Inspection Reports for Atria Walnut Creek
1400 Montego, Walnut Creek, CA 94598, United States, CA, 94598
Back to Facility ProfileInspection Report Summary
The facility’s most recent inspection on October 27, 2025, found no deficiencies, continuing a pattern of clean quarterly visits. Earlier reports included several substantiated complaints and deficiencies primarily related to resident care, staffing shortages, and environmental safety, including a serious incident in early 2023 where inadequate supervision and toxic substance storage contributed to a resident’s death. The facility also had issues with timely refunds and maintaining comfortable temperatures during air conditioning repairs, but these were addressed promptly. Many complaint investigations over time were unsubstantiated, indicating that some concerns raised were not confirmed by inspectors. Overall, the facility appears to have improved its compliance and resolved prior deficiencies, with recent inspections showing no citations.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Census: 135
Capacity: 200
Deficiencies: 0
Oct 27, 2025
Visit Reason
The inspection was an unannounced quarterly visit conducted to ensure compliance with the stipulation dated 11/29/2023.
Findings
The Licensing Program Analyst observed that the stipulation was properly posted, kitchen and dining area signage was in place, and staffing ratios met the required levels. All staff were trained as required, and no citations were issued during the visit.
Report Facts
Staffing ratio: 33
Quarterly audit number: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John O'Neil | Executive Director | Met with Licensing Program Analyst during inspection and named in report |
| James Sampair | Licensing Program Analyst | Conducted the inspection visit |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 38
Capacity: 200
Deficiencies: 0
Aug 25, 2025
Visit Reason
The inspection was an unannounced quarterly visit conducted to ensure compliance with the stipulation dated 11/29/2023.
Findings
The Licensing Program Analyst observed that the stipulation was posted conspicuously, kitchen and dining area signage was properly displayed, and staffing ratios met the required levels for the 38 residents. The Quality Evaluation Committee completed the seventh quarterly audit with documentation reviewed for May, June, and July 2025. No citations were issued during the visit.
Report Facts
Staff to resident ratio: 8
Staff to resident ratio: 10
Quarterly audit number: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the inspection and verified compliance with stipulation. |
| Jobelle Dungca | Community Business Director | Met with Licensing Program Analyst during inspection. |
| Kelli Greene | Administrator/Director | Named as facility administrator/director. |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager. |
Inspection Report
Annual Inspection
Census: 146
Capacity: 200
Deficiencies: 0
May 30, 2025
Visit Reason
The inspection was an unannounced Required Annual Inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The inspection found the facility to be in compliance with all licensing requirements, including adequate food supplies, secure medication storage, inaccessible dangerous objects, and up-to-date fire safety equipment. No citations were issued during the inspection.
Report Facts
Fire extinguisher last serviced date: Apr 10, 2025
Fire suppression system last inspection date: Apr 18, 2025
Administrator minimum hours on site: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John O'Neil | National Operations Specialist | Met during inspection and stated purpose of visit |
| Kelli Greene | Executive Director | Facility Executive Director present during inspection |
| James Sampair | Licensing Program Analyst | Conducted the inspection |
| Andrew Christy | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Census: 146
Capacity: 200
Deficiencies: 0
May 30, 2025
Visit Reason
The inspection was an unannounced quarterly visit conducted to ensure compliance with the stipulation dated 11/29/2023.
Findings
The Licensing Program Analysts observed that the stipulation was properly posted, kitchen and dining signage was in place, and staffing ratios met the required levels. Documentation review confirmed that new residents or their responsible parties acknowledged receipt of the stipulation, and relevant manuals were available to staff. No citations were issued during the visit.
Report Facts
Staffing ratio: 6
Staffing ratio: 4
Residents: 30
Deficiency audits completed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John O'Neil | National Operations Specialist | Met with during inspection and informed of visit purpose |
| Kelli Greene | Executive Director | Met with during inspection and informed of visit purpose |
| James Sampair | Licensing Program Analyst | Conducted the inspection |
| Andrew Christy | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 200
Deficiencies: 0
May 7, 2025
Visit Reason
The inspection visit was an unannounced Case Management visit concerning an incident report submitted regarding an allegation of sexual molestation by a caregiver during assistance with a shower.
Findings
The Executive Director reported findings from a police officer and an internal investigation concluding that no sexual molestation had occurred. No citations were issued during the inspection.
Complaint Details
The visit was triggered by a complaint alleging that Resident R1 was sexually molested by caregiver Staff S1 during a shower, as reported by family member W1. The allegation was investigated and found to be unsubstantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Met with Licensing Program Analyst to discuss the complaint and investigation findings. |
| James Sampair | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
Inspection Report
Complaint Investigation
Census: 157
Capacity: 200
Deficiencies: 0
Apr 1, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff did not ensure a resident's room was free of bed bugs and that the resident's air conditioning was not in disrepair.
Findings
The investigation found that staff acted to ensure the resident's room was free of bed bugs and that the HVAC system was fully operational, which did not confirm the allegations. Therefore, the complaint was unsubstantiated.
Complaint Details
The complaint was unsubstantiated as there was not a preponderance of evidence to prove the allegations regarding bed bugs and air conditioning disrepair.
Report Facts
Capacity: 200
Census: 157
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| Kelli Greene | Executive Director | Facility administrator interviewed during investigation |
| James Campers | Maintenance Director | Interviewed about HVAC system operation |
Inspection Report
Census: 150
Capacity: 200
Deficiencies: 0
Feb 20, 2025
Visit Reason
The unannounced visit was conducted to perform the quarterly inspection of the facility to ensure compliance with the stipulation dated 11/29/2023.
