Citations (last 6 years)
Citations (over 6 years)
5 citations/year
Citations are regulatory findings recorded during state inspections.
25% worse than California average
California average: 4 citations/yearCitations per year
12
9
6
3
0
Occupancy
Latest occupancy rate
94% occupied
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Capacity: 125
Citations: 0
Date: Feb 21, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that a resident was inappropriately touched by an outside agency staff member and that money was taken from the resident by staff.
Complaint Details
The complaint involved allegations that Resident #1 was touched inappropriately by an outside agency staff member and that money was taken from the resident by facility staff. The complaint was found to be unfounded after investigation.
Findings
The investigation found the allegations to be unfounded after review of records and interviews. It was determined that the resident had been upset due to an eviction notice and later recanted the allegations. Staff documented a cash gift from the resident properly, and no evidence supported the claims.
Report Facts
Facility capacity: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sasha Hightower | Administrator | Facility administrator named in the report |
| Simon Jacob | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Census: 117
Capacity: 125
Citations: 0
Date: Dec 17, 2025
Visit Reason
An unannounced case management visit was conducted to investigate a resident death reported on 12/15/2025, concerning a death that occurred on 12/13/2025.
Findings
During the visit, a health and safety check was conducted, residents were observed, facility records were reviewed, and staff were interviewed. No deficiencies were cited on the date of the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Daynes | Executive Director | Met with during the visit and named in the report narrative. |
| Ariana Ventura | Care Coordinator | Present during the visit and participated in the exit interview. |
| Rebecca A Borunda | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Sabel Martinez | Licensing Program Manager | Named in the report. |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 125
Citations: 0
Date: Nov 19, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation received on 2025-08-13 regarding lack of supervision resulting in resident elopement.
Complaint Details
The complaint alleged lack of supervision resulting in resident elopement. The allegation was found to be unsubstantiated based on interviews, records, and observations indicating appropriate facility response and resident capability.
Findings
The investigation included staff and outside source interviews, records review, and direct observations. The evidence showed that the resident was alert, oriented, and independent, with the facility implementing multiple interventions to address elopement concerns. The allegation was determined to be unsubstantiated as there was no evidence of harm or regulatory violation.
Report Facts
Capacity: 125
Census: 113
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ramin Hashemi | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Pamela Talamentes | Resident Services Director | Facility staff member met during the investigation and recipient of exit interview |
| Thomas Daynes | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 125
Citations: 0
Date: Nov 18, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation received on 2025-10-23 that the licensee did not safeguard a resident's personal belongings.
Complaint Details
The complaint alleged that the facility did not safeguard a resident's personal belongings. The investigation found no corroborating evidence from staff interviews, observations, or records. Resident statements were inconsistent and noted to be influenced by paranoia. The allegation was unsubstantiated.
Findings
The investigation included interviews with staff and residents, observations, and records review. No evidence was found to substantiate the allegation, and the complaint was determined to be unsubstantiated due to lack of proof despite some resident claims and noted mental health issues.
Report Facts
Staff interviewed: 4
Residents interviewed: 2
Capacity: 125
Census: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janet Ngallo | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Pamela Talamantes | Resident Services Director | Facility staff member met during the investigation and exit interview |
| Thomas Daynes | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 125
Citations: 0
Date: Sep 19, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the licensee did not ensure a resident received timely medical care.
Complaint Details
The complaint was investigated and deemed unfounded because Resident 1 was not a resident of the facility.
Findings
The investigation found that the alleged resident was not actually a resident of the facility, rendering the allegation unfounded. The complaint was determined to be false and without reasonable basis.
Report Facts
Capacity: 125
Census: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Daynes | Executive Director | Met with during the complaint investigation and identified as facility administrator |
| Rebecca A Borunda | Licensing Evaluator | Conducted the complaint investigation |
| Janet Ngallo | Licensing Program Analyst | Conducted the complaint investigation |
| Pamela Talamantes | Resident Services Director | Interviewed during investigation and participated in exit interview |
Inspection Report
Complaint Investigation
Capacity: 125
Citations: 0
Date: Jul 17, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on 04/27/2022 regarding resident injuries, restrictions on residents going to their rooms during the day, and staff response to call lights.
