Inspection Report Summary
Most inspections found no deficiencies, and the facility’s annual inspections in 2024 and 2025 showed full compliance with regulations. The most recent report from July 10, 2025, was a complaint investigation that found no deficiencies and deemed the allegation of staff sexual assault unsubstantiated after thorough review. Historically, the facility had isolated issues related to reporting incidents to licensing authorities in mid-2023 and infection control and personal rights violations in 2022, which resulted in some deficiencies and civil penalties but no fines or license suspensions are listed in the available reports. Several complaint investigations over the years were unsubstantiated, including allegations of neglect, improper medication, and mistreatment. The facility’s record shows improvement over time, with recent inspections free of deficiencies and no serious enforcement actions reported.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
4.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
89% occupied
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 123
Capacity: 138
Deficiencies: 0
Date: Jul 10, 2025
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff sexually assaulted a resident in care.
Complaint Details
The complaint alleged that Staff #1 sexually assaulted Resident #1 about two months prior. Investigations included multiple visits, interviews with residents and staff, and review of police and facility records. Staff #1 denied the allegations and stated awareness of facility policies prohibiting sexual contact. The police investigation ended due to consensual encounters unrelated to the facility. The allegation was unsubstantiated due to insufficient evidence.
Findings
The investigation included interviews with staff and residents, review of records, and a police report. No sufficient evidence was found to substantiate the allegation, and the complaint was deemed unsubstantiated. No immediate health or safety hazards were observed during the visit.
Report Facts
Complaint Control Number: 31
Complaint Control Number Suffix: 20250416153601
Number of residents interviewed: 4
Number of sexual encounters reported in police report: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation visit and report |
| Christine Ferris | Senior Investigator | Conducted subsequent investigation visits and interviews |
| Carolina Garcia-Trejo | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 138
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations that facility staff were not following physician's orders related to Resident #1's post-surgery discharge instructions.
Complaint Details
The complaint alleged that facility staff did not follow discharge orders from Resident #1's surgery on 03/06/2025. The allegation was unsubstantiated based on interviews, observations, and record review.
Findings
The investigation found that Resident #1 was capable of following discharge orders independently and did not report needing assistance. Staff were aware of the orders, and the allegation that staff failed to follow physician's orders was deemed unsubstantiated.
Report Facts
Facility capacity: 138
Resident census: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation visit |
| Carolina Garcia-Trejo | Administrator | Facility administrator mentioned in the report |
Inspection Report
Annual Inspection
Census: 124
Capacity: 138
Deficiencies: 0
Date: Jan 15, 2025
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with Title 22 regulations and assess the facility's conditions and operations.
Findings
The facility was found to be in compliance with Title 22 regulations with no immediate health and safety risks observed. All resident files were complete, safety equipment was operational, and medication storage and records were accurate.
Report Facts
Resident bedrooms: 108
Resident bedrooms: 19
Approved hospice waivers: 25
Fire extinguisher last inspection date: Oct 18, 2024
Hot water temperature: 118.8
Room temperature: 71
Delayed egress alarm duration: 15
Walk-in refrigerator temperature: 40
Walk-in freezer temperature: -2
Medication supplies reviewed: 5
Washing machines: 4
Dryers: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the inspection and authored the report |
| Naira Margaryan | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Joyce Martinez | Met with Licensing Program Analyst during inspection | |
| Carolina Garcia-Trejo | Administrator/Director | Facility Administrator/Director named in report |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 138
Deficiencies: 0
Date: Dec 27, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that a resident sustained injury from a fall due to lack of supervision and that the resident did not receive timely medical attention.
Complaint Details
The complaint involved two allegations: 1) Resident sustained injury from a fall due to lack of supervision, and 2) Resident did not receive timely medical attention. Both allegations were investigated and found to be unsubstantiated.
Findings
The investigation found that staff provided sufficient supervision to the resident and timely medical attention was offered but refused by the resident. Both allegations were deemed unsubstantiated based on interviews, record reviews, and observations.
Report Facts
Capacity: 138
Census: 122
Date complaint received: Dec 6, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Carolina Garcia-Trejo | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 177
Capacity: 138
Deficiencies: 0
Date: Sep 20, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation that staff did not ensure reporting requirements were followed regarding a cut on the arm of a resident.
Complaint Details
The complaint alleged that staff did not report a cut on the arm of Resident #1 to family in April 2023. The investigation revealed the injury was reported to the hospice agency and the responsible party, leading to the allegation being unsubstantiated.
Findings
The investigation found that the injury was reported to the resident's hospice agency and the responsible party, and facility staff followed reporting requirements. The allegation was deemed unsubstantiated. No immediate health and safety hazards were observed.
Report Facts
Capacity: 138
Census: 177
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation visit |
| Carolina Garcia-Trejo | Administrator | Facility administrator mentioned in the report |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 138
Deficiencies: 0
Date: Aug 9, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate the allegation that staff did not safeguard a resident's personal belongings.
Complaint Details
The complaint alleged that staff did not safeguard resident's personal belongings, including a dresser, monitor, blanket, shirts, compression socks, sodas, waters, and a wheelchair. After interviews and record reviews, the allegation was found to be unsubstantiated.
Findings
The investigation found that the facility properly safeguarded the resident's belongings and sent them to the resident's Skilled Nursing Facility and new residence. Therefore, the allegation was unsubstantiated. No immediate health and safety risks were observed during the visit.
Report Facts
Capacity: 138
Census: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation |
| Carolina Garcia-Trejo | Administrator | Named in relation to the investigation and interviews |
| Joyce Martinez | Met with during the visit | |
| Naira Margaryan | Licensing Program Manager | Named in report signature |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 138
Deficiencies: 0
Date: Aug 2, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit to address allegations of unlawful eviction of a resident from the facility.
Complaint Details
The complaint alleged unlawful eviction of Resident #1 (R1) from the facility. After interviews and record reviews, it was determined that R1 was not evicted but was placed in an alternate facility based on medical recommendations and social worker advice. The allegation was unsubstantiated.
Findings
The investigation found that the facility did not evict the resident; the resident was noncompliant with medical advice and was recommended for placement at an alternate facility. The allegation of unlawful eviction was deemed unsubstantiated. No immediate health and safety risks were observed.
Report Facts
Capacity: 138
Census: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Carolina Garcia-Trejo | Administrator | Interviewed regarding eviction allegation |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 138
Deficiencies: 0
Date: Aug 2, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that the facility was overcharging a resident in care.
Complaint Details
The complaint alleged that the facility was overcharging a resident by charging $75 per day for leaving belongings in a previous room. The allegation was investigated and found to be unsubstantiated.
Findings
The investigation found that the resident was not being overcharged. Interviews and record reviews confirmed that the resident did not pay rent on time but was not charged any late fees or extra charges, and was not charged for belongings left in a previous room. The allegation was deemed unsubstantiated.
Report Facts
Capacity: 138
Census: 135
Late fee amount: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation and interviews |
Inspection Report
Complaint Investigation
Census: 132
Capacity: 138
Deficiencies: 0
Date: Jul 3, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility did not report resident relocations to the required agencies.
