unsubstantiated, including allegations about resident care, hygiene, staffing, and communication. Some substantiated issues involved resident supervision lapses leading to elopements and falls, medication administration errors, failure to notify families about changes in care, and one incident of staff physical abuse resulting in termination. The facility received citations related to these findings but no fines or license actions are listed in the available reports. The most recent report from February 24, 2025, was free of deficiencies, indicating improvement in compliance over time.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 123
Capacity: 160
Deficiencies: 0
Feb 24, 2025
Visit Reason
An unannounced annual inspection was conducted as a required one-year visit to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be clean, well-maintained, and appropriately furnished with no obstructions in passageways. Residents were observed eating healthy food, and safety features such as grab bars and emergency pull cords were in place. The inspection was not completed due to time constraints and will continue at a later date.
Report Facts
Floors: 3
Hospice waiver beds: 13
Non-ambulatory licensed beds: 160
Bedridden beds: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| April Princesa | Executive Director | Met during inspection and named in the report. |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the unannounced annual inspection. |
| Troy Agard | Licensing Program Manager | Named in the report. |
Inspection Report
Complaint Investigation
Census: 132
Capacity: 160
Deficiencies: 0
Sep 19, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 06/06/2023 regarding resident falls and failure to provide incident reports to the resident's authorized representative.
Findings
The investigation found that the resident did sustain several falls due to a change in mobility, but the facility responded appropriately and there was no neglect. The allegation that staff failed to provide incident reports was unsubstantiated due to insufficient evidence.
Complaint Details
The complaint involved two allegations: 1) Resident sustained multiple falls while in care, and 2) Staff failed to provide resident's authorized representative with incident reports. Both allegations were found to be unsubstantiated based on documentation and interviews.
Report Facts
Capacity: 160
Census: 132
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tuesday Cabiness | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| April Princesa | Executive Director | Met with Licensing Program Analyst during investigation |
| Venca Avivi | Residential Services Director | Met with Licensing Program Analyst during investigation |
| Michelle Lagoy | Life Guidance Director | Met with Licensing Program Analyst during investigation |
| Johnny Ortiz | Administrator | Facility Administrator named in report header |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 160
Deficiencies: 1
Aug 21, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-08-12 regarding inadequate resident care including failure to ensure residents are showered, lack of daily activities, and a resident wandering away from the facility due to lack of supervision.
Findings
The investigation found the first two allegations (failure to ensure residents are showered and lack of daily activities) to be unsubstantiated based on interviews, observations, and document review. However, the allegation that a resident wandered away from the facility due to lack of staff supervision was substantiated, representing an immediate health and safety risk. A citation was issued and a plan of correction was implemented during the visit.
Complaint Details
The complaint investigation was triggered by allegations that staff did not ensure residents were showered, did not provide daily activities, and that a resident wandered away from the facility due to lack of care and supervision. The first two allegations were unsubstantiated, while the third was substantiated with a citation issued.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to monitor residents under supervision, resulting in a resident wandering out of the memory care unit front door without staff awareness, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 160
Census: 135
Deficiencies cited: 1
Plan of Correction Due Date: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| April Princesa | Administrator / Executive Director | Met with Licensing Program Analyst during complaint investigation and named in findings |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 160
Deficiencies: 0
Aug 16, 2024
Visit Reason
The inspection was conducted as a complaint investigation following allegations including illegal eviction of a resident, billing for services not agreed upon, and failure to provide requested records to a resident's authorized representative.
Findings
The investigation found all allegations to be unsubstantiated based on interviews, record reviews, and documentation provided by the facility and residents.
Complaint Details
The complaint investigation addressed allegations that staff illegally evicted a resident, billed a resident for unauthorized services, and did not provide requested records to a resident's authorized representative. All allegations were found unsubstantiated after review of notices, payment records, assessments, interviews with residents and staff, and confirmation that requested records were received by the authorized representative.