Findings
The inspection found that the stipulation was properly posted, kitchen and dining signage was in place, staffing ratios met the required levels, and documentation requirements were met. No citations were issued during the visit.
Report Facts
Staffing ratio: 5
Staffing ratio: 4
Residents: 36
Audit date: Dec 10, 2024
Audit date: Dec 11, 2024
Audit report submission date: Dec 17, 2024
Outside audit date: Oct 2, 2024
Outside audit report submission date: Dec 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Met with during inspection and named in visit narrative |
| Patricia Holguin | Compliance Director | Met with during inspection and named in visit narrative |
| James Sampair | Licensing Program Analyst | Conducted the inspection visit |
| Harpreet Humpal | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 200
Deficiencies: 0
Feb 20, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff did not ensure a resident was provided meals and that the admissions agreement was not being followed.
Findings
The investigation found that the resident was provided meals and the admissions agreement was being followed, which did not confirm the allegations. Therefore, the allegations were unsubstantiated.
Complaint Details
The complaint alleged that staff did not ensure the resident was provided meals and that the admissions agreement was not being followed. After interviews and record reviews, the allegations were found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 200
Census: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Met with during investigation and interviewed regarding allegations |
| Patricia Hoguin | Compliance Director | Interviewed during investigation regarding allegations |
| Risa Austria | Resident Services Director | Interviewed during investigation regarding allegations |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 200
Deficiencies: 0
Jan 9, 2025
Visit Reason
An unannounced complaint investigation was conducted based on allegations that staff do not ensure the facility is maintained in good repair and sanitary conditions.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews with the Executive Director, Maintenance Director, and Compliance Director confirmed ongoing efforts to maintain the facility in good repair and sanitary condition.
Complaint Details
The complaint alleged that staff did not maintain the facility in good repair and sanitary conditions. The allegations were found to be unsubstantiated after investigation.
Report Facts
Complaint Control Number: 15-AS-20250109115336
Investigation duration: 2.5
Estimated repair completion timeframe: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Met with Licensing Program Analyst during investigation and provided information on allegations |
| James Campers | Maintenance Director | Interviewed regarding facility repair allegations |
| Patty Hoguin | Compliance Director | Interviewed regarding facility sanitation allegations |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 200
Deficiencies: 0
Dec 26, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff do not ensure the facility is maintained in good repair and sanitary conditions.
Findings
The investigation found no evidence to substantiate the allegations. Interviews with the Executive Director and Maintenance Director confirmed that repairs are made promptly and the facility is maintained in sanitary condition.
Complaint Details
The complaint was unsubstantiated as there was not a preponderance of evidence to prove the allegations regarding facility maintenance and sanitation.
Report Facts
Capacity: 200
Census: 143
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Met during investigation and provided statements regarding allegations |
| James Campers | Maintenance Director | Interviewed regarding facility maintenance and repairs |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 200
Deficiencies: 0
Dec 5, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that due to lack of supervision, a resident eloped from the facility resulting in death from the heat.
Findings
The investigation included interviews and record reviews, and found that the resident was independent and often declined assistance. Staffing levels were consistent with standards, and there was no preponderance of evidence to substantiate the allegation. The complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged lack of supervision leading to resident elopement and death. The allegation was found to be unsubstantiated after investigation.
Report Facts
Staff on duty: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Met with during the investigation and informed of the visit reason |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| David Doidge | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 150
Capacity: 200
Deficiencies: 0
Nov 19, 2024
Visit Reason
The unannounced visit was conducted to perform the quarterly inspection of the facility to ensure compliance with the stipulation dated 11/29/2023.
Findings
The inspection found that the stipulation was posted conspicuously, kitchen and dining area signage was properly displayed, and staffing ratios met the required standards. Documentation review confirmed that new residents or responsible parties acknowledged receipt of the stipulation, and relevant manuals were available to staff. No citations were issued during the visit.
Report Facts
Staffing ratio: 5
Staffing ratio: 4
Residents: 36
Audit date: Sep 19, 2024
Audit report submission date: Oct 14, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the inspection and verified compliance |
| Jobelle Dungca | Community Business Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 187
Capacity: 200
Deficiencies: 0
Oct 8, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate multiple allegations including failure to seek timely medical attention, inadequate temperature control, hydration issues, lack of resident privacy, and insufficient activities.
Findings
The investigation found all allegations to be unsubstantiated based on interviews, observations, and document reviews. The facility had adequate staffing, appropriate temperature and hydration measures, resident privacy was not violated, and a variety of activities were provided.
Complaint Details
The complaint included nine allegations such as staff not seeking timely medical attention, inadequate temperature and hydration, lack of privacy, and no activities. Conflicting statements were received regarding medical attention. Observations and documentation supported that the facility met requirements. The allegations were unsubstantiated and no citations were issued.
Report Facts
Capacity: 200
Census: 187
Temperature: 75
Temperature: 74
Staff count: 6
Complaint receipt date: Jul 11, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Met with Licensing Program Analyst during the investigation |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation visit |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 149
Capacity: 200
Deficiencies: 0
Aug 20, 2024
Visit Reason
The visit was an unannounced quarterly inspection to ensure that the requirements of the 11/29/2023 stipulation were being followed.
Findings
The inspection found that the stipulation was posted conspicuously, kitchen and dining area signage was properly displayed, and Life Guidance staffing ratios met the required levels. Documentation review confirmed compliance with stipulation requirements, including acknowledgment of stipulation receipt by new residents or responsible parties and availability of a Hazardous Materials and Policies and Procedures Manual to staff. No citations were issued during the visit.