Complaint Details
The complaint alleged that the facility failed to report the relocation of resident R1 to R1’s case manager and failed to report resident R2’s hospitalization and placement in a skilled nursing facility to R2’s family member. The investigation revealed that notifications were properly made, and the legal authority of the family member was expired.
Findings
The investigation found that the facility properly notified the appropriate individuals and agencies regarding resident relocations. The allegation was deemed unsubstantiated based on interviews and record reviews.
Report Facts
Capacity: 138
Census: 132
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation visit |
| Carolina Garcia-Trejo | Administrator | Facility administrator met during the investigation |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 138
Deficiencies: 0
Date: Apr 11, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff would not accept a resident back into the facility.
Complaint Details
The complaint alleged that staff would not accept Resident #1 back into the facility. The investigation revealed the resident was hospitalized due to a fall and had an unstageable pressure injury. The facility refused readmission until the injury could be treated at a skilled nursing facility. The resident was readmitted on 04/09/2024. The allegation was unsubstantiated.
Findings
The investigation found that the facility refused to readmit the resident due to an unstageable pressure injury, which was supported by medical advice and compliance with Title 22 regulations. The allegation was deemed unsubstantiated, and no immediate health and safety risks were observed.
Report Facts
Capacity: 138
Census: 137
Date of hospital admission: Apr 5, 2024
Date resident ready for readmission: Apr 7, 2024
Date resident readmitted: Apr 9, 2024
Pressure ulcer size: 1
Number of skilled nursing facilities arranged: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation visit |
| Carolina Garcia-Trejo | Administrator | Facility administrator involved in the investigation |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 138
Deficiencies: 0
Date: Mar 1, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 2024-02-23 regarding staff assistance with medical care, notice of rate increase, unspecified fees, assistance with showering and grooming, and the comfort of the resident's environment.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to assist resident with medical care, failure to provide notice of rate increase, charging unspecified fees, failure to assist with showering and grooming, and not providing a comfortable environment. Interviews and record reviews showed the resident refused some services, was properly notified of rent increases, and had control over their environment.
Findings
All allegations were investigated through interviews, record reviews, and observations. The investigation found that the facility assisted the resident with obtaining medical care, provided proper notice of rent increase, did not charge unspecified fees, offered assistance with showering and grooming which the resident refused, and allowed the resident to control lighting in their room. Therefore, all allegations were deemed unsubstantiated with no immediate health or safety concerns observed.
Report Facts
Capacity: 138
Census: 134
Complaint Control Number: 31-AS-20240223083524
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Carolina Garcia-Trejo | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Annual Inspection
Census: 134
Capacity: 138
Deficiencies: 0
Date: Mar 1, 2024
Visit Reason
The inspection was an unannounced continuation of the 2024 annual inspection to review compliance with Title 22 regulations.
Findings
During the inspection conducted on 02/29/2024 and 03/01/2024, the facility was found to be in compliance with Title 22 regulations.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolina Garcia Trejo | Administrator / Executive Director | Met with Licensing Program Analyst during the inspection. |
| Nicholas Reed | Licensing Program Analyst | Conducted the unannounced continuation of the 2024 annual inspection. |
| Naira Margaryan | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Census: 134
Capacity: 138
Deficiencies: 0
Date: Feb 29, 2024
Visit Reason
An unannounced annual inspection was conducted by Licensing Program Analyst Nicholas Reed to evaluate compliance with Title 22 regulations and assess the facility's conditions and operations.
Findings
The facility was found to be in compliance with Title 22 regulations with no immediate health and safety risks observed. The inspection included a review of the facility's environment, medication management, emergency preparedness, and resident living areas.
Report Facts
Room temperature: 70
Water temperature: 105
Water temperature: 106.8
Walk-in refrigerator temperature: 38
Walk-in freezer temperature: -10
Number of bedrooms: 108
Number of bedrooms: 19
Approved capacity: 138
Bedridden capacity: 18
Hospice waivers: 25
Medication counts: 3
Washing machines: 4
Dryers: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the unannounced annual inspection and authored the report |
| Carolina Garcia-Trejo | Administrator / Executive Director | Facility administrator met with LPA during inspection |
| Naira Margaryan | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 138
Deficiencies: 0
Date: Feb 21, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that staff did not seek timely medical attention for a resident.
Complaint Details
The complaint alleged that staff did not call 9-1-1 when Resident #1 experienced a serious health condition. After investigation, including interviews and record review, the allegation was unsubstantiated.
Findings
The investigation found that the resident did not report signs of distress to staff and vital signs were normal, indicating no medical attention was necessary. The allegation was deemed unsubstantiated.
Report Facts
Capacity: 138
Census: 134
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation |
| Carolina Garcia-Trejo | Administrator | Facility administrator met during the investigation |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 138
Deficiencies: 0
Date: Jan 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff did not ensure residents had access to a working telephone in the memory care unit.
Complaint Details
The complaint alleged that staff did not ensure residents had access to a working telephone, specifically that the memory care unit phone was not working and calls were disconnected. The allegation was found unsubstantiated after investigation.
Findings
The investigation found that the facility phone was operational, the memory care unit phone was recently misplaced but promptly replaced, and no immediate health and safety hazards were observed. Therefore, the allegation was deemed unsubstantiated.
Report Facts
Capacity: 138
Census: 134
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation visit |
| Carolina Garcia-Trejo | Administrator | Facility administrator met during the visit |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 138
Deficiencies: 0
Date: Dec 27, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff stole residents' personal belongings, specifically cash and perfume from Resident #1.
Complaint Details
The complaint alleged staff stole cash and perfume from Resident #1. Interviews with staff and residents, including 14 residents and 6 staff, revealed no evidence supporting theft. Residents #2 and #3 believed items were taken but did not report or document missing items. The facility provided lockboxes and reimbursement offers. The allegation was unsubstantiated.
Findings
The investigation included interviews with staff and residents, record reviews, and a facility tour. No evidence was found to substantiate the theft allegations, and the facility followed policies to safeguard residents' property and offered reimbursement for missing items. The allegation was deemed unsubstantiated.
Report Facts
Residents interviewed: 14
Staff interviewed: 6
Capacity: 138
Census: 134
Lockboxes provided: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Carolina Garcia-Trejo | Administrator / Executive Director | Facility administrator who met with the investigator and provided lockboxes and reimbursement offers. |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 138
Deficiencies: 0
Date: Nov 30, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate multiple allegations including unexplained injuries to residents, rough handling by staff, improper medication assistance, residents sustaining rashes due to incontinence care, and staff yelling at residents.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included unexplained injuries, rough handling, improper medication assistance, rashes from incontinence care neglect, and staff yelling. All were found unsubstantiated based on interviews, observations, and record reviews.
Findings
After interviews with staff and residents, record reviews, medication checks, and observations, all allegations were found to be unsubstantiated. No unexplained injuries, rough handling, improper medication assistance, unmet incontinence needs, or staff yelling were observed or reported during the investigation.
Report Facts
Residents interviewed: 14
Staff interviewed: 6
Medications reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation visit |
| Carolina Garcia-Trejo | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 138
Deficiencies: 0
Date: Nov 14, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that licensee neglect resulted in a resident sustaining unexplained injuries.