Report Facts
Past due balance amount: 25833.95
Complaint control number: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Spaeth | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| April Princesa | Executive Director | Met with Licensing Program Analyst during investigation |
| Venca Avivi | Resident Services Director | Provided information about resident assessments and billing |
| Wendy Rose | Business Director | Provided information about resident payments |
| Johnny Ortiz | Administrator | Named as facility administrator |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 132
Capacity: 160
Deficiencies: 0
Jun 18, 2024
Visit Reason
The inspection was conducted as a required unannounced annual inspection to evaluate compliance with licensing regulations for the assisted living facility.
Findings
The facility was found to be clean, well-maintained, and appropriately furnished with no health or safety hazards noted. Resident and staff records were complete and up to date, medications were administered as prescribed, and emergency equipment was in place and functional.
Report Facts
Memory Care Unit census: 38
Hospice waiver capacity: 13
Bedridden capacity: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| April Princesa | Executive Director | Met during inspection and involved in facility tour |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the annual inspection |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 160
Deficiencies: 1
May 30, 2024
Visit Reason
An unannounced case management visit was conducted due to a resident eloping from the facility multiple times.
Findings
The facility was cited for failing to have an auditory device or staff alert feature to monitor exits, which resulted in a resident with dementia eloping on three occasions. This posed an immediate health and safety risk to residents.
Complaint Details
The visit was triggered by a complaint regarding a resident (#1) diagnosed with dementia eloping from the facility on 05/05/2024, 05/18/2024, and 05/24/2024. The resident was not allowed to leave unassisted. The complaint was substantiated as the facility was cited and a civil penalty assessed.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have an auditory device or other staff alert feature to monitor exits, resulting in a resident with dementia eloping multiple times. | Type A |
Report Facts
Incident reports received: 3
Civil penalty due date: May 31, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| April Princesa | Executive Director | Met during inspection and informed of visit reason |
| Venca Avivi | Resident Services Director | Met during inspection and informed of visit reason |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the unannounced case management visit |
| Troy Agard | Licensing Program Manager | Supervisor named on the report |
Inspection Report
Complaint Investigation
Census: 133
Capacity: 160
Deficiencies: 2
Mar 14, 2024
Visit Reason
An unannounced case management visit was conducted due to a resident eloping from the facility on 03/09/2024.
Findings
The investigation revealed that resident #1, diagnosed with dementia, eloped from the facility due to lack of supervision and staff alert systems. The resident was returned by police, and the incident posed an immediate health and safety risk to residents.
Complaint Details
The visit was complaint-related due to a resident eloping incident. The lack of care and supervision was determined to be the cause, posing an immediate health and safety risk.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The licensee failed to have an auditory device or other staff alert feature to monitor exits, which is required if exiting presents a hazard to any resident. | Type A |
| Resident #1, diagnosed with dementia, eloped from the facility and was returned by the police, representing an immediate health and safety risk. | Type A |
Report Facts
Deficiencies cited: 2
Capacity: 160
Census: 133
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| April Princesa | Administrator | Named as Executive Director not available during visit |
| Wendy Rose | Community Business Director | Met with Licensing Program Analyst during visit |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the unannounced case management visit |
| Troy Agard | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the visit |
Inspection Report
Complaint Investigation
Census: 124
Capacity: 160
Deficiencies: 1
Jan 23, 2024
Visit Reason
An unannounced complaint investigation was conducted due to allegations that residents' safety pendents were inoperable.
Findings
The investigation confirmed that the resident safety pendents were not working for four days due to a computer system crash, which was repaired by 01/22/2024. Residents were notified, and no health or safety concerns were found. The allegation was substantiated and the plan of correction was cleared during the visit.
Complaint Details
The complaint was substantiated. The resident safety pendents were inoperable for four days due to a computer system crash. The system was repaired and verified to be operational by the time of the visit.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Maintenance and Operation: The facility failed to maintain the resident safety pendents in working order for four days, posing a potential health and safety risk. | Type B |
Report Facts
Days pendents were inoperable: 4
Capacity: 160
Census: 124
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| April Princesa | Executive Director | Met with Licensing Program Analyst during the complaint investigation and provided information about the pendents issue. |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the unannounced complaint investigation visit. |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 160
Deficiencies: 0
Apr 27, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff failed to properly report an incident to an authorized representative.
Findings
The investigation found that staff did contact the family member and primary care physician on the night of the incident. Based on interviews and record reviews, the allegation was deemed unsubstantiated at this time.