Report Facts
Staffing ratio: 5
Staffing ratio: 4
Staff to resident ratio: 8
Staff to resident ratio: 10
Audit completion date: Jun 13, 2024
Audit report submission date: Jun 26, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Met with Licensing Program Analyst during inspection and named in relation to stipulation compliance |
| James Sampair | Licensing Program Analyst | Conducted the inspection visit |
| Harpreet Humpal | Licensing Program Manager | Named in report header |
Inspection Report
Census: 145
Capacity: 200
Deficiencies: 0
Jul 12, 2024
Visit Reason
The visit was an unannounced Case Management health and safety check related to the facility's air conditioning being inoperable since April.
Findings
The facility mitigated the broken air conditioning by purchasing fans, portable AC units, and renting commercial ACs, ensuring all resident rooms and common areas were at comfortable temperatures. Additional staff were hired to monitor room temperatures and water stations were added in hallways.
Report Facts
Fans purchased: 110
Portable AC units purchased: 200
Resident rooms checked: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Met with Licensing Program Analyst during inspection and provided information about AC issues and mitigation |
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the unannounced Case Management health and safety check |
| Harpreet Humpal | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 145
Capacity: 200
Deficiencies: 0
Jul 10, 2024
Visit Reason
An unannounced Case Management visit was conducted regarding an incident reported to the Community Care Licensing Division on 2024-07-08 involving a resident who left the facility and was later found deceased.
Findings
The Licensing Program Analyst reviewed relevant documents including physician's report, police report, assessments, and staff schedules. No deficiencies were issued during the visit.
Complaint Details
The visit was triggered by a complaint related to a resident who left the facility on 2024-07-04 and was subsequently found deceased nearby by police. The cause of death was unknown at the time of the visit.
Report Facts
Incident date: Jul 4, 2024
Report date: Jul 8, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Met with Licensing Program Analyst during the visit |
| Laura Hall | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Harpreet Humpal | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 200
Deficiencies: 1
Jul 8, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility air conditioner was in disrepair.
Findings
The allegation that the facility air conditioner was in disrepair was substantiated. The air conditioner had been in disrepair since the end of May and was in the process of being fixed, with parts awaited from a third-party vendor. The thermostat on the first floor was observed at 89 degrees Fahrenheit, posing a potential health and safety risk to residents.
Complaint Details
The complaint alleging that the facility air conditioner was in disrepair was substantiated based on interviews and observations during the investigation.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to maintain a comfortable temperature for residents as the air conditioner was in disrepair and thermostats were observed at 89 degrees Fahrenheit. | Type B |
Report Facts
Capacity: 200
Census: 154
Plan of Correction Due Date: Aug 31, 2024
Thermostat Temperature: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Interviewed regarding the air conditioner disrepair and responsible for follow-up with vendor |
| Kelly Nguyen | Licensing Program Analyst | Conducted the complaint investigation |
| Bennett Fong | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 133
Capacity: 200
Deficiencies: 0
Apr 30, 2024
Visit Reason
The unannounced visit was conducted to perform a quarterly inspection to ensure compliance with the stipulation dated 11/29/2023.
Findings
The inspection found that the stipulation was properly posted, kitchen and dining signage was in place, staffing ratios met the required levels, and documentation was reviewed and verified. No citations were issued during the visit.
Report Facts
Staffing ratio: 5
Staffing ratio: 4
Audit report submission timeframe: 14
Quarterly audit completion date: Mar 6, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Met with during inspection and named in report |
| Patricia Hoguin | Compliance Director | Met with during inspection and named in report |
| James Sampair | Licensing Program Analyst | Conducted inspection |
| A. Gharachorloo | Licensing Program Analyst | Conducted inspection |
Inspection Report
Annual Inspection
Census: 133
Capacity: 200
Deficiencies: 0
Apr 30, 2024
Visit Reason
The inspection visit was conducted as a continuation of the required annual inspection of the facility that began on 2024-04-24, to verify compliance with licensing requirements.
Findings
The Licensing Program Analysts, along with the Executive Director and Compliance Director, reviewed emergency supplies, staff training records, and resident and staff files. The annual inspection was completed with no citations issued.
Report Facts
Resident files reviewed: 7
Staff files reviewed: 5
Staff interviewed: 5
Residents interviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Met with Licensing Program Analysts during inspection |
| Patricia Hoguin | Compliance Director | Participated in examination of emergency supplies and staff training verification |
| James Sampair | Licensing Program Analyst | Conducted inspection |
| A. Gharachorloo | Licensing Program Analyst | Conducted inspection |
Inspection Report
Annual Inspection
Census: 131
Capacity: 200
Deficiencies: 0
Apr 24, 2024
Visit Reason
The visit was an unannounced required annual inspection of the facility conducted by the Licensing Program Analyst.
Findings
The Licensing Program Analyst inspected the physical plant, including kitchens, dining areas, restrooms, community living spaces, resident rooms, and storage. No citations were issued during the inspection, and the annual inspection was not complete at the time of the report, with a return visit planned to complete it.
Report Facts
Fire extinguisher last service date: May 25, 2023
Fire suppression system last inspection date: Mar 22, 2024
Administrator minimum hours per week: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Met with Licensing Program Analyst during inspection |
| Matthew Maroquin | Maintenance Director | Assisted in inspection of physical plant |
| Patricia Hoguin | Compliance Director | Assisted in examination of chemical storage areas |
| James Sampair | Licensing Program Analyst | Conducted the inspection |
| Harpreet Humpal | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Capacity: 200
Deficiencies: 0
Apr 24, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 12/20/2022 regarding staff neglect resulting in a resident sustaining a fracture and failure to seek timely medical attention for a resident.
Findings
The investigation found the allegation of staff neglect resulting in a resident sustaining a fracture to be unsubstantiated due to lack of preponderance of evidence. The allegation that facility staff did not seek timely medical attention was found to be unfounded based on evidence including 911 call records and staff interviews. No citations were issued during the visit.