Complaint Details
The complaint alleged licensee neglect causing unexplained bruising and swelling to Resident #1. The investigation found no evidence to confirm the allegation; it was deemed unsubstantiated.
Findings
The investigation included record reviews, staff and resident interviews, and facility tours. The allegation was found to be unsubstantiated as staff followed the resident's care plan, injuries were reported timely, and no staff witnessed or knew the cause of the injuries. No immediate health or safety hazards were observed during the visit.
Report Facts
Residents interviewed: 13
Facility capacity: 138
Facility census: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation visit |
| Carolina Garcia-Trejo | Administrator | Facility administrator met during investigation |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 138
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-06-22 regarding personnel qualifications and alleged unprofessional conduct by the administrator.
Complaint Details
The complaint alleged that the administrator conducted themselves in an unprofessional manner. The allegation was found to be unsubstantiated based on interviews and record reviews.
Findings
The investigation included interviews with residents, staff, and the administrator, as well as a review of records. The findings revealed that the administrator conducts themselves professionally and is knowledgeable and respectful. There was insufficient information to support the allegation, and the complaint was unsubstantiated.
Report Facts
Capacity: 138
Census: 129
Number of residents interviewed: 5
Number of staff interviewed: 6
Number of staff interviewed (additional): 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolina Garcia-Trejo | Administrator | Named in complaint allegation and interviewed during investigation |
| Tihesha Smith | Licensing Program Analyst | Conducted the complaint investigation visit |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 138
Deficiencies: 0
Date: Sep 12, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations including resident injury, rough handling by staff, unexplained injuries, inappropriate medication, and force feeding.
Complaint Details
The complaint investigation was triggered by allegations that a resident sustained a fracture due to staff neglect, staff handled a resident roughly causing bruises, residents sustained unexplained injuries due to neglect, staff were inappropriately medicating residents, and staff forcefed a resident. All allegations were found to be unsubstantiated based on interviews, observations, and record reviews.
Findings
After interviews, observations, and record reviews, there was insufficient evidence to substantiate any of the allegations. No immediate health or safety risks were observed, and staff were found to be following proper procedures.
Report Facts
Capacity: 138
Census: 127
Complaint Control Number: 31-AS-20230911115014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Carolina Garcia-Trejo | Administrator | Facility administrator named in the report |
| Joyce Martinez | Person met with during the visit | |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 133
Capacity: 138
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit to investigate allegations that a resident developed a pressure injury due to staff neglect, that staff were not repositioning the resident, and that staff failed to monitor the resident's water and food intake resulting in hospitalization.
Complaint Details
The complaint investigation was unannounced and conducted due to allegations of neglect causing a pressure injury, failure to reposition the resident, and failure to monitor water and food intake resulting in hospitalization. The allegations were found unsubstantiated based on staff interviews, record reviews, and resident interview.
Findings
The investigation found insufficient evidence to substantiate the allegations. The resident was repositioned every two hours and had only a stage II pressure injury being treated by hospice and facility staff. The resident was hospitalized for weakness and loss of appetite, but there was no evidence that staff failed to monitor water and food intake causing the hospitalization. Therefore, all allegations were deemed unsubstantiated.
Report Facts
Capacity: 138
Census: 133
Resident weight at admission: 161
Resident weight at last measurement: 158
Complaint control number: 31-AS-20230725162316
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cava | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva Miller | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 138
Deficiencies: 0
Date: Jul 5, 2023
Visit Reason
An unannounced complaint investigation was conducted to investigate an allegation that staff did not issue a refund to the responsible party for the unused portion of an advance payment after a resident passed away.
Complaint Details
The complaint alleged that staff did not issue a refund to the responsible party. The allegation was investigated and found to be unsubstantiated.
Findings
The investigation found that the Power of Attorney had already received the requested refund check of $580.65 four days prior to the visit, and the allegation was deemed unsubstantiated based on interviews and record review.
Report Facts
Refund amount: 580.65
Capacity: 138
Census: 137
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Carolina Garcia-Trejo | Executive Director | Met with Licensing Program Analyst during investigation |
| Troy Agard | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 136
Capacity: 138
Deficiencies: 0
Date: Jul 3, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that staff refused to admit a resident back to the facility and that staff were withholding a resident's personal belongings.
Complaint Details
The complaint involved two allegations: 1) staff refused to admit resident back to the facility, and 2) staff withheld resident's personal belongings. Both allegations were investigated and found unsubstantiated based on interviews, record reviews, and witness statements.
Findings
The investigation found insufficient evidence to substantiate the allegations. The resident had self-admitted to a Skilled Nursing Facility without notifying the facility and had departed with personal belongings. Staff and witnesses denied withholding belongings. The allegations were deemed unsubstantiated.
Report Facts
Capacity: 138
Census: 136
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolina Garcia-Trejo | Administrator | Met with Licensing Program Analyst during investigation and denied allegations |
| Mariana Agban | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 138
Deficiencies: 1
Date: Jun 26, 2023
Visit Reason
The visit was a Case Management inspection conducted in conjunction with a complaint regarding an incident involving kitchen plumbing that was not reported to the Community Care Licensing Department as required.
Complaint Details
Complaint number 31-AS-20230622091845 triggered the visit. The deficiency was substantiated based on the administrator's admission of failure to notify the department about the incident.
Findings
The inspection found that the administrator failed to notify the licensing agency about the kitchen plumbing incident that occurred on 05/26/2023, which posed a potential health and safety risk to residents. A written Incident Report was provided during the visit.
Deficiencies (1)
Failure to report an incident involving kitchen plumbing within the required timeframe to the licensing agency.
Report Facts
Capacity: 138
Census: 137
Plan of Correction Due Date: Jun 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolina Garcia-Trejo | Administrator | Named in relation to the failure to report the kitchen plumbing incident |
| Tihesha Smith | Licensing Program Analyst | Conducted the Case Management visit and complaint investigation |
| Naira Margaryan | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 136
Capacity: 138
Deficiencies: 1
Date: Jun 23, 2023
Visit Reason
The visit was a Case Management inspection conducted in conjunction with a complaint regarding the facility's failure to submit an incident report in a timely manner related to an event on 11/04/22 involving resident R1.
Complaint Details
Complaint #31-AS-20230615153708 triggered the visit. The complaint involved failure to timely report an incident that occurred on 11/04/22 with resident R1. The deficiency was substantiated as the licensee did not notify CCLD as required.
Findings
The licensee failed to comply with reporting requirements by not notifying the Community Care Licensing Department about the incident involving resident R1, which poses a potential health and safety risk to persons in care.
Deficiencies (1)
Failure to submit a written Unusual Incident / Injury Report to the licensing agency within seven days as required by Title 22 regulations.
Report Facts
Capacity: 138
Census: 136
Plan of Correction Due Date: Jun 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolina Garcia-Trejo | Administrator | Met with Licensing Program Analysts during the visit and provided a written Incident Report |
| Mariana Agban | Licensing Program Analyst | Conducted the inspection and authored the report |
| Angela Panushkina | Licensing Program Analyst | Conducted the inspection |
| Eva Miller | Licensing Program Manager / Supervisor | Supervisor of the licensing program analysts and named in the report |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 138
Deficiencies: 0
Date: May 25, 2023
Visit Reason
An unannounced complaint investigation was conducted to investigate the allegation that staff were not following the admission agreement, specifically regarding reimbursement of a resident's community fee.