Complaint Details
The complaint alleged that there was no communication from the facility about Resident #1 being rushed to emergency surgery for a broken hip on 10/21/19. The allegation was found unsubstantiated after investigation.
Report Facts
Complaint Control Number: 31
Capacity: 160
Census: 118
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation |
| Johnny Ortiz | Administrator | Facility administrator mentioned in report |
| Wendy Rose | Business Office Manager | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 160
Deficiencies: 1
Apr 7, 2023
Visit Reason
The visit was a case management inspection triggered by an incident report concerning resident #1, where staff failed to follow physician orders when administering medication.
Findings
The inspection found that staff did not administer medication according to the physician's orders, posing a health and safety risk to residents. A citation was issued during the visit.
Complaint Details
The visit was complaint-related due to an incident report about medication administration errors for resident #1. The complaint was substantiated as staff failed to follow physician orders.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff did not administer medication according to physician's orders, resulting in a health and safety risk to residents. | Type A |
Report Facts
Deficiencies cited: 1
Capacity: 160
Census: 118
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johnny Ortiz | Executive Director | Met with Licensing Program Analyst during inspection and named in findings |
| Venca Avivi | Resident Services Director | Provided information about medication administration error |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the inspection and authored the report |
| Cassandra Harris | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 160
Deficiencies: 0
Mar 18, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-05-10 alleging lack of care and supervision resulting in dehydration.
Findings
The investigation found insufficient information to support the allegation of lack of care and supervision resulting in dehydration. The allegation was deemed unsubstantiated based on hospital records, staff interviews, and review of facility care practices.
Complaint Details
The complaint was received on 2021-05-10 and investigated through interviews with staff, family members, and review of hospital and sheriff department records. The allegation was unsubstantiated.
Report Facts
Complaint Control Number: 31-AS-20210510084331
Facility Capacity: 160
Census: 111
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the unannounced complaint investigation visit and signed the report |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Johnny Ortiz | Administrator | Facility Administrator mentioned in the report |
| Venca Avivi | Resident Services Director | Met with during the inspection visit |
| Olivia Spindola | Investigator | Investigator assigned to the complaint investigation branch who conducted interviews and record reviews |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 160
Deficiencies: 0
Nov 9, 2022
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations including staff diagnosing a resident without proper consent and a resident sustaining an injury from a fall while in care.
Findings
The investigation found that the resident was diagnosed with Dementia prior to moving in and the evaluation was ordered by the resident's primary care physician, not facility staff. Regarding the fall injury allegation, records and staff interviews confirmed that the resident was assessed as a minimal fall risk and was monitored every two hours as scheduled. The allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff diagnosing a resident without proper consent and a resident sustaining an injury from a fall. The investigation found no evidence supporting these allegations.
Report Facts
Complaint Control Number: 31-AS-20200225154209
Capacity: 160
Census: 113
Time of visit start: 09:15 AM
Time of visit completion: 03:00 PM
Fall date: Resident fell on 10/20/2019
Pre-move-in assessment date: 07/19/2019
Move-in assessment date: 08/21/2019
30-day assessment date: 09/19/2019
Fall check frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on report |
| Venca Avivi | Resident Services Director | Interviewed during investigation |
| Johnny Ortiz | Administrator | Facility Administrator |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 160
Deficiencies: 0
Oct 31, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that facility staff were not providing assistance to residents in a timely manner.
Findings
Based on interviews with residents and staff, record reviews, and observations, there was insufficient evidence to verify the allegation of delayed assistance due to understaffing. Residents and staff reported that response times were generally between five to ten minutes, and no health or safety hazards were noted.
Complaint Details
The complaint alleged that facility staff were not providing assistance to residents in a timely manner due to understaffing. The allegation was unsubstantiated after investigation.
Report Facts
Call button uses: 264
Average response time (minutes): 7
Residents per caregiver (Memory Care): 10
Residents per caregiver (Assisted Living): 28
Response time observed (minutes): 3
Response time range reported by staff (minutes): 5
Response time range reported by staff (minutes): 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johnny Ortiz | Executive Director | Met with Licensing Program Analyst during the complaint investigation |
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 160
Deficiencies: 2
Oct 28, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of lack of care and supervision resulting in multiple falls with severe injuries, and insufficient staffing leading to unmet resident needs.