Complaint Details
Complaint allegations included resident sustained injuries while in care, residents not allowed to go to their rooms during the day, and staff did not respond to resident's call light in a timely manner. The complaint was investigated and deemed unsubstantiated.
Findings
The investigation found conflicting information regarding resident injuries and staff response to call lights, but outside source interviews and records did not support neglect. The allegation that residents were not allowed to go to their rooms during the day was also not supported. The complaint was deemed unsubstantiated based on interviews and records review.
Report Facts
Facility capacity: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Pamela Talamantes | Resident Service Director | Met with Licensing Program Analyst during investigation and exit interview |
| Simon Jacob | Supervisor | Supervisor overseeing the investigation |
| Sasha Hightower | Administrator | Facility administrator named in the report |
Inspection Report
Census: 101
Capacity: 125
Citations: 0
Date: May 28, 2025
Visit Reason
The visit was conducted to sign an amended report as part of case management. No other business was conducted during this unannounced visit.
Findings
No violations or deficiencies were observed during the visit. The only activity was signing the amended report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Becky Kennedy | Licensing Program Analyst | Conducted the visit and explained the reason for the visit. |
| Ariana Ventura | Care Coordinator | Met with the Licensing Program Analyst during the visit. |
| Thomas Daynes | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 125
Citations: 0
Date: May 7, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2025-04-30 that staff handled a resident in a rough manner and did not treat the resident with dignity.
Complaint Details
The complaint alleged that Staff #1 shoved Resident #1 with a transfer board and used inappropriate language. The investigation included interviews with staff and review of resident assessments and physician reports. No evidence supported the allegations, resulting in an unsubstantiated finding.
Findings
The investigation, including interviews and record reviews, did not find sufficient evidence to substantiate the allegations that staff handled the resident roughly or treated them without dignity. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 125
Census: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hannah Rodgers | Licensing Program Analyst | Conducted the complaint investigation visit |
| Pamela Talamantes | Resident Services Director | Met with during the investigation and exit interview |
| Thomas Daynes | Administrator | Facility administrator named in the report |
| Lizzette Tellez | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 125
Citations: 0
Date: May 5, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff did not treat a resident with dignity and did not safeguard residents' confidential information.
Complaint Details
The complaint investigation was unsubstantiated for both allegations: staff not treating a resident with dignity and staff not safeguarding resident confidential information. The hospice agency prematurely contacted the family about a resident's death, but the facility staff acted appropriately. No evidence was found that confidential information was compromised.
Findings
The investigation found that the allegation regarding lack of dignity was unsubstantiated as the facility staff acted within their role when they alerted hospice staff about a resident who appeared lifeless but was later found alive. The allegation about unsecured confidential information was also unsubstantiated due to lack of direct evidence or witnesses.
Report Facts
Complaint Control Number: 08-AS-20210722142429
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Becky Kennedy | Licensing Program Analyst | Conducted the complaint investigation and visit. |
| Ozz Daynes | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview. |
| Sasha Hightower | Administrator | Named as facility administrator. |
| Icela Estrada | Supervisor | Supervisor overseeing the complaint investigation. |
Inspection Report
Census: 109
Capacity: 125
Citations: 0
Date: May 5, 2025
Visit Reason
The visit was conducted to sign an amended report as explained by the Licensing Program Analyst to the Executive Director.
Findings
No violations were observed during the visit. The only business conducted was signing the amended report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Becky Kennedy | Licensing Program Analyst | Conducted the visit and explained the reason for the visit. |
| Ozz Daynes | Executive Director | Met with the Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Capacity: 125
Citations: 0
Date: Apr 28, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations of insufficient staff to meet residents' care needs and that the facility was not kept clean.