Complaint Details
The complaint alleged staff neglect causing a resident's fracture and failure to seek timely medical attention. The investigation included interviews with staff and review of multiple records. The fracture allegation was unsubstantiated, and the medical attention allegation was unfounded.
Report Facts
Facility capacity: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Freeth | Former Assistant Executive Director | Interviewed regarding resident's fall and medical attention |
| Kelli Greene | Executive Director | Met with Licensing Program Analyst during investigation |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 200
Deficiencies: 0
Mar 20, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not follow the resident's care plan and did not do a proper assessment of the resident.
Findings
The Licensing Program Analyst reviewed relevant care plans, assessments, resident notes, physician reports, and task lists, and interviewed witnesses and facility staff. The analysis showed that staff were following the resident's care plan and conducting proper assessments. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff did not follow the resident's care plan and did not do a proper assessment of the resident. After investigation, the allegations were found to be unsubstantiated.
Report Facts
Capacity: 200
Census: 139
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Ann Arabos | Resident Services Director | Met with during inspection and involved in investigation |
| Kelli Greene | Administrator / Executive Director | Informed of visit and involved in investigation |
| Aron Alexander | Regional Vice President | Informed of visit and involved in investigation |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 128
Capacity: 200
Deficiencies: 0
Jan 11, 2024
Visit Reason
The visit was conducted to deliver an updated license including probationary status and to perform the initial inspection of the facility after a stipulation went into effect on 11/29/2023.
Findings
The Licensing Program Analyst observed compliance with stipulation posting, staff-to-resident ratios, and documentation requirements including staff training, Quality Evaluation Committee formation, and audit reporting. No citations were issued during the visit.
Report Facts
Staff to resident ratio: 1
Staff to resident ratio: 4
Staff scheduled: 4
Audit timeframe: 14
Audit report submission timeframe: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Met with Licensing Program Analyst during visit and involved in license delivery and facility tour |
| James Sampair | Licensing Program Analyst | Conducted the inspection visit and license delivery |
| Bennett Fong | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 200
Deficiencies: 0
Dec 4, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff do not ensure a comfortable living environment for residents due to noise caused by a resident's pet.
Findings
The investigation found that although the allegation may have occurred, there was insufficient evidence to prove that staff failed to ensure a comfortable living environment. The complaint was therefore unsubstantiated.
Complaint Details
The complaint alleged that staff did not ensure a comfortable living environment due to noise from Resident 2's pet. The pet was brought without notification and the responsible party did not disclose it at lease signing. The Executive Director has been working to remove the pet since the disturbance was first reported on 11/21/2023. The allegation was unsubstantiated.
Report Facts
Complaint Control Number: 15-AS-20231201092619
Capacity: 200
Census: 135
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Named in relation to the complaint investigation and findings |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation visit |
| Bennett Fong | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 200
Deficiencies: 1
Nov 29, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility did not issue a refund to a resident in care.
Findings
The investigation substantiated the allegation that the facility failed to issue a refund of $1,278.00 to Resident 1 after departure. The facility corrected the deficiency during the visit by issuing a refund of $2,186.63, which was $908.63 more than required.
Complaint Details
The complaint was substantiated. The allegation was that the facility did not issue a refund to a resident in care. The facility issued the refund during the investigation.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to refund Resident 1's preadmission fee of $1,278.00 as required by regulation. | Type B |
Report Facts
Refund amount issued: 2186.63
Refund amount required: 1278
Census: 135
Total capacity: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Administrator | Named in relation to the refund processing error and investigation. |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation. |
| Bennett Fong | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 200
Deficiencies: 0
Nov 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff changed a resident's service plan without consent and that a resident was billed for services not rendered.
Findings
The investigation found that the facility acted in the best interest of the resident regarding the service plan changes, and the billed services were verified as provided. There was no preponderance of evidence to substantiate the allegations, and the complaint was unsubstantiated.
Complaint Details
The complaint was unsubstantiated. Allegations included unauthorized changes to a resident's service plan and billing for services not rendered. Documentation and reports reviewed confirmed the facility's compliance.
Report Facts
Capacity: 200
Census: 135
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Met with during the investigation and named in findings |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation visit |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 200
Deficiencies: 0
Oct 11, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the facility did not have a certified administrator and that the facility administrator was not qualified.
Findings
The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations were unsubstantiated.
Complaint Details
The complaint was unsubstantiated due to insufficient evidence to prove the alleged violations regarding the certification and qualification of the facility administrator.
Report Facts
Complaint Control Number: 15-AS-20230517131516
Capacity: 200
Census: 128
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Jeffrey Freeth | Former Executive Director | Referenced in records review regarding certification and qualification |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation visit |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Capacity: 200
Deficiencies: 0
Oct 10, 2023
Visit Reason
The visit was an unannounced Case Management inspection concerning 5 Unusual Incident Reports of 5 unwitnessed falls occurring on the same day, 10/06/2023, including two falls involving the same resident.
Findings
The Licensing Program Analyst interviewed the Resident Services Director and Executive Director, who explained that all events were managed in accordance with Title 22 regulations. No citations were issued during the visit.
Report Facts
Unusual Incident Reports: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Arabos | Resident Services Director | Interviewed regarding the incident reports |
| Kelli Greene | Executive Director | Interviewed regarding the incident reports |
| James Sampair | Licensing Program Analyst | Conducted the inspection visit |
| Bennett Fong | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 200
Deficiencies: 0
Aug 9, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations regarding the facility's air conditioning being in disrepair and staff not maintaining a comfortable room temperature for residents.