Findings
The investigation substantiated the allegations that Resident #1 experienced multiple falls due to inadequate supervision and that the memory care unit was understaffed at times, impacting resident care. However, more recent staff interviews indicated sufficient staffing during later periods. A citation was issued and appeal rights discussed.
Complaint Details
The complaint was substantiated. Allegations included lack of care and supervision causing multiple falls with severe injuries, and insufficient staffing in the memory care unit. Investigations included interviews with staff and review of hospital and sheriff department records. The findings confirmed lapses in supervision and staffing during the relevant periods.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to monitor and supervise residents to ensure their health, safety, and well-being, resulting in Resident #1 sustaining injuries from multiple falls. | Type A |
| Failure to ensure adequate direct care staff to meet residents' physical, social, emotional, safety, and health care needs as identified in their current appraisal. | Type A |
Report Facts
Resident falls: 4
Staff interviewed: 6
Plan of Correction Due Date: Oct 31, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation |
| Venca Avivi | Resident Care Director | Met with Licensing Program Analyst during the investigation |
| Johnny Ortiz | Administrator | Facility administrator named in the report |
| Olivia Spindola | Investigations Branch Investigator | Conducted interviews and record reviews during the investigation |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 160
Deficiencies: 1
Oct 17, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff billed a resident for services not being provided and failed to discuss changes in the resident's condition with the family and physician.
Findings
The investigation substantiated that the resident's level of care was increased from Level One to Level Two without notifying the resident's responsible party and physician in writing, which violates regulations. No health and safety hazards were observed during the visit.
Complaint Details
The complaint was substantiated. Allegations included billing for services not provided and failure to notify family and physician of changes in resident's condition. Investigation confirmed the latter as substantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify the resident's family and physician in writing about changes in the resident's level of care, posing potential health, safety, and personal rights risks. | Type B |
Report Facts
Capacity: 160
Census: 103
Plan of Correction Due Date: Oct 24, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Johnny Ortiz | Administrator | Facility administrator met during the investigation and discussed the visit |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 160
Deficiencies: 0
Oct 10, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 08/29/2022 regarding resident hygiene, incontinent care, and eviction notice issues at the facility.
Findings
After interviews with staff, residents, and the reporting party, as well as physical inspections, the investigation found insufficient evidence to substantiate the allegations. Residents appeared clean and well-groomed, incontinent care was reportedly provided timely, and no eviction notice was issued to the resident in question.
Complaint Details
The complaint included allegations that staff did not ensure resident hygiene needs were met, did not provide appropriate incontinent care, and issued an improper eviction notice to a resident. All allegations were found to be unsubstantiated based on interviews, observations, and record reviews.
Report Facts
Facility capacity: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johnny Ortiz | Executive Director | Met with Licensing Program Analyst during the complaint investigation |
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 160
Deficiencies: 0
Aug 8, 2022
Visit Reason
An unannounced Case Management visit was conducted following an SOC341 received on 2022-08-02 alleging that staff grabbed and pulled a resident by the arm and wrist to re-direct them, causing soreness.
Findings
The Licensing Program Analyst interviewed staff and a resident, found no health and safety hazards, and no action was taken during the visit.
Complaint Details
The complaint alleged that staff #1 grabbed and pulled resident #1 by the arm and wrist causing soreness. The complaint was investigated through interviews with three staff and one resident. No action was taken.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johnny Ortiz | Executive Director | Met with Licensing Program Analyst during the visit |
| Abeye Duguma | Licensing Program Analyst | Conducted the unannounced Case Management visit and investigation |
| Naira Margaryan | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 160
Deficiencies: 0
Jun 29, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-03-15 regarding resident care, communication with authorized representatives, and facility disrepair.
Findings
The investigation found insufficient evidence to substantiate the allegations that a resident was not assisted with services, that the facility failed to communicate changes in services to the authorized representative, and that the facility was in disrepair. All allegations were determined to be unsubstantiated based on interviews, observations, and record reviews.