Complaint Details
The complaint was unsubstantiated. Allegations included insufficient staff leading to neglect of Resident 1 and facility cleanliness issues. Investigation revealed no time when only one direct care staff was responsible for the entire facility, and no evidence of unmet resident care needs. Cleanliness concerns were addressed by professional carpet cleaning and replacement of stained carpet and ceiling tile.
Findings
The investigation found no evidence to substantiate the allegations. Staffing strategies were in place to ensure care needs were met despite concerns, and the facility made appropriate efforts to address cleanliness issues including carpet cleaning and replacement of stained areas.
Report Facts
Facility capacity: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Becky Kennedy | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Pamela Talmantes | Resident Services Director | Met with the investigator during the visit and participated in the exit interview |
| Icela Estrada | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 108
Capacity: 125
Citations: 0
Date: Apr 23, 2025
Visit Reason
An unannounced case management visit was conducted to deliver an amended report and obtain the Executive Director's signature on the amended report dated April 15, 2025.
Findings
The visit involved the Licensing Program Analyst meeting with the Executive Director, obtaining a signature on the amended report, and conducting an exit interview confirming receipt of the report and licensee appeal rights. No deficiencies or violations were detailed in this report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ozz Daynes | Executive Director | Met during the visit and provided signature on the amended report. |
| Hannah Rodgers | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 125
Citations: 1
Date: Apr 15, 2025
Visit Reason
An unannounced complaint investigation was conducted following an allegation received on 2024-12-06 that staff handled a resident in a rough manner resulting in injury.
Complaint Details
The complaint was substantiated. The allegation involved rough handling of Resident #1 by a staff member in training, resulting in bruising. The investigation included an unannounced visit, records review, and interviews with staff, residents, and outside sources.
Findings
The investigation found that a new staff member in training improperly transferred Resident #1 by grabbing the tops of their hands instead of under the palms, causing bruising. The allegation was substantiated based on interviews and record reviews, and one deficiency was cited related to personal rights and staff competency.
Citations (1)
Failure to provide care and services delivered by staff that are sufficient in competency to meet residents' needs, resulting in rough handling of one resident.
Report Facts
Resident count: 108
Facility capacity: 125
Deficiencies cited: 1
Plan of Correction due date: Apr 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hannah Rodgers | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Pamela Talamantes | Resident Services Director | Met with during the investigation and exit interview |
| Chad Coleman | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 109
Capacity: 125
Citations: 0
Date: Apr 9, 2025
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements and facility conditions.
Findings
The facility was found to be in compliance with all licensing requirements. No deficiencies were cited. The facility was clean, safe, and well-maintained with all required equipment and supplies present and in working order.
Report Facts
Licensed capacity: 125
Residents present: 109
Hospice waiver: 27
Bedridden residents allowed: 15
Perishable food supply: 2
Non-perishable food supply: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ozz Daynes | Executive Director | Met during inspection and exit interview |
| Pamela Talamantes | Resident Services Director | Met during inspection and exit interview |
| Hannah Rodgers | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Census: 116
Capacity: 125
Citations: 0
Date: Mar 26, 2025
Visit Reason
The purpose of the visit was to sign an amended prior report that was found to contain some erroneous information.
Findings
The only business conducted during the visit was the signing of the amended report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Talmantes | Resident Services Director | Met with during the visit and exit interview. |
| Becky Kennedy | Licensing Program Analyst | Conducted the unannounced visit and signed the report. |
| Thomas Daynes | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 125
Citations: 1
Date: Mar 24, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff administered medications to a resident not prescribed by a physician.
Complaint Details
The complaint was substantiated based on evidence including record review and interviews. The incident involved medication administration error by staff member 1 (S1) on 7-30-2021. The facility took immediate action by notifying the resident's family and physician and sending the resident to the hospital for observation.
Findings
The investigation substantiated the allegation that a recently hired and in-training staff member gave medication prescribed for one resident to another resident. The facility immediately notified the resident's family and physician, and the resident was sent to the hospital for observation with no adverse consequences.
Citations (1)
The facility did not operate in accordance with the Plan of Operation by medication staff giving a resident's medication to another resident, posing potential health risks.