Complaint Details
The complaint alleged that staff were not following the admission agreement related to reimbursement of a community fee. The allegation was investigated and found to be unsubstantiated.
Findings
The investigation found that the facility reimbursed Resident #1's Power of Attorney $2100 on 05/10/2023, representing 60% of the pro-rated refund for the community fee as per the admission agreement. The allegation was deemed unsubstantiated.
Report Facts
Refund amount: 2100
Capacity: 138
Census: 137
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolina Garcia-Trejo | Executive Director | Met with Licensing Program Analyst during investigation and provided information about the refund |
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 138
Deficiencies: 1
Date: Jan 11, 2023
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation of financial abuse involving the prior facility administrator.
Complaint Details
The complaint was substantiated. The allegation involved financial abuse by the prior administrator, who was terminated due to embezzlement. Documentation and police reports were reviewed, confirming the allegation.
Findings
The investigation substantiated that the prior facility administrator was terminated for financial abuse/embezzlement. A deficiency was cited for failure to ensure residents' personal rights were observed and respected, posing an immediate safety and personal rights risk.
Deficiencies (1)
Failure to ensure that the resident’s personal rights were observed and respected by the previous administrator, including being free from neglect and financial exploitation.
Report Facts
Capacity: 138
Census: 116
Deficiencies cited: 1
Plan of Correction Due Date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolina Garcia-Trejo | Administrator | Interviewed during investigation and corroborated termination of prior administrator due to embezzlement |
| Erin Mahoney | Administrator | Named as current administrator in report header |
| Evelin Rios | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 138
Deficiencies: 0
Date: Jan 4, 2023
Visit Reason
The inspection was conducted as a complaint investigation following an allegation that facility staff were not providing adequate supervision.
Complaint Details
The complaint alleged that facility staff were not providing adequate supervision, specifically regarding an incident where Resident 1 was reported to have hit Resident 2 several times in June 2021. The investigation found no visible bruising, no recent incidents, and no staff awareness of physical aggression, only verbal aggression. Resident 2 denied the allegation of inadequate supervision and declined to move rooms despite offers. The complaint was unsubstantiated.
Findings
The investigation found insufficient evidence to corroborate the allegation of inadequate supervision by staff. The complaint was deemed unsubstantiated as no recent incidents or witnesses were identified, and residents and staff interviews did not confirm the allegation.
Report Facts
Capacity: 138
Census: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cava | Licensing Program Analyst | Conducted the complaint investigation visit |
| Abigail Gigante | Assistant administrator met during the investigation | |
| Carolina Garcia-Trejo | Administrator | Facility administrator named in the report |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 115
Capacity: 138
Deficiencies: 0
Date: Dec 23, 2022
Visit Reason
Licensing Program Analysts conducted an Annual Required visit and inspection of the facility to evaluate compliance with licensing regulations.
Findings
The facility was found to be in compliance with no deficiencies observed. The physical plant, resident rooms, common areas, medication storage, and records were all reviewed and found satisfactory.
Report Facts
Bedrooms: 108
Hot water temperature range: 111
Hot water temperature range: 119
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abigail Gigante | Assistant Administrator | Met with Licensing Program Analysts during the inspection. |
| Michael Cava | Licensing Program Analyst | Conducted the annual inspection. |
| Gary Tan | Licensing Program Analyst | Conducted the annual inspection. |
| Eva Miller | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 138
Deficiencies: 0
Date: Nov 1, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff do not treat residents with respect and do not follow through with residents' medical appointments.
Complaint Details
The complaint included allegations that staff do not treat residents with respect and do not follow through with residents' medical appointments. Both allegations were deemed unsubstantiated after investigation, including interviews with residents, staff, social worker, and nurse practitioner, and review of records.
Findings
The investigation found insufficient evidence to corroborate the allegations. Interviews with residents and staff, as well as record reviews, indicated that residents were not treated differently or disrespectfully, and that staff did assist with medical appointments, although one resident refused to attend some appointments independently.
Report Facts
Capacity: 138
Census: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cava | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva Miller | Licensing Program Manager | Named in report as Licensing Program Manager |
| Carolina Garcia-Trejo | Administrator | Facility administrator named in report |
| Abigail Gigante | Assistant administrator met during investigation | |
| Joyce Martinez | Staff met during investigation | |
| Alberta Cedano | Staff met during investigation |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 138
Deficiencies: 0
Date: Oct 13, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff did not answer authorized representatives' questions regarding a resident, did not provide updated medication lists, and did not ensure new doctor orders for medications were received.
Complaint Details
The complaint involved three allegations: staff not answering authorized representatives' questions, not providing updated medication lists, and not ensuring receipt of new doctor medication orders. All allegations were investigated and found unsubstantiated.
Findings
The investigation found insufficient evidence to corroborate the allegations. Interviews with staff and review of records indicated that staff responded appropriately to family inquiries, provided updated medication lists, and received new medication orders as required. Therefore, all allegations were deemed unsubstantiated.
Report Facts
Capacity: 138
Census: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cava | Licensing Program Analyst | Conducted the complaint investigation visit |
| Abigail Gigante | Assistant Administrator | Interviewed during the investigation and involved in findings |
| Carolina Garcia-Trejo | Administrator | Named as facility administrator in the report |
| Eva Miller | Licensing Program Manager | Named as licensing program manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 138
Deficiencies: 0
Date: Sep 22, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that staff was threatening to drug a resident and that the facility did not safeguard a resident's personal belongings.
Complaint Details
The complaint investigation was triggered by allegations that staff threatened to drug Resident 1 and that the facility failed to safeguard the resident's personal belongings. Both allegations were found unsubstantiated after interviews, record reviews, and verification with the resident's physician and law enforcement.
Findings
The investigation found insufficient evidence to corroborate the allegations. Interviews with staff, residents, and the administrator denied the claims, and records confirmed the resident had been refusing medication. The allegations were deemed unsubstantiated.
Report Facts
Capacity: 138
Census: 106
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cava | Licensing Program Analyst | Conducted the complaint investigation visit |
| Carolina Garcia-Trejo | Administrator | Met with Licensing Program Analyst during investigation and provided information |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 138
Deficiencies: 0
Date: Aug 29, 2022
Visit Reason
The visit was conducted as an unannounced investigation of a complaint received on 01/26/2021 alleging that the licensee was in financial distress and that several employees were not being paid during December 2020 through January 2021.
Complaint Details
The complaint alleged that several employees were not paid during December 2020 through January 2021. The allegation was investigated and found to be unsubstantiated based on interviews and payroll documentation.
Findings
The investigation found that employees were paid during the period of December 2020 through January 2021 based on interviews with staff and review of payroll documents. The allegation was deemed unsubstantiated.
Report Facts
Capacity: 138
Census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendell Smith | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Erin Mahoney | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 138
Deficiencies: 0
Date: Aug 24, 2022
Visit Reason
The inspection was conducted as a complaint investigation following an allegation that staff did not safeguard a resident's confidential information.