Findings
The HVAC system did require repair starting on 08/06/2023, but this was not considered a long-term neglectful act. Staff acted quickly to maintain a comfortable room temperature by providing approximately 50 air conditioning units or fans. Some residents acted contrary to staff instructions, affecting room temperatures. No citations were issued and the allegations were unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Although the allegations may have happened or be valid, there was insufficient evidence to prove the alleged violations did or did not occur.
Report Facts
Air conditioning units or fans provided: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Administrator | Met with during investigation and named in report |
| Matthew Marroquin | Maintenance Director | Interviewed during investigation |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| Bennett Fong | Licensing Program Manager | Named in report |
Inspection Report
Annual Inspection
Census: 122
Capacity: 200
Deficiencies: 0
Jun 29, 2023
Visit Reason
The visit was a continuation of the Annual Inspection that began on 06/21/2023, conducted to evaluate the facility's compliance and operations.
Findings
During the inspection, the Licensing Program Analyst toured the facility, reviewed resident and staff files, and interviewed residents and staff. No citations were issued during this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Administrator | Met with during the inspection and named in the report narrative. |
| James Sampair | Licensing Program Analyst | Conducted the inspection and named in the report narrative. |
| Harpreet Humpal | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Census: 118
Capacity: 200
Deficiencies: 0
Jun 21, 2023
Visit Reason
The inspection was an unannounced Required - 1 Year Inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The inspection was stopped early due to the size of the facility and recent administrative changes, with no citations issued during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Mentioned in relation to not being present during the inspection. |
| Antoine Rabbat | Life Guidance Director | Met with the Licensing Program Analyst during the inspection and exit interview. |
| James Sampair | Licensing Program Analyst | Conducted the inspection. |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Follow-Up
Census: 116
Capacity: 200
Deficiencies: 0
May 12, 2023
Visit Reason
Unannounced Case Management visit to follow-up on the accusation document provided to the facility.
Findings
The Licensing Program Analyst toured the facility, confirmed that written notice regarding the accusation was posted and residents received the notice. No deficiencies were issued during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelli Greene | Executive Director | Met with Licensing Program Analyst during the visit and explained the purpose of the visit. |
| Laura Hall | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Harpreet Humpal | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 200
Deficiencies: 2
Apr 18, 2023
Visit Reason
This was a Case Management visit conducted as a follow-up on a case management citation related to a questionable death of a resident due to inadequate supervision and staff competency.
Findings
The investigation determined that the facility failed to adequately supervise a resident (R1) who ingested a caustic liquid cleaning agent, resulting in injury and death. The facility also failed to have competent staff to meet residents' needs and violated regulations regarding storage of toxic substances and personnel requirements.
Complaint Details
The visit was complaint-related due to a questionable death of resident R1 who ingested a caustic liquid cleaning agent. The complaint was substantiated based on autopsy and investigation findings.
Deficiencies (2)
| Description |
|---|
| Violation of CCR Title 22 § 87705(f)(2) – Care of Persons with Dementia regarding storage of toxic substances inaccessible to residents. |
| Violation of CCR Title 22 § 87411(a) – Personnel Requirements, insufficient and incompetent staff to meet resident needs. |
Report Facts
Civil penalty amount: 14500
Immediate civil penalty amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Freeth | Administrator | Facility administrator named in report header. |
| Kelli Greene | Executive Director | Met with Licensing Program Analyst during visit. |
| Laura Hall | Licensing Program Analyst | Conducted the Case Management visit and authored the report. |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager overseeing the case. |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 200
Deficiencies: 2
Mar 7, 2023
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation related to failure to submit reports for a resident's fall incident and concerns about facility maintenance.
Findings
The facility failed to submit required incident reports for a resident's fall in 2015 and had an old mattress in a resident's room for over a year, posing potential safety and personal rights risks. Deficiencies were cited under Title 22 California Code of Regulations.
Complaint Details
Complaint Control # 15-AS-20210323144314 regarding failure to submit reports for resident R1's fall and maintenance issues with an old mattress in the resident's room.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to submit incident report for resident R1's fall incident, posing potential personal right risk. | Type B |
| Facility did not maintain a clean, safe, sanitary environment as evidenced by an old mattress in resident R1's room for an extended period. | Type B |
Report Facts
Capacity: 200
Census: 127
Deficiencies cited: 2
Plan of Correction Due Date: Mar 21, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Freeth | Assistant Executive Director | Met with Licensing Program Analyst during inspection and discussed deficiencies |
| Alicia Delmundo | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Bennett Fong | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 200
Deficiencies: 5
Mar 7, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to allegations including resident sustaining a fractured leg, multiple falls, pressure injury, unlawful eviction, and insufficient staffing to meet resident needs.
Findings
The investigation substantiated allegations that Resident R1 sustained multiple injuries including fractures and pressure injuries while in care, the facility issued an unlawful eviction notice related to dietary needs, and the facility was short-staffed impacting resident care. Another allegation regarding failure to provide resident's authorized representative with records was unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations that Resident R1 sustained a fractured leg, multiple falls, pressure injuries, unlawful eviction, and insufficient staffing. The allegation that facility staff did not provide the resident's authorized representative with a copy of the resident's records was unsubstantiated.