Complaint Details
The complaint involved three main allegations: 1) Resident not being assisted with services such as diaper changing and wound care; 2) Facility did not communicate with the authorized representative about changes in services; 3) Facility was in disrepair with a leaking ceiling in a resident's room. All allegations were investigated through interviews, record reviews, and physical inspections and were found to be unsubstantiated.
Report Facts
Facility capacity: 160
Census: 101
Complaint receipt date: Mar 15, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Johnny Ortiz | Executive Director | Met with Licensing Program Analyst during the investigation |
| Miriam Zepeda Aguilar | Med Tech | Interviewed regarding resident care during the investigation |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Capacity: 160
Deficiencies: 1
May 24, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-03-09 regarding a resident's door being in disrepair.
Findings
The allegation that the resident's door was in disrepair was substantiated. The door was left in disrepair while the room was occupied, which posed a potential health, safety, or personal rights risk to residents. No other health and safety hazards were noted during the visit.
Complaint Details
The complaint investigation was substantiated based on interviews, observations, and record review. The resident's door was found to be in disrepair, and the facility failed to completely remove the mechanism from the disrepaired door, resulting in a visitor and resident being locked in the room.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to maintain the resident's door in good repair, leaving it disrepaired while the room was occupied, posing a potential health, safety, or personal rights risk to residents. | Type B |
Report Facts
Capacity: 160
Deficiency Type B: 1
Plan of Correction Due Date: May 27, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation |
| Johnny Ortiz | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 160
Deficiencies: 1
May 24, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not providing resident medications as prescribed.
Findings
The allegation that Resident #1 was given potassium pills twice daily instead of once daily as prescribed was substantiated. No other health and safety hazards were noted during the visit.
Complaint Details
The complaint was substantiated based on investigation findings that Resident #1 was administered potassium medication twice daily contrary to the physician's order for once daily. The investigation included document review and staff interviews.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee did not ensure that medications were given as prescribed, posing an immediate health, safety, or personal rights risk to persons in care. | Type A |
Report Facts
Capacity: 160
Census: 101
Deficiency Type: 1
Plan of Correction Due Date: May 25, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation |
| Johnny Ortiz | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 160
Deficiencies: 0
Apr 26, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not seek timely medical care for a resident and that the facility had C diff contamination.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff notified the resident's physician timely and called 911 upon rapid decline. No other cases of C diff were found in the facility, and no health and safety hazards were noted during the visit.
Complaint Details
The complaint was unsubstantiated based on interviews, record reviews, and observations. Allegations included failure to seek timely medical care and presence of C diff contamination, both found unsubstantiated.
Report Facts
Capacity: 160
Census: 98
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johnny Ortiz | Executive Director | Met with Licensing Program Analyst during the complaint investigation |
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 160
Deficiencies: 0
Apr 20, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff do not assist residents with showering.
Findings
Based on interviews and observations, there was not enough information to verify the allegation. The investigation found that all hygiene needs were being met, residents had shower schedules, and caregivers were available to assist those who needed help. The allegation was unsubstantiated.
Complaint Details
The complaint alleged that staff did not assist with showering, specifically that a resident (R1) did not shower for weeks. The allegation was found to be unsubstantiated after investigation.
Report Facts
Capacity: 160
Census: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johnny Ortiz | Executive Director | Met with Licensing Program Analyst during the complaint investigation |
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 160
Deficiencies: 0
Apr 13, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations including a resident's walker being in disrepair and staff not safeguarding residents' personal belongings.
Findings
The investigation found that the resident's walker was repaired promptly after the family reported it, and there was insufficient information to substantiate the allegation regarding lost personal belongings. Therefore, the allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on interviews and record reviews. The resident's walker issue was addressed promptly after being reported, and there was no evidence supporting the claim that staff failed to safeguard the resident's personal belongings.
Report Facts
Capacity: 160
Census: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Johnny Ortiz | Administrator | Facility administrator mentioned in report header |
| Venca Avivi | Resident Care Director | Met with Licensing Program Analyst during investigation |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 160
Deficiencies: 0
Apr 6, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 03/10/2022 regarding resident overheating, dehydration, and lack of hot water for a week.