Complaint Details
The complaint alleged that staff did not safeguard Resident 1's confidential information. The allegation was deemed unsubstantiated after investigation.
Findings
The investigation found insufficient evidence to prove that staff failed to safeguard the resident's confidential information. The resident confirmed willingly giving access to their personal information to the administrator's friend.
Report Facts
Capacity: 138
Census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cava | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva Miller | Licensing Program Manager | Named in report as Licensing Program Manager |
| Carolina Garcia-Trejo | Administrator | Facility administrator involved in the investigation |
| Joyce Martinez | Staff member met during the investigation |
Inspection Report
Plan of Correction
Census: 110
Capacity: 138
Deficiencies: 6
Date: Aug 9, 2022
Visit Reason
An unannounced Plan of Correction (POC) visit was conducted to follow up on pending Plan of Corrections issued during the annual visit on 01/25/2022 and additional citations from a complaint investigation on 07/27/2022.
Findings
The facility was re-cited for failure to submit complete Plans of Correction for multiple deficiencies including personal rights violations, infection control, reporting requirements, dementia care assessments, hospice care plans, and postural supports. Civil penalties were issued and continue to accrue until corrections are made.
Deficiencies (6)
Personal Rights of Residents in all facilities were violated as staff did not wear face masks during work, posing health and safety risks.
Infection Control Requirements were not met as staff failed to follow infection control protocols, posing immediate health and safety risks.
Residents with dementia did not have annual medical assessments and reappraisals as required.
Hospice care plans were incomplete or not maintained for hospice residents.
Full bed rails were used for hospice residents without a hospice care plan specifying the need.
Postural supports lacked a written physician order for 6 residents.
Report Facts
Civil penalty amount: 250
Accrued civil penalties: 1300.99
Daily civil penalty: 100
Residents without annual dementia assessment: 7
Residents without hospice care plan: 7
Residents with unauthorized full bed rails: Hospice residents with full bed rails without proper care plan
Residents without physician order for postural supports: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yelena Avetisyan | Licensing Program Analyst | Conducted the Plan of Correction visit and authored the report |
| Eva Miller | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
| Carolina Garcia-Trejo | Administrator | Facility administrator cited for deficiencies and responsible for submitting Plans of Correction |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 138
Deficiencies: 2
Date: Jul 27, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff were not wearing masks in the facility.
Complaint Details
The complaint was substantiated. Staff were observed wearing masks inappropriately or not wearing masks at all during the unannounced visit. The administrator was contacted but was not present during the visit.
Findings
The investigation substantiated the allegation that staff were not wearing masks appropriately, posing a potential health, safety, and personal rights risk to residents. Multiple staff were observed wearing masks improperly or not at all during the visit.
Deficiencies (2)
Staff did not comply with wearing face masks/coverings while working in the facility, posing a potential health, safety, and personal rights risk to residents.
Licensee/administrator did not ensure staff followed infection control requirements, posing an immediate health and safety and personal rights risk to persons in care.
Report Facts
Capacity: 138
Census: 112
Deficiencies cited: 2
Plan of Correction due date: Jul 27, 2022
Training completion date: Aug 12, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolina Garcia-Trejo | Administrator | Administrator contacted during investigation but not present at facility |
| Evelin Rios | Licensing Program Analyst | Conducted the complaint investigation |
| Yelena Avetisyan | Licensing Program Analyst | Assisted in conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 138
Deficiencies: 1
Date: Jul 27, 2022
Visit Reason
The visit was an unannounced Case Management-Deficiencies inspection conducted due to deficiencies observed during the investigation of complaint control #31-AS-20220721125636.
Complaint Details
The visit was triggered by complaint control #31-AS-20220721125636. The deficiency was substantiated as the facility did not comply with reporting requirements for a COVID-19 positive resident.
Findings
The facility failed to report a resident who tested positive for COVID-19 within 24 hours as required, posing an immediate health and safety risk. This was a repeat violation resulting in a civil penalty.
Deficiencies (1)
Failure to report a resident tested positive for COVID-19 within 24 hours, posing an immediate health, safety or personal rights risk to persons in care.
Report Facts
Civil penalty amount: 250
Daily civil penalty: 100
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolina Garcia-Trejo | Administrator | Named in relation to failure to report COVID-19 positive resident |
| Alberta Cedano | Care Coordinator | Met with Licensing Program Analysts during inspection |
| Yelena Avetisyan | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Eva Miller | Licensing Program Manager / Supervisor | Supervisor of the inspection |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 138
Deficiencies: 0
Date: May 24, 2022
Visit Reason
The visit was conducted as a Case Management follow-up on an incident report alleging a possible personal rights violation involving a resident.
Complaint Details
The complaint involved an alleged personal rights violation of Resident 1 (R1). The allegation was not substantiated due to lack of sufficient information.
Findings
Based on interviews and record review, there was insufficient information to confirm a personal rights violation, and therefore no citations were issued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cava | Licensing Program Analyst | Conducted the Case Management visit and investigation. |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Carolina Garcia-Trejo | Administrator | Facility administrator named in the report header. |
| David Aguiniga | Met with during the visit. |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 138
Deficiencies: 0
Date: May 13, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-02-09 regarding inappropriate staff comments towards residents, inadequate food service, and staff denying residents food.
Complaint Details
The complaint investigation addressed three allegations: staff making inappropriate comments towards residents, inadequate food service, and staff denying residents food. All allegations were found to be unsubstantiated based on interviews and inspections.
Findings
The investigation found no sufficient evidence to substantiate any of the allegations. Interviews with residents and staff, as well as physical inspections, indicated that the allegations were unsubstantiated at this time.
Report Facts
Capacity: 138
Census: 112
Residents on ALW program: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cava | Licensing Program Analyst | Conducted the complaint investigation visit |
| Carolina Garcia-Trejo | Administrator | Facility administrator met during the investigation |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 138
Deficiencies: 0
Date: Apr 26, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate an allegation that staff did not provide medical attention for a resident in care.
Complaint Details
The complaint alleged that staff did not provide medical attention for a resident who complained of shortness of breath. The allegation was investigated and found to be unsubstantiated based on interviews, record review, and statements from the resident's responsible person.
Findings
The investigation found that the resident had called 911 on their own and was transported to the hospital, with no evidence supporting the allegation that staff failed to provide medical attention. The allegation was deemed unsubstantiated.
Report Facts
Capacity: 138
Census: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cava | Licensing Program Analyst | Conducted the complaint investigation visit |
| Carolina Garcia-Trejo | Administrator | Met with investigator and provided information during the investigation |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 138
Deficiencies: 0
Date: Apr 15, 2022
Visit Reason
The visit was conducted to investigate a complaint received on 2020-09-14 regarding multiple allegations including staff failing to protect residents from harm, improper destruction of non-active medications, residents receiving hospice care without cause, and administrator availability.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff failing to protect residents from harm by another resident, failure to destroy non-active medications, residents receiving hospice care without cause, and administrator not being available. None of these allegations were supported by evidence.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Interviews, record reviews, and facility inspections did not corroborate claims of staff failing to protect residents, improper medication destruction, inappropriate hospice care, or administrator unavailability. All allegations were deemed unsubstantiated.