Report Facts
Capacity: 125
Census: 115
Deficiency Type: 1
Plan of Correction Due Date: Mar 26, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Becky Kennedy | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Pam Talamantes | Resident Services Director | Met with Licensing Program Analyst during investigation and exit interview |
| Icela Estrada | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Citations: 1
Date: Mar 21, 2025
Visit Reason
An unannounced visit was made to the facility in response to a complaint regarding pain management for a resident.
Complaint Details
The investigation was triggered by a complaint. Resident 1 was no longer at the facility at the time of the visit. The complaint was substantiated based on record review and interviews.
Findings
The facility failed to consistently provide non-pharmacological interventions prior to administering pain medication and did not administer pain medication doses according to the physician's pain scale orders. These failures posed a risk of inappropriate pain medication use, including over or under administration.
Citations (1)
F 0697: The facility failed to provide safe, appropriate pain management for a resident by not consistently applying non-pharmacological interventions before administering pain medication and not following the physician's pain scale orders for medication dosing.
Report Facts
Pain medication administrations: 20
Non-pharmacological interventions attempted: 3
Pain medication administrations: 24
Non-pharmacological interventions attempted: 5
Inspection Report
Complaint Investigation
Census: 114
Capacity: 125
Citations: 0
Date: Mar 12, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the licensee did not dispense medications as prescribed and that facility staff falsified medication records.
Complaint Details
The complaint involved allegations that medications were not administered as prescribed and that medication records were falsified. The investigation included review of records, interviews, and observations, concluding the allegations were unsubstantiated.
Findings
The investigation found no discrepancies in medication documentation or administration for Resident 1, and the allegations were unsubstantiated as the preponderance of evidence standard was not met to prove a violation occurred.
Report Facts
Capacity: 125
Census: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Becky Kennedy | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Pamela Talmantes | Resident Services Director | Met with the Licensing Program Analyst during the investigation and exit interview |
Inspection Report
Annual Inspection
Citations: 5
Date: Feb 6, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, inadequate assistance with activities of daily living, inconsistent fire safety practices, lack of physician orders and documentation for catheter care, and delayed response to call lights. All deficiencies were cited with minimal harm or potential for actual harm.
Citations (5)
F 0636: The facility failed to ensure a comprehensive assessment was completed accurately for one of 12 sampled residents when the Minimum Data Set did not reflect an indwelling catheter. This increased the risk of inappropriate care.
F 0677: The facility failed to provide assistance with nail care and removal of facial hair for a resident unable to perform activities of daily living, resulting in long fingernails and facial hair that could impact self-esteem and comfort.
F 0689: The facility staff failed to consistently document removal of lint from the laundry drying machine trap, posing a potential fire hazard affecting resident and staff safety.
F 0690: The facility failed to ensure one resident screened for an indwelling catheter had a physician's order and consistent catheter care, increasing the risk of urinary tract infection.
F 0725: The facility failed to ensure call lights were answered in a timely manner, potentially leaving residents' needs unmet.
Report Facts
Residents sampled: 12
Residents unable to perform ADLs sampled: 2
Residents screened for indwelling catheter: 3
Missed lint removal log entries: 18
Staffing quality rating: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding deficiencies in resident assessment, catheter care, call light response, and laundry safety |
| Director of Staff Development | Director of Staff Development | Interviewed regarding resident assessment and catheter care documentation |
| CNA 11 | Certified Nursing Assistant | Interviewed regarding assistance with resident nail care and facial hair removal |
| Laundry Staff 12 | Laundry Staff | Interviewed regarding lint removal from drying machine |
Inspection Report
Census: 117
Capacity: 125
Citations: 0
Date: Nov 6, 2024
Visit Reason
The visit was an unannounced Case Management - Incident inspection conducted in response to an LIC624 Incident Report regarding a resident fall and fracture.
Findings
During the visit, the Licensing Program Analyst conducted a facility tour, welfare check, collected records, and interviewed involved parties. No health or safety concerns were observed and no deficiencies were cited.