Severity Breakdown
Type A: 3
Type B: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to provide safe, healthful, and comfortable accommodations, furnishings, and equipment resulting in Resident R1 sustaining a fracture. | Type A |
| Failure to provide basic services including care and supervision leading to Resident R1 sustaining injuries such as broken hip, bruising, broken wrist, and hematoma. | Type A |
| Failure to prevent pressure injuries for Resident R1, posing immediate health and personal right risks. | Type A |
| Failure to follow proper eviction procedures by issuing a 30-day eviction notice to Resident R1 for being on a pureed diet. | Type B |
| Insufficient staffing to meet resident needs, posing potential safety and personal right risks. | Type B |
Report Facts
Capacity: 200
Census: 127
Civil penalty: 500
Plan of Correction Due Date: Mar 8, 2023
Plan of Correction Due Date: Mar 21, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Freeth | Assistant Executive Director | Met with Licensing Program Analyst during investigation |
| Jennifer Coons | Administrator | Facility administrator named in report header |
| Alicia Delmundo | Licensing Program Analyst | Conducted complaint investigation |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager overseeing investigation |
Inspection Report
Follow-Up
Census: 123
Capacity: 200
Deficiencies: 2
Feb 2, 2023
Visit Reason
Unannounced case management follow-up visit regarding a questionable resident death on 2022-08-31 due to inadequate supervision leading to ingestion of chemical substances.
Findings
Investigation substantiated that staff failed to adequately supervise resident R1, resulting in ingestion of toxic cleaning chemicals and subsequent death. Deficiencies were cited related to improper storage of toxic substances and insufficient staffing.
Complaint Details
The visit was a follow-up investigation related to a substantiated complaint regarding the death of resident R1 due to staff failing to supervise, resulting in ingestion of chemical substances.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to store cleaning supplies and disinfectants inaccessible to residents with dementia, resulting in resident ingesting chemicals. | Type A |
| Failure to maintain sufficient and competent staff to meet resident needs, leading to inadequate supervision of resident. | Type A |
Report Facts
Civil penalty: 500
Capacity: 200
Census: 123
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Freeth | Assistant Executive Director | Met with Licensing Program Analyst during visit and involved in delivery of findings |
| Laura Hall | Licensing Program Analyst | Conducted the inspection and investigation |
Inspection Report
Census: 123
Capacity: 200
Deficiencies: 0
Feb 2, 2023
Visit Reason
The visit was an unannounced Case Management visit conducted to deliver an Immediate Exclusion letter and verify that the excluded individual was no longer present or working at the facility.
Findings
No deficiencies were cited during the visit. The Immediate Exclusion letter was delivered to the Assistant Executive Director, and an exit interview was conducted.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Freeth | Assistant Executive Director | Met during the visit and received the Immediate Exclusion letter. |
| Jay Thomas | Assistant General Counsel | Requested to listen to the reading of the report via telephone. |
| Laura Hall | Licensing Program Analyst | Conducted the Case Management visit and delivered the Immediate Exclusion letter. |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 123
Capacity: 200
Deficiencies: 1
Feb 2, 2023
Visit Reason
The visit was an unannounced Case Management visit conducted to review compliance related to an incident reported on 8/24/2022 and follow up on appraisal needs and services plan for a resident.
Findings
The licensee failed to ensure that Resident 1's appraisal needs and services plan was updated and signed by the resident's representative, which posed an immediate health and safety risk. This deficiency was cited under California Code of Regulation, Title 22.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure Resident 1's appraisal needs and services plan was up-to-date and signed by the resident's representative. | Type B |
Report Facts
Capacity: 200
Census: 123
Plan of Correction Due Date: Feb 9, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Freeth | Assistant Executive Director | Met with Licensing Program Analyst during the visit and involved in citation delivery |
| Laura Hall | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Harpreet Humpal | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Capacity: 200
Deficiencies: 0
Jan 12, 2023
Visit Reason
An unannounced Case Management visit was conducted regarding a prior incident that was reported to the Community Care Licensing Division (CCLD).
Findings
During the visit, the Licensing Program Analyst interviewed five staff members and collected the staff schedule for memory care to gather information about the prior incident. An exit interview was conducted and a copy of the report was provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Freeth | Assistant Executive Director | Met with Licensing Program Analyst during the visit. |
| Laura Hall | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Harpreet Humpal | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 200
Deficiencies: 0
Dec 22, 2022
Visit Reason
The inspection visit was conducted as a result of a Priority 2 complaint to perform a health and safety check at the facility.
Findings
The Licensing Program Analysts toured the facility and found that the facility temperature, hot water temperature, food supplies, medication storage, smoke and carbon monoxide detectors, first-aid kit, and fire extinguisher were all in compliance. No citations were issued.
Complaint Details
The visit was triggered by a Priority 2 complaint. No citations or deficiencies were issued, indicating no substantiated violations.
Report Facts
Facility capacity: 200
Resident census: 129
Facility temperature: 70.9
Hot water temperature: 118
Non-perishable food supply days: 7
Perishable food supply days: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Antoine Rabbat | Life Guidance Director | Met with Licensing Program Analysts during inspection |
| Jeffrey Freeth | Administrator | Facility administrator named in report header |
| James Sampair | Licensing Program Analyst | Conducted the inspection |
| G. Luk | Licensing Program Analyst | Conducted the inspection |
| Harpreet Humpal | Licensing Program Manager | Named in report |
Inspection Report
Census: 128
Capacity: 200
Deficiencies: 0
Nov 29, 2022
Visit Reason
An unannounced Case Management visit was conducted to review the facility's Emergency and Disaster Plan update and the reporting of Unusual Incidents to the Regional Office.
Findings
The facility was advised to update its Emergency and Disaster Plan from the 2003 to the 2019 version and to improve the timeliness and completeness of Unusual Incident Reports. No citations were issued during the inspection.
Report Facts
Unusual Incident Reports: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Freeth | Associate Executive Director | Met with Licensing Program Analyst during the visit and discussed facility compliance |
| James Sampair | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Harpreet Humpal | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Capacity: 200
Deficiencies: 0
Sep 9, 2022
Visit Reason
An unannounced Case Management visit was conducted by Licensing Program Analyst L. Hall to review requested documents and assess compliance.