Report Facts
Capacity: 138
Census: 111
Hospice waiver capacity: 25
Residents receiving hospice care: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cava | Licensing Program Analyst | Conducted the complaint investigation |
| Erin Mahoney | Administrator | Former administrator alleged to be unavailable |
| Carolina Garcia-Trejo | Administrator | Current administrator interviewed during investigation |
| Eva Miller | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 138
Deficiencies: 1
Date: Mar 25, 2022
Visit Reason
The visit was conducted as a case management visit in conjunction with a complaint investigation regarding an incident involving staff and a resident.
Complaint Details
Complaint visit 31-AS-20211101161122 triggered the investigation. The complaint was substantiated based on interviews and observations.
Findings
It was found that staff member S1 engaged in a sexual relationship with resident R1, posing an immediate health and safety risk. S1 was removed from the facility and the Los Angeles Police Department was notified but did not take a report as the relationship was deemed consensual. A deficiency was cited for conduct inimical to the health, morals, welfare, or safety of residents.
Deficiencies (1)
Staff member engaged in a sexual relationship with a resident, posing an immediate health and safety risk to residents in care.
Report Facts
Capacity: 138
Census: 111
Plan of Correction Due Date: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendell Smith | Licensing Program Analyst | Conducted the case management and complaint visit |
| Carolina Garcia-Trejo | Administrator | Facility administrator met during the visit |
| Cassandra Harris | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 138
Deficiencies: 0
Date: Mar 25, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of sexual abuse of a resident while in care.
Complaint Details
The complaint alleged that resident #1 was sexually abused by staff #1. Interviews and review of physician reports were conducted. The Los Angeles Police Department noted the relationship was consensual and no incident report was filed. The allegation was deemed unsubstantiated.
Findings
The investigation found that the alleged sexual abuse was unsubstantiated as the relationship between the resident and staff was consensual according to interviews and police information.
Report Facts
Capacity: 138
Census: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendell Smith | Licensing Program Analyst | Conducted the complaint investigation visit |
| Erin Mahoney | Administrator | Facility administrator alerted after incident |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 138
Deficiencies: 0
Date: Mar 17, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the facility had insects, specifically fleas, observed in a resident's room, bed, and carpeting.
Complaint Details
The complaint alleged the presence of insects (fleas) in the facility. The investigation included resident and staff interviews, physical inspection, and record review. The allegation was found to be unsubstantiated as the facility acted appropriately to treat the affected residents and prevent spread.
Findings
The investigation found that two residents were observed with fleas and flea eggs and were treated accordingly. The facility took preventive measures including quarantining the residents, disinfecting the room, and laundering bedding. No other residents were affected, and the allegation was determined to be unsubstantiated.
Report Facts
Capacity: 138
Census: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cava | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Carolina Garcia-Trejo | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 138
Deficiencies: 0
Date: Mar 17, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that the facility was not keeping residents' rooms free from pests and that staff were isolating residents.
Complaint Details
The complaint investigation was triggered by allegations of pest infestation (cockroaches and lice) and staff isolating residents. Both allegations were found unsubstantiated after investigation.
Findings
The investigation included resident and staff interviews, physical inspection, and record review. The allegations of pest infestation and staff isolating residents were found to be unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 138
Census: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cava | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Named in report as Licensing Program Manager |
| Carolina Garcia-Trejo | Administrator | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 138
Deficiencies: 0
Date: Mar 3, 2022
Visit Reason
The inspection visit was conducted to investigate a complaint alleging unqualified staff assessing resident's care, signing off on resident's documents, and that resident's care is not being assessed for a higher level of care.
Complaint Details
The complaint alleged that unqualified staff were assessing resident care, signing prescription forms, and placing residents on hospice care improperly. It also alleged that residents were not being assessed for higher levels of care and that staff were signing forms to receive kickbacks. The investigation found no evidence to substantiate these allegations, and the complaint was deemed unsubstantiated.
Findings
The investigation included a physical plant inspection, record review, and interviews with residents and staff. It was found that the allegations of unqualified staff assessing care or signing documents, and failure to assess residents for higher levels of care, could not be substantiated based on the evidence gathered.
Report Facts
Residents on hospice care: 24
Residents census: 111
Facility capacity: 138
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolina Garcia-Trejo | Administrator | Interviewed regarding allegations and described as a licensed nurse responsible for resident assessments |
| Michael Cava | Licensing Program Analyst | Conducted the complaint investigation |
| Gary Tan | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 138
Deficiencies: 0
Date: Mar 3, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations including staff pushing a resident and staff stealing a resident's personal property.
Complaint Details
The complaint investigation was unsubstantiated based on interviews, record reviews, and lack of evidence supporting the allegations of staff pushing a resident and stealing personal property.
Findings
The investigation found that the allegations were unsubstantiated. Staff #1 was not on duty at the times of the alleged incidents, and no evidence supported the claims of pushing or theft.
Report Facts
Capacity: 138
Census: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Michael Cava | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Carol Trejo | Executive Director | Met with investigators during the visit |
| Naira Margaryan | Licensing Program Manager | Named in report signature |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 138
Deficiencies: 0
Date: Feb 15, 2022
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit following allegations received on 2022-02-09 regarding hospice resident ratios, qualifications of the facility director, and overmedication of residents.
Complaint Details
The complaint investigation addressed three allegations: 1) Facility is out of ratio with hospice residents; 2) Unqualified Director operating facility; 3) Residents are being overmedicated. All allegations were deemed unsubstantiated after review and interviews.
Findings
The investigation included a physical plant inspection, record review, and interviews with residents and staff. All allegations were found to be unsubstantiated based on evidence and interviews; the facility was not out of hospice resident ratio, the director was qualified, and there was no evidence of overmedication.
Report Facts
Hospice residents approved: 25
Hospice residents counted: 22
Facility census: 112
Facility capacity: 138
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cava | Licensing Program Analyst | Conducted complaint investigation |
| Gary Tan | Licensing Program Analyst | Conducted complaint investigation |
| David Aguiniga | Operations Manager | Interviewed during investigation |
| Carolina Garcia-Trejo | Facility Administrator | Subject of qualification allegation, found qualified |
| Eva Miller | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 138
Deficiencies: 0
Date: Feb 1, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation that the facility did not issue a refund to a resident's Power of Attorney (POA).
Complaint Details
The complaint alleged that the facility did not refund resident #1's pre-admission fee after the resident moved out. The allegation was investigated and found to be unsubstantiated.
Findings
The investigation found that the resident had lived in the facility for more than four months, and according to the admission agreement, the licensee may but is not required to refund the pre-admission fee. Based on the information obtained, the allegation was deemed unsubstantiated.
Report Facts
Capacity: 138
Census: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendell Smith | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Annual Inspection
Census: 112
Capacity: 138
Deficiencies: 9
Date: Jan 25, 2022
Visit Reason
An unannounced required annual inspection was conducted with a specific emphasis on infection control practices and procedures.
Findings
The facility was inspected for compliance with health and safety regulations including infection control, physical plant conditions, resident care documentation, and staff training. Several deficiencies were identified related to fire clearance for bedridden residents, incomplete hospice care plans, lack of physician orders for bed rails, missing annual medical assessments for residents with dementia, incomplete staff training and documentation, and failure to properly notify the department of COVID-19 cases.