Report Facts
Capacity: 125
Census: 117
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Ozz Daynes | Executive Director | Met during the inspection and involved in the incident discussion |
| Ariana Ventura | Care Coordinator | Met during the inspection and involved in the incident discussion |
| Liliana Silveira | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 117
Capacity: 125
Citations: 0
Date: Nov 6, 2024
Visit Reason
The visit was conducted in response to an LIC624 Incident Report submitted by the licensee regarding a resident fall and fracture incident on 09/26/2024.
Complaint Details
The complaint involved Resident #1 who fell and suffered a fracture on 09/26/2024, was sent to the Emergency Room on 09/27/2024, and then transferred back to the facility. The complaint was investigated and no deficiencies were found.
Findings
During the unannounced case management incident visit, no health or safety concerns were observed and no deficiencies were cited.
Report Facts
Capacity: 125
Census: 117
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Ozz Daynes | Executive Director | Met with during the inspection |
| Ariana Ventura | Care Coordinator | Met with during the inspection and involved in the incident discussion |
| Liliana Silveira | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Annual Inspection
Census: 118
Capacity: 125
Citations: 0
Date: Jun 18, 2024
Visit Reason
Licensing Program Analyst Ryan Fulton conducted an unannounced Required Annual Inspection to evaluate compliance with licensing requirements and facility conditions.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies cited. All safety equipment, medication storage, and environmental conditions were compliant with regulations.
Report Facts
Hot water temperature: 113.6
Hot water temperature: 108.2
Hot water temperature: 113
Hot water temperature: 110.9
Capacity: 125
Census: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Talamantes | Resident Services Director | Met with Licensing Program Analyst during inspection and exit interview |
| Ryan Fulton | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Jennifer Lott | Supervisor | Supervisor overseeing the inspection process |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 125
Citations: 0
Date: Mar 28, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that facility staff forced a resident to take a shower.
Complaint Details
The complaint alleged that facility staff forced a resident to take a shower. The investigation included interviews with the resident, facility staff, and an outside agency, as well as records review. The resident stated staff never forced showering. Staff confirmed they encourage but do not force residents. The allegation was unsubstantiated.
Findings
The investigation found that the resident refused to shower multiple times and that staff used protocols such as 'change of face' and multiple attempts to encourage showering, but did not force the resident. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 125
Census: 119
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ramon Serrano | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Pamela Talamantes | Resident Services Director | Interviewed during investigation and participated in exit interview |
| Chad Coleman | Administrator | Facility administrator named in the report |
| Simon Jacob | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Citations: 0
Date: Mar 12, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for a nursing home inspection conducted on 2024-03-12.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 41
Citations: 12
Date: Feb 29, 2024
Visit Reason
Routine inspection of Bayshire Carlsbad nursing home to assess compliance with health, safety, nutrition, medication administration, and care standards.
Findings
The facility had multiple deficiencies including failure to provide prescribed nutritional supplements, medication errors, inadequate trauma-informed care, improper food safety and sanitation practices, and issues with food storage and preparation. Several residents experienced risks related to nutrition, medication administration, and psychosocial care.
Citations (12)
F692: Facility failed to provide a resident with prescribed nutritional supplements, resulting in severe unplanned weight loss of 14.98% in 30 days.
F695: Licensed nurses failed to monitor oxygen concentrator humidifier per physician's order, risking dry mucus membranes and injury.
F699: Facility failed to identify and address PTSD diagnosis for a resident, risking re-traumatization due to lack of trauma-informed care.
F740: Facility failed to provide necessary behavioral health care and psychosocial assessment for a resident with PTSD.
F759: Medication error rate exceeded 5% due to administration of incorrect aspirin form and omeprazole given after resident ate.
F760: Licensed nurse administered metoprolol without checking resident's heart rate as required, risking harm.
F761: Medication refrigerators' temperatures were not consistently monitored, risking medication efficacy.
F802: Food safety violations included undated thawed chicken, malfunctioning dish machine, weak sanitizer, dirty refrigerator floor, worn cutting boards, and dirty ice machine.