Findings
The Licensing Program Analyst requested and obtained documents from facility leadership via email and telephone during the visit. An exit interview was conducted and a copy of the report was provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eleasha Brown | Resident Service Director | Met with Licensing Program Analyst during the visit and provided requested documents. |
| Jeffrey Freeth | Assistant Executive Director | Contacted via email and telephone to provide requested documents. |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 200
Deficiencies: 0
Sep 2, 2022
Visit Reason
An unannounced Case Management visit was conducted regarding an incident reported to the Community Care Licensing Division on 08/30/2022 involving a resident found walking unattended outside the community.
Findings
The Licensing Program Analyst met with the Resident Services Director to discuss the incident involving resident R1, who has mild dementia and is able to leave the facility unassisted. The facility responded by returning the resident to the community after being found by a bus driver.
Complaint Details
The visit was triggered by a complaint incident reported on 08/30/2022 concerning resident R1 walking unattended outside the community on 08/29/2022. The incident was investigated and discussed with facility staff.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leasha Brown | Resident Services Director | Met with Licensing Program Analyst regarding the incident involving resident R1. |
| James Sampair | Licensing Program Analyst | Conducted the unannounced Case Management visit and investigation. |
| Harpreet Humpal | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 124
Capacity: 200
Deficiencies: 0
Sep 1, 2022
Visit Reason
An unannounced Case Management visit was conducted regarding an incident reported to the Community Care Licensing Division on 2022-08-24 involving a resident who experienced a choking incident and subsequent death.
Findings
The incident involved a resident taken to the emergency room due to choking on 2022-08-23, with the facility submitting a death report on 2022-08-31. The Assistant Executive Director provided information about the incident and communication with hospital staff and family.
Complaint Details
The visit was triggered by a complaint related to a choking incident resulting in a resident's death. The facility was not aware of the resident's death until the coroner arrived on 2022-08-31.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Freeth | Assistant Executive Director | Met with Licensing Program Analyst to provide information regarding the incident. |
| Laura Hall | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Harpreet Humpal | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 200
Deficiencies: 0
Jul 29, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2020-11-25 regarding resident care, staffing, accommodations, and pest infestation at the facility.
Findings
The investigation found that the facility was scheduling an appropriate number of staff and conducting regular pest control visits. However, there was insufficient evidence to substantiate the allegations, and therefore the complaint was unsubstantiated.
Complaint Details
The complaint included allegations that residents were not receiving assistance with activities of daily living, insufficient staff to meet resident needs, unsafe and uncomfortable accommodations, and rodent infestation. The investigation concluded these allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Complaint Control Number: 15-AS-20201125093323
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
| Lauren Cottman | Life Guidance Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 200
Deficiencies: 0
Jul 29, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-12-10 alleging issues such as no activity director and insufficient food service personnel.
Findings
Based on records review and staff interviews, the facility was delivering meals to rooms following current COVID guidelines, with care staff assisting dining staff. There was insufficient evidence to substantiate the allegations, so the complaint was unsubstantiated.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations did or did not occur.
Report Facts
Complaint Control Number: 15-AS-20201210130725
Capacity: 200
Census: 121
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Cottman | Life Guidance Director | Met with Licensing Program Analyst during investigation |
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 200
Deficiencies: 0
Jul 27, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that a resident caused injuries to other residents in care.
Findings
The investigation found that the facility properly attended to the rights, needs, and safety of all residents. The allegation was determined to be unsubstantiated as there was not a preponderance of evidence to prove it did or did not occur.
Complaint Details
The complaint alleged that a resident caused injuries to other residents. The investigation was unsubstantiated based on the evidence reviewed and interviews conducted.
Report Facts
Capacity: 200
Census: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Freeth | Assistant Executive Director | Met with during the investigation and exit interview |
| Leash Brown | Resident Services Director | Met with during the investigation and exit interview |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 200
Deficiencies: 0
Jul 27, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2022-05-04 regarding staff not meeting residents' hygiene needs, not noticing change of condition in a resident, and not providing an authorized representative a refund.
Findings
The investigation found that the facility properly attended to the resident's needs. Based on interviews and record reviews, the allegations were unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint was unsubstantiated after investigation, meaning there was insufficient evidence to prove the allegations occurred.
Report Facts
Capacity: 200
Census: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Freeth | Assistant Executive Director | Met with Licensing Program Analyst during investigation |
| Leash Brown | Resident Services Director | Met with Licensing Program Analyst during investigation |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Annual Inspection
Census: 125
Capacity: 200
Deficiencies: 0
Jul 21, 2022
Visit Reason
The inspection was an infection control annual inspection conducted as a required one-year unannounced visit to evaluate the facility's infection control practices.
Findings
The facility has an infection control plan in place and is following it, including universal entry screening, daily cleaning and sanitation, and COVID-19 signage. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Freeth | Assistant Executive Director | Met with Licensing Program Analyst during the inspection and involved in the facility tour. |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 200
Deficiencies: 0
Jun 29, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that residents were being overcharged for services.
Findings
The investigation found that although residents received a rate increase notification with reasons and history of rate changes, there was no preponderance of evidence to substantiate the allegation of overcharging. Therefore, the complaint was unsubstantiated.
Complaint Details
The complaint alleged that residents were being overcharged for services. The investigation included review of admission agreements and rate increase notifications. The allegation was found to be unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 200
Census: 121
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Freeth | Assistant Executive Director | Met with Licensing Program Analyst during the investigation |
| Leslie Ibo | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 200
Deficiencies: 0
Dec 9, 2021
Visit Reason
The visit was conducted as a case management incident investigation concerning errors in the delivery of medications on 12/05/21 and 12/06/21 to two different residents by medical technicians.