Findings
The investigation found insufficient evidence to substantiate the allegations. The facility maintained room temperatures between 72-75º, residents had access to water and hydration, and the hot water issue was resolved within a week with alternate arrangements made for resident hygiene. No health or safety hazards were noted.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included resident overheating, resident dehydration, and lack of hot water for a week. All allegations were found unsubstantiated based on interviews, observations, and documentation.
Report Facts
Capacity: 160
Census: 109
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johnny Ortiz | Executive Director | Met with Licensing Program Analyst during the complaint investigation |
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Gary Tan | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 160
Deficiencies: 0
Mar 26, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that the facility was malodorous and that residents' rooms were dirty.
Findings
The investigation found no evidence to support the allegations; no malodor was detected in the Memory Care unit hallways and common areas, and inspections of multiple resident rooms found them clean and free of filth, dust, or sticky floors. The allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on the findings of the unannounced visit and prior inspections.
Report Facts
Rooms inspected: 20
Prior rooms inspected: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Venca Avivi | Resident Care Director | Met with the Licensing Program Analyst during the investigation. |
| Naira Margaryan | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Capacity: 160
Deficiencies: 0
Mar 11, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2020-03-09 regarding staff locking residents in their rooms and residents' doors being in disrepair.
Findings
The investigation found that residents' rooms could only be locked from the inside and no staff locked residents in their rooms. The allegation of locked rooms was unsubstantiated. Regarding the door disrepair allegation, it was found that the resident had aggressively handled the door causing damage, but a repair work order was placed and completed promptly. This allegation was also unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on interviews, physical inspection, and document review. Allegations included staff locking residents in rooms and residents' doors being in disrepair.
Report Facts
Facility capacity: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johnny Ortiz | Executive Director | Met with during the investigation and discussed the reason for the visit |
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation |
| Gary Tan | Licensing Program Analyst | Conducted the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 160
Deficiencies: 0
Feb 22, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-01-21 regarding staff not safeguarding a resident's personal belongings.
Findings
The investigation found no relevant information to support the allegation that staff did not safeguard the resident's personal belongings. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff did not safeguard Resident #1's dentures, which were reported lost. The investigation included interviews and record reviews, concluding the allegation was unsubstantiated.
Report Facts
Facility capacity: 160
Census: 104
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johnny Ortiz | Executive Director | Met with Licensing Program Analyst during the complaint investigation |
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 160
Deficiencies: 0
Feb 8, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-01-21 regarding allegations about resident care and facility conditions.
Findings
The investigation found no relevant information to support any of the allegations, including that a resident was left in their room all day, failure to provide a 60-day notice of rent increase for COVID expenses, and a resident's closet door being in disrepair. All allegations were unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included a resident being left in their room all day, failure to provide proper rent increase notice, and a broken closet door. Investigations included interviews, observations, and record reviews, all resulting in no substantiation.
Report Facts
Capacity: 160
Census: 102
Rent increase amount: 500
Notice date: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation |
| Johnny Ortiz | Executive Director | Facility administrator met during the investigation |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 160
Deficiencies: 0
Feb 2, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 01/21/2022 regarding resident hygiene, laundry service, room cleanliness, proper dressing, and water provision.
Findings
All allegations were investigated through interviews, observations, and room inspections. The investigation found no relevant information to support any of the allegations, and all were determined to be unsubstantiated.
Complaint Details
The complaint included nine allegations such as staff not meeting resident's hygiene needs, inadequate laundry service, dirty resident rooms, improper dressing of residents, and insufficient water provision. The investigation concluded all allegations were unsubstantiated.
Report Facts
Facility capacity: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johnny Ortiz | Executive Director | Met with Licensing Program Analyst during the complaint investigation |
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 160
Deficiencies: 1
Jan 29, 2022
Visit Reason
Unannounced complaint investigation visit conducted to investigate an allegation that staff hit a resident.
Findings
The allegation that staff member S2 hit Resident #1 was substantiated based on witness testimony and investigation. S2 was immediately suspended and later terminated. The facility failed to ensure the resident's personal rights were respected, posing an immediate safety risk.