F803: Facility failed to follow menus as printed, including inconsistent milk service, risking nutritional adequacy.
F804: Food was not palatable or prepared according to standardized recipes, including use of unapproved liquids in pureed foods.
F806: Facility failed to honor food preferences for a resident, contributing to decreased nutrient intake and weight loss.
F808: Therapeutic diets and prescribed supplements were not consistently provided as ordered, risking resident nutrition.
Report Facts
Medication error rate: 6.6
Weight loss percentage: 14.98
Facility census: 41
Calories in milk carton: 140
Protein in milk carton: 10
Calories in Ensure Plus supplement: 350
Protein in Ensure Plus supplement: 16
Average calories served per day: 2583
Average protein served per day: 114
Sanitizer strength: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 2 | Licensed Nurse | Named in medication error findings for incorrect aspirin form and omeprazole administration. |
| LN 3 | Licensed Nurse | Named in medication error finding for failure to check heart rate before metoprolol administration. |
| RD | Registered Dietitian | Named in findings related to nutritional supplement provision and menu adherence. |
| DON | Director of Nursing | Named in multiple interviews regarding deficiencies in care and medication administration. |
| FSM | Food Services Manager | Named in findings related to food safety, sanitation, and kitchen practices. |
| CK 1 | Cook | Named in findings related to food preparation and recipe adherence. |
| DA 1 | Dietary Aide | Named in findings related to improper food safety and sanitation practices. |
| DA 2 | Dietary Aide | Named in findings related to improper food safety and sanitation practices. |
Inspection Report
Annual Inspection
Citations: 0
Date: Feb 13, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at the nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 113
Capacity: 125
Citations: 0
Date: Feb 8, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff yell at residents in care.
Complaint Details
The complaint alleged that facility staff yell at residents in care. The investigation was unsubstantiated based on interviews and observations.
Findings
The investigation found no supporting evidence or witness statements to substantiate the allegation. Interviews with residents and staff indicated that staff speak loudly due to residents' hearing impairments but do not yell. The complaint was determined to be unsubstantiated.
Report Facts
Capacity: 125
Census: 113
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pam Talamantes | Head Nurse | Met with Licensing Program Analyst during the complaint investigation |
| Tiffany Holmes | Licensing Program Analyst | Conducted the complaint investigation visit |
| Chad Coleman | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 125
Citations: 0
Date: Jan 29, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation received on 2023-12-11 that facility staff were stealing residents' clothes.
Complaint Details
The complaint alleged staff were stealing residents' clothes. Interviews with residents revealed some missing items but no evidence of theft by staff. Resident 1 reported missing money and clothing but was reimbursed and given replacements. Other residents reported missing personal items but acknowledged possible alternative explanations. The allegation was unsubstantiated.
Findings
The investigation included facility visits, record reviews, and resident interviews. The allegation that staff were stealing residents' clothes was found to be unsubstantiated based on the preponderance of evidence, with some missing items possibly lost in laundry or due to residents leaving doors open.
Report Facts
Capacity: 125
Census: 114
Complaint received date: Dec 11, 2023
Missing money amount: 90
Gift card value: 50
Resident 4 length of stay: 7.5
Resident 1 move-in date: Jun 30, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Mandel | Licensing Program Analyst | Conducted the complaint investigation visit |
| Simon Jacob | Licensing Program Manager | Participated in initial visit and investigation |
| Pamela Talamantes | Resident Services Director | Met with during investigation and exit interview |
Inspection Report
Plan of Correction
Citations: 1
Date: Dec 6, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to pharmaceutical services and medication management at the facility.
Findings
The facility failed to keep an accurate accounting of oxycontin, a schedule 2 controlled substance, resulting in missing medication. Interviews and record reviews confirmed missing pills and incomplete narcotic count documentation.
Citations (1)
F 0755: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. The facility did not keep an accurate accounting of oxycontin, allowing medication to go missing.