Deficiencies (9)
Retaining 4 bedridden residents in rooms without bedridden fire clearance.
Utilizing full bed rails for hospice residents without hospice care plans indicating the need.
Utilizing half bed rails for 6 residents without written physician orders for postural support.
7 residents with dementia did not have annual medical assessment and reappraisal.
Not retaining current and complete hospice care plans for 7 hospice residents.
Failure to properly notify the department of 2 residents testing positive for COVID-19.
Staff did not receive required annual training including dementia care, postural supports, restricted health conditions, and hospice care.
Staff training documentation was incomplete and improperly maintained.
Staff did not receive training on infection prevention, symptoms, transmission, PPE use, and were not fit tested for N95 masks as required.
Report Facts
Residents without current physician reports: 7
Hospice residents without current hospice care plans: 7
Hospice residents using full bed rails without hospice care plan: 2
Hospice residents using half bed rails without physician orders: 5
Bedridden residents without fire clearance: 4
Hospice residents: 7
Residents with dementia lacking annual assessment: 7
Staff without required training: 6
Newly hired staff without training verification: 2
Residents testing positive for COVID-19: 2
Civil penalty: 500
Civil penalty daily accrual: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolina Garcia'Trejo | Administrator | Met with Licensing Program Analyst during inspection and discussed findings |
| Yelena Avetisyan | Licensing Program Analyst | Conducted the inspection and authored the report |
| Eva Miller | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 138
Deficiencies: 0
Date: Nov 19, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-11-03 regarding residents being left in soiled diapers for extended periods, untimely medication administration, and understaffing at the facility.
Complaint Details
The complaint investigation addressed three allegations: 1) residents left in soiled diapers for extended periods, 2) untimely medication administration, and 3) facility understaffing. All allegations were deemed unsubstantiated after interviews and review of staff schedules.
Findings
The investigation included interviews with residents and staff and a physical plant tour. All allegations were found to be unsubstantiated based on interviews and schedule reviews, with residents satisfied with care and medication administration occurring on schedule.
Report Facts
Capacity: 138
Census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendell Smith | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Cassandra Harris | Licensing Program Manager | Named in report as Licensing Program Manager |
| Erin Mahoney | Administrator | Facility administrator met during investigation |
| Carolina Garcia-Trejo | Met with during the inspection visit |
Inspection Report
Complaint Investigation
Capacity: 138
Deficiencies: 0
Date: Nov 1, 2021
Visit Reason
An unannounced case management visit was conducted following a serious incident report regarding a staff member acting inappropriately in a resident's room.
Complaint Details
The visit was triggered by a serious incident report involving a staff member seen acting inappropriately in a resident's room. The staff member was removed, and authorities and relevant parties were notified. Interviews and file reviews were conducted, and a follow-up visit is planned.
Findings
No immediate health and safety issues were noted during the physical plant tour. The staff member involved was immediately escorted out, and the administrator notified law enforcement, Adult Protective Services, Long Term Care Ombudsman, and the resident's family. Interviews and file reviews were conducted, with a follow-up visit planned for further information.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erin Mahoney | Administrator | Administrator who conducted interviews and notified authorities regarding the incident. |
| Wendell Smith | Licensing Program Analyst | Conducted the unannounced case management visit and interviews. |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 138
Deficiencies: 0
Date: Oct 20, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that smoke alarms were not working and that staff working with hospice residents were not qualified.
Complaint Details
The complaint was unsubstantiated. The smoke alarm allegation was investigated through interviews and testing, confirming proper function. The hospice staff qualification allegation was investigated through interviews with staff and administrators, confirming appropriate qualifications and staffing.
Findings
The investigation found that the smoke alarms were functioning properly and did not activate due to the small amount of smoke from a lamp incident. The allegation regarding unqualified hospice staff was unsubstantiated as hospice and facility staff were appropriately providing care and assistance.
Report Facts
Capacity: 138
Census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yelena Avetisyan | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Erin Mahoney | Administrator | Facility administrator interviewed during the investigation |
| Carolina Garcia-Trejo | Met with during the investigation | |
| Eva Miller | Licensing Program Manager | Named in report as licensing program manager |
| Staff 1 | Licensed CHHS | Hospice agency staff interviewed regarding qualifications and work schedule |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 138
Deficiencies: 0
Date: Oct 5, 2021
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that the facility did not issue a refund to a Resident's Representative and did not provide timely written notice of policies regarding contract termination upon death.
Complaint Details
The complaint was unsubstantiated. Allegations included failure to issue a refund for prepaid rent after resident's death and failure to provide written notice of contract termination policies. Interviews and record reviews showed no refund was owed and no additional fees were charged after death.
Findings
The investigation found no immediate health and safety issues. The allegation that the facility did not issue a refund was unsubstantiated as records showed the resident's rent for October 2021 had not been paid. The allegation that the facility did not provide timely written notice regarding contract termination policies was also unsubstantiated, with no fees charged after the resident's death and the family managing personal belongings.
Report Facts
Facility capacity: 138
Census: 104
Refund amount: 217.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendell Smith | Licensing Program Analyst | Conducted complaint investigation and interviews |
| LaQueena Lacy | Licensing Program Analyst | Conducted complaint investigation and facility tour |
| Erin Mahoney | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 138
Deficiencies: 0
Date: Oct 5, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-01-20 regarding medication administration, resident's ability to purchase a new bed, and resident's access to outdoors.
Complaint Details
The complaint involved three allegations: 1) staff not administering medications according to physician instructions, 2) staff not allowing a resident to purchase a new bed, and 3) staff not allowing a resident to go outdoors. All allegations were investigated and deemed unsubstantiated.
Findings
The investigation found all allegations unsubstantiated based on interviews, record reviews, and observations. Staff were not found to be improperly administering medications, restricting bed purchases, or denying outdoor access to the resident.
Report Facts
Facility capacity: 138
Census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendell Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Cassandra Harris | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 138
Deficiencies: 0
Date: Sep 28, 2021
Visit Reason
Unannounced complaint investigation visit to investigate allegations that staff do not ensure residents are properly fed and that residents' personal belongings are mishandled while in care.
Complaint Details
The complaint involved allegations that staff did not ensure residents were properly fed, with claims of poor food quality, small portions, and inconsistent meal times, and that residents' personal belongings were mishandled, specifically lost in laundry. Both allegations were unsubstantiated based on resident interviews and observations.
Findings
Both allegations were found to be unsubstantiated after interviews with residents and observations. Residents reported receiving enough food and no lost personal items in laundry were reported.
Report Facts
Facility census: 103
Total capacity: 138
Resident interviews: 13
Percentage of census interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Calvin Tsui | Licensing Program Analyst | Conducted the complaint investigation |
| Alex Pritz | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 138
Deficiencies: 0
Date: Sep 27, 2021
Visit Reason
The inspection was an unannounced visit to investigate a complaint alleging that staff failed to check on residents in a timely manner when they pushed their pendant in their room.
Complaint Details
The complaint alleged that staff failed to check on residents in a timely manner when they pushed their pendant in their room. The allegation was investigated through interviews and previous visits, and was determined to be unsubstantiated.