Findings
The investigation found that the medication errors were related to new medical technicians lacking sufficient support and training. Retraining was provided to all med techs, one med tech resigned, and another is being shadowed to complete training. No deficiencies were cited during this visit.
Complaint Details
The visit was triggered by medication delivery errors reported for two residents. The complaint was investigated and found to be related to training and support issues for new medical technicians. No deficiencies were cited.
Report Facts
Census: 111
Total Capacity: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Tudda | Acting Executive Director | Met with Licensing Program Analyst regarding medication errors and training issues |
| James Sampair | Licensing Program Analyst | Conducted the inspection visit and investigation |
| Eleasha Brown | Resident Services Director, LVN | Involved in reviewing training deficiencies for medical technicians |
| Kulbhushan Rai | Medical Technician | Involved in medication delivery error and gave two week notice |
| Camille Mallari | Medical Technician | Involved in medication delivery error and undergoing retraining and shadowing |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 200
Deficiencies: 0
Nov 22, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff did not safeguard a resident's personal property.
Findings
The investigation found the complaint to be unfounded, meaning the allegation was false or without reasonable basis. No deficiencies were cited.
Complaint Details
The complaint alleged that staff did not safeguard resident R1's personal property, specifically an auditory device. The investigation reviewed medical and facility records and found no evidence of loss or theft. The complaint was dismissed as unfounded.
Report Facts
Capacity: 200
Census: 115
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
| Barbara Tudda | Executive Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Annual Inspection
Census: 96
Capacity: 200
Deficiencies: 0
Jun 12, 2021
Visit Reason
The visit was an infection control annual inspection conducted to evaluate COVID-19 mitigation practices and overall infection control compliance at the facility.
Findings
The facility was found to be in compliance with COVID-19 infection control practices, including mask usage, symptom screening, social distancing, and vaccination of all staff and residents. No deficiencies were cited during the visit.
Report Facts
Days of nonperishable food supply: 7
Days of perishable food supply: 2
Facility room temperature: 73
Administrator onsite hours per week: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Coons | Administrator | Facility administrator met during inspection and infection control designated leader |
| Daisy Panlilio | Licensing Program Analyst | Conducted the inspection |
| Bennett Fong | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 200
Deficiencies: 0
Mar 24, 2021
Visit Reason
The inspection was conducted as a result of a complaint received by the Department (Control # 15-AS-20210323144314). Due to management directive to telework, the inspection was done via video conference.
Findings
The Licensing Program Analyst inspected various areas including living and dining rooms, activity area, and resident apartments in assisted living and memory care units. Hallways were observed free of obstructions and an evacuation chair was noted on the stairwell. No citations were issued during this inspection.
Complaint Details
Inspection was triggered by a complaint (Control # 15-AS-20210323144314). No citations were issued, indicating no substantiated deficiencies.
Report Facts
Facility capacity: 200
Census: 107
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Coons | Executive Director | Met with Licensing Program Analyst during inspection and facilitated the tour |
| Alicia Delmundo | Licensing Program Analyst | Conducted the health and safety inspection |
| Isaac Taggart | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 200
Deficiencies: 1
Dec 18, 2020
Visit Reason
An unannounced continuing complaint visit was conducted by telephone due to the State’s Shelter-in-Place order, to investigate a subject resident issued a 30-day letter for altercations with other residents.
Findings
The investigation found that the altercations did occur but were not solely due to the subject resident, who was assumed to be the perpetrator. The facility's evaluation shortly before the incidents showed the resident did not have behavioral concerns. A deficiency was cited related to personal rights violations.
Complaint Details
The visit was complaint-related, investigating a subject resident's 30-day letter for altercations. It was determined the resident was not solely responsible, and the deficiency was cited accordingly.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personal Rights of Residents in All Facilities were not met as a subject resident was subjected to disciplinary action when multiple residents were involved in altercations. | Type B |
Report Facts
Deficiency count: 1
Plan of Correction Due Date: Jan 1, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeremy Fong | Acting Licensing Program Manager | Conducted the unannounced continuing complaint visit. |
| Julio Montes | Licensing Program Manager | Supervisor named in the report and deficiency section. |
| Bennett Fong | Licensing Program Analyst / Evaluator | Created the report and acknowledged licensing appeal rights. |
| Jennifer Coons | Administrator | Facility administrator met during the visit. |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 200
Deficiencies: 2
Dec 18, 2020
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations including resident injury and failure to seek timely medical attention.
Findings
The investigation substantiated that a resident sustained an injury which was not observed or timely addressed by staff, supported by photo evidence and hospital records. Other allegations related to sanitation and resident care were unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for allegations that a resident sustained injury while in care and staff failed to seek medical attention in a timely manner. Other allegations including resident locked in restroom, unsanitary conditions, failure to respond to call button, failure to meet hygiene needs, failure to provide safe environment, and illegal eviction were unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided. This requirement was not met as evidenced by LPAs observed a color photo time/date stamped within subject time period illustrating an injury and confirmed by hospital record. | Type A |
| Basic Services - Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by LPAs observed that a photo of R1s, time and date stamped with the subject time period, illustrating an injury and confirmed by hospital record, but staff failed to observe the condition and no evaluation was performed. | Type B |
Report Facts
Capacity: 200
Census: 108
Deficiency Type A POC Due Date: Dec 21, 2020
Deficiency Type B POC Due Date: Jan 1, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeremy Fong | AGPA / Acting Licensing Program Manager | Conducted the unannounced continuing complaint visit and investigation |
| Jennifer Coons | Administrator | Facility administrator met during the investigation |
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