Report Facts
Missing medication count: 60
Missing medication count: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding missing medication and narcotic count procedures | |
| Licensed Nurse 1 | Did not sign narcotic count sheet for 7 A.M. to 3 P.M. shift on 11/4/23 | |
| Licensed Nurse 2 | Initialed narcotic count sheet for 3 P.M. to 11 P.M. shift on 11/4/23 |
Inspection Report
Annual Inspection
Census: 113
Capacity: 125
Citations: 0
Date: Oct 18, 2023
Visit Reason
An unannounced required One-Year Inspection was conducted to ensure substantial compliance with Title 22 regulations.
Findings
The facility was found to be in substantial compliance with regulations. All areas were clean and unobstructed, safety systems were operational, resident rooms and bathrooms were sanitary and properly equipped, food and medication storage were compliant, and staff records met required certifications. Residents were treated with dignity and staffing was sufficient.
Report Facts
Hospice Waiver residents: 27
Food supply duration: 2
Food supply duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Daynes | Executive Director | Accompanied LPAs during inspection and participated in exit interview |
| Amy Rodgers | Licensing Program Analyst | Conducted the inspection |
| Juliana Barfield | Licensing Program Analyst | Conducted the inspection and signed the report |
| Chad Coleman | Administrator | Facility Administrator listed in report |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 125
Citations: 0
Date: Aug 29, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff inappropriately sexually touched a resident.
Complaint Details
The complaint alleged that staff inappropriately sexually touched Resident 1. The investigation found no evidence to substantiate the allegation based on interviews and record reviews.
Findings
The investigation included record reviews and interviews with staff and outside sources. The allegation was determined to be unsubstantiated as the resident did not recall any inappropriate touching and no evidence was found to support the claim.
Report Facts
Complaint Control Number: 08-AS-20221123145756
Capacity: 125
Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Domingo | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Pamela Talamantes | Resident Service Director | Met with the evaluator and participated in the exit interview |
| RinaJoy Ramirez | Administrator | Facility administrator named in the report |
| Simon Jacob | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 125
Citations: 1
Date: Jul 21, 2023
Visit Reason
The visit was an unannounced Case Management – Incident inspection conducted in response to an LIC624 Incident Report regarding a medication error where a resident was given two medications not prescribed to them.
Complaint Details
The visit was complaint-related, triggered by a medication error incident reported by the licensee. The deficiency was substantiated with one deficiency cited and one technical violation issued regarding reporting requirements.
Findings
The licensee did not assist one resident with self-administered medications as prescribed, which posed a potential health risk. The medication errors were timely reported, and the resident did not experience adverse symptoms. The licensee counseled and retrained staff involved and developed a Plan of Correction.
Citations (1)
Licensee did not assist one resident with self-administered medications as needed/prescribed, posing a potential health risk.
Report Facts
Deficiencies cited: 1
Technical Violations issued: 1
Census: 111
Total Capacity: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Daynes | Executive Director | Met during inspection and exit interview. |
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection. |
| Lizzette Tellez | Supervisor | Supervisor overseeing the inspection. |
Inspection Report
Routine
Citations: 3
Date: Apr 14, 2023
Visit Reason
The inspection was conducted to assess compliance with resident rights, medication storage, and room change notification policies at the nursing home.
Findings
The facility failed to maintain resident dignity by not covering a urinary catheter drainage bag, failed to notify the responsible party of multiple room changes, and failed to safely store medication by leaving tablets unattended at a resident's bedside.
Citations (3)
F 0550: The facility failed to provide dignity when a urinary catheter drainage bag was not covered for Resident 3, potentially affecting the resident's privacy and self-esteem.
F 0559: The facility failed to notify the responsible party of room changes for Resident 1, denying the opportunity to accept or decline the moves.
F 0761: The facility failed to safely store prescribed medication when two tablets were left unattended at Resident 2's bedside, risking misuse or diversion.
Report Facts
Room changes: 5
Cognitive score: 11
Cognitive score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding catheter care, room change notifications, and medication storage policies. | |
| Certified Nurse Assistant 1 | Interviewed about the uncovered urinary catheter drainage bag for Resident 3. | |
| Certified Nurse Assistant 2 | Interviewed about dignity bag use for urinary catheter drainage bags. | |
| Licensed Nurse 1 | Observed medication left unattended at Resident 2's bedside. | |
| Licensed Nurse 2 | Interviewed about medication administration and storage practices. |
Inspection Report
Follow-Up
Census: 110
Capacity: 125
Citations: 1
Date: Oct 11, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on two self-reported medication error incidents received by the Regional Office on 7/07/22 and 7/20/22.
Findings
The facility self-reported two medication errors involving incorrect medication administration and failure to administer medication to 26 residents. Staff involved were suspended and terminated. The licensee provided on-site pharmacy training to medication technicians. A deficiency was cited related to failure to give medications according to physician's orders but was cleared after corrective actions.
Citations (1)
Licensee did not give medications in accordance to the physician's orders in 27 of 96 persons in care, posing a potential Health or Personal Rights risk.
Report Facts
Residents affected: 27
Residents not administered medication: 26
Total persons in care reviewed: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniela Huerta | Licensing Program Analyst | Conducted the unannounced case management visit |
| Icela Estrada | Interim Assistant Program Administrator | Conducted the unannounced case management visit |
| Pam Talamantes | Residence Services Director | Met with evaluators during the visit and received report |
| Chad Coleman | Executive Director | Met with evaluators during the visit |
| Simon Jacob | Supervisor | Named as supervisor on the report |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 125
Citations: 1
Date: Oct 11, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on two self-reported incident reports involving medication errors received by the Regional Office on 7/07/22 and 7/20/22.
Complaint Details
The visit was complaint-related, following up on two medication error incidents self-reported by the facility. The Department verified cross-reporting to Primary Care Physicians and responsible parties. Staff involved were suspended and terminated. The complaint was substantiated by the cited deficiency.
Findings
The facility self-reported two medication errors: one where a resident was given another resident's medication with no adverse effects, and another where medication was not administered to 26 residents. Staff responsible were suspended and terminated. The licensee provided on-site pharmacy training to medication technicians. A deficiency was cited related to medication administration not being given according to physician's orders in 27 of 96 persons in care.
Citations (1)
Failure to give medications in accordance to the physician's orders in 27 of 96 persons in care, posing a potential Health or Personal Rights risk.
Report Facts
Residents affected by medication error: 27
Residents census: 110
Facility capacity: 125
Residents missed medication: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pam Talamantes | Residence Services Director | Met with inspectors during visit and received report and appeals rights |
| Chad Coleman | Executive Director | Met with inspectors during visit |
| Daniela Huerta | Licensing Program Analyst | Conducted inspection and signed report |
| Simon Jacob | Licensing Program Manager / Supervisor | Named as supervisor and licensing program manager on report |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 125
Citations: 0
Date: Aug 3, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff interfered with a resident's sleep and did not respond to residents' call assistance button.
Complaint Details
The complaint was investigated and determined to be unfounded because the alleged incidents did not occur at the licensed Residential Facility for the Elderly but at a Skilled Nursing Facility outside the licensing division's jurisdiction.
Findings
The investigation found that the alleged resident had never resided at the facility and the incidents actually occurred at a Skilled Nursing Facility on the same campus, which is outside the jurisdiction of the Community Care Licensing Division. Therefore, the allegations were determined to be unfounded.
Report Facts
Capacity: 125
Census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Hamilton | Licensing Program Analyst | Conducted the complaint investigation |
| Chad Coleman | Executive Director | Interviewed during the investigation |
| Denise Powell | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Citations: 3
Date: Apr 28, 2022
Visit Reason
The inspection was conducted based on complaints regarding failure to protect a resident from financial abuse and medication administration errors.
Complaint Details
The investigation was triggered by complaints related to financial abuse of a resident and medication administration errors. The financial abuse complaint was substantiated with findings of missing cash and inadequate inventory. Medication errors were documented with a medication error rate exceeding 5 percent.
Findings
The facility failed to protect a resident from financial abuse due to inadequate