Findings
The investigation included interviews with random residents and found the allegation to be unsubstantiated based on the information obtained during the visit.
Report Facts
Capacity: 138
Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendell Smith | Licensing Program Analyst | Conducted the complaint investigation visit |
| Erin Mahoney | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 138
Deficiencies: 0
Date: Aug 24, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 08/16/2021 regarding communication issues with staff, unanswered facility phone calls due to insufficient staffing, and inadequate resident services.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included residents not able to communicate with staff, facility phone not answered due to lack of staff, and residents not being provided adequate service. Interviews and observations did not support these claims.
Findings
The investigation found all allegations to be unsubstantiated based on interviews with residents and staff, observations of communication, phone responsiveness, and resident services including meal service and bathing.
Report Facts
Capacity: 138
Census: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendell Smith | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Cassandra Harris | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Capacity: 138
Deficiencies: 0
Date: Aug 2, 2021
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that the facility failed to report active COVID-19 cases.
Complaint Details
The complaint alleged that the facility failed to report COVID-19 cases. The allegation was investigated and found to be unsubstantiated as the facility reported the cases promptly.
Findings
The investigation found that the facility did conduct COVID-19 testing and reported the positive cases to the Department of Public Health in a timely manner. The allegation was deemed unsubstantiated based on interviews and documentation.
Report Facts
Capacity: 138
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendell Smith | Licensing Program Analyst | Conducted the complaint investigation visit |
| Erin Mahoney | Administrator | Interviewed regarding the COVID-19 case reporting |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 138
Deficiencies: 0
Date: Jul 24, 2021
Visit Reason
Unannounced visit to investigate complaints alleging that staff did not give a resident a sufficient amount of water and that staff handled a resident in a rough manner.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included insufficient water given to a resident and rough handling by staff. Interviews and record reviews did not support these allegations.
Findings
The investigation found that staff routinely checked on residents' needs and that the resident had water and juice at their bedside. Interviews with staff and residents revealed no evidence of rough handling or mistreatment. Both allegations were deemed unsubstantiated based on gathered information.
Report Facts
Capacity: 138
Census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation |
| Erin Mahoney | Administrator | Facility administrator mentioned in the report |
| Jero Argota | Assistant Care Coordinator | Met with Licensing Program Analyst during investigation |
| Carolina Garcia Trejo | Executive Director | Spoke with Licensing Program Analyst by phone during investigation |
| Naira Margaryan | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 138
Deficiencies: 0
Date: Jun 26, 2021
Visit Reason
Unannounced visit/investigation of a complaint received on 2020-05-19 regarding allegations that the facility denied resident access to oxygen, forced residents into receiving hospice services, and gave false information to a resident's family member.
Complaint Details
Complaint investigation was unsubstantiated based on interviews, record reviews, and findings. Allegations included denial of oxygen, forced hospice services, and false information to family members.
Findings
The investigation found that the allegations were unsubstantiated. Resident #1 had an order for oxygen administration under specific conditions but was not denied oxygen. Hospice services were not forced by facility staff but suggested by hospice agency staff, with all hospice agreements properly signed. The facility promptly reported COVID-19 cases and coordinated with public health authorities. Attempts to identify who gave false information were unsuccessful.
Report Facts
Capacity: 138
Census: 103
Complaint received date: May 19, 2020
Oxygen administration duration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation report |
| Jero Argota | Assistant Care Coordinator | Met with Licensing Program Analyst during investigation |
| Carolina Garcia Trejo | Executive Director | Interviewed by Licensing Program Analyst regarding allegations |
| Erin Mahoney | Administrator | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 138
Deficiencies: 0
Date: Jun 18, 2021
Visit Reason
Unannounced visit/investigation of a complaint received on 01/27/2021 regarding staff failing to check on residents in a timely manner.
Complaint Details
The complaint alleged that resident #1 sustained a fall on 01/26/2021 and staff took over thirty minutes to respond to the call button. After interviews and file review, the allegation was unsubstantiated.
Findings
The investigation found that residents feel they are checked on in a timely manner, and the allegation that staff failed to respond promptly to a resident's call button was deemed unsubstantiated.
Report Facts
Capacity: 138
Census: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendell Smith | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Erin Mahoney | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 138
Deficiencies: 0
Date: Jun 18, 2021
Visit Reason
Unannounced visit/investigation of a complaint received on 01/20/2021 regarding allegations that the facility has insufficient staff to meet resident's needs and that staff yell at resident's family while at the facility.
Complaint Details
Complaint investigation was unsubstantiated based on interviews with residents and the Long Term Care Ombudsman, and a physical plant walkthrough.
Findings
The investigation found that the facility has sufficient staff to meet resident's needs and that staff do not yell at resident's family while in the facility. Both allegations were deemed unsubstantiated based on interviews and observations.
Report Facts
Capacity: 138
Census: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendell Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Erin Mahoney | Administrator | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 138
Deficiencies: 0
Date: Jun 7, 2021
Visit Reason
An unannounced complaint investigation visit was conducted to investigate multiple allegations including physical assault, neglect of injury care, over medication, denial of access to medication records, and failure to safeguard resident's personal belongings.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included physical assault resulting in injury, staff neglect of injury care, over medication, denial of access to medication records, and failure to safeguard personal belongings. Interviews and record reviews did not support these claims.
Findings
All allegations investigated were found to be unsubstantiated based on interviews with the resident, administrator, staff, and review of relevant documentation and records.
Report Facts
Capacity: 138
Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendell Smith | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Cassandra Harris | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Erin Mahoney | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 138
Deficiencies: 0
Date: Feb 12, 2021
Visit Reason
The visit was a case management incident investigation conducted due to a serious incident report involving an allegation that a resident was hit by staff.
Complaint Details
The complaint involved resident #1 alleging being hit by staff. The allegation was investigated and found unsubstantiated based on interviews and medical evaluation.
Findings
Interviews and a medical evaluation found no signs of abuse or staff misconduct. The resident was determined to be confused and disoriented, and no further action was necessary.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erin Mahoney | Administrator | Facility Administrator involved in the case management visit and interviews. |
| Wendell Smith | Licensing Program Analyst | Conducted the case management visit and investigation. |
| Cassandra Harris | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 138
Deficiencies: 0
Date: Feb 11, 2021
Visit Reason
The visit was conducted as a case management incident investigation following an allegation by resident #1 that they were being hit by staff while lying in bed.
Complaint Details
Resident #1 alleged being hit by staff. The allegation was investigated with interviews and a body check showing no bruising or marks. The administrator took precautionary measures and reported to appropriate authorities. More investigation is needed.
Findings
The investigation included interviews with the administrator, staff, residents, and a body check of the resident, which found no physical evidence of abuse. The administrator implemented a two-person assist for the resident and reported the incident to Adult Protective Services, the Long Term Care Ombudsman, and the police. Further investigation was deemed necessary.
Report Facts
Staff interviewed: 18
Residents interviewed: 4
Facility capacity: 138
Facility census: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erin Mahoney | Administrator | Facility administrator interviewed regarding the incident and involved in investigation |
| Wendell Smith | Licensing Program Analyst | Conducted the case management visit and investigation |
| Cassandra Harris | Licensing Program Manager | Named in report header |
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