Complaint Details
The complaint alleged that staff hit a resident. The allegation was substantiated based on witness statements and investigation. Staff member S2 was suspended and terminated. Citation was issued and appeal rights were discussed.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure resident's personal rights were observed and respected, including protection from physical abuse. | Type A |
Report Facts
Capacity: 160
Census: 94
Deficiency Type: 1
Plan of Correction Due Date: Jan 31, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johnny Ortiz | Executive Director | Interviewed during investigation and named as facility administrator |
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation |
| John Spohn | Staff | Witnessed the incident and met during investigation |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 160
Deficiencies: 1
Jan 3, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2021-10-20 regarding staff not reporting incidents to a resident's responsible party, significant resident weight loss, and insufficient staffing.
Findings
The investigation substantiated that staff failed to report an incident to the resident's responsible party and that a resident suffered significant weight loss due to medical condition, not neglect. The allegation of insufficient staffing was unsubstantiated. One deficiency was cited related to failure to file an incident report and notify the responsible party.
Complaint Details
The complaint investigation was substantiated for failure to report an incident to the resident's responsible party and for significant resident weight loss, which was determined to be due to medical condition and not neglect. The allegation of insufficient staffing was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to file an incident report and notify the resident’s responsible party within seven days of the occurrence, posing a potential health safety risk. | Type B |
Report Facts
Capacity: 160
Census: 103
Deficiencies cited: 1
Plan of Correction Due Date: Jan 13, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johnny Ortiz | Executive Director | Met with Licensing Program Analyst during the investigation and named in findings |
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 113
Capacity: 160
Deficiencies: 0
Dec 24, 2021
Visit Reason
The inspection was a required one-year unannounced infection control visit to evaluate compliance with health and safety standards.
Findings
The facility was found to have appropriate infection control measures in place, including PPE availability, mask usage, and COVID-19 prevention signage. The physical plant was clean and well-maintained, with proper food storage, fire safety equipment, and resident accommodations. No deficiencies or violations were noted in the report.
Report Facts
Number of bedrooms: 134
Memory care bedrooms: 39
Non-ambulatory capacity: 160
Bedridden capacity: 67
Hospice waiver capacity: 10
Non-ambulatory residents: 79
Hospice care residents: 6
Hot water temperature: 115.3
Fire extinguisher last inspection date: Nov 15, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the inspection and met with the nurse |
| Venca Avivi | Nurse | Facility nurse who met with the Licensing Program Analyst during the inspection |
| Johnny Ortiz | Administrator | Facility administrator |
| Naira Margaryan | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 160
Deficiencies: 0
Nov 17, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 10/20/2021 regarding resident injury, room cleanliness, hygiene needs, and hazard removal in the resident's room.
Findings
The investigation found that the resident sustained a minor self-inflicted injury from a broken picture frame that staff were unaware of. The resident's room was inspected multiple times and found to be clean and free of hazards. Staff reported removing hazardous items when discovered. The resident's hygiene needs were met and the resident appeared clean and well-groomed. All allegations were unsubstantiated based on interviews, inspections, and observations.
Complaint Details
The complaint included allegations that a resident sustained injury while in care, the resident's room was not being cleaned, the resident's hygiene needs were not being met, and staff did not ensure the resident's room was free of hazards. The investigation concluded all allegations were unsubstantiated.
Report Facts
Facility capacity: 160
Resident census: 112
Complaint control number: 31-AS-20211020154028
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Johnny Ortiz | Executive Director | Met with Licensing Program Analyst during investigation |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 160
Deficiencies: 0
Oct 19, 2021
Visit Reason
The inspection was conducted as an unannounced complaint investigation in response to an allegation that facility staff failed to meet a resident's needs.
Findings
Based on interviews with residents and staff, as well as a review of the staffing schedule, the allegation was found to be unsubstantiated. Residents and staff reported that staffing was sufficient and residents felt safe and well cared for.
Complaint Details
The complaint alleged that facility staff failed to meet a resident's needs. The investigation included interviews with the resident in question, other residents, and staff, as well as a review of staffing schedules. The allegation was determined to be unsubstantiated.
Report Facts
Staff on memory care shifts: 4
Staff on overnight shift: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Shanahan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Johnny Ortiz | Administrator | Facility administrator met with during investigation |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager on report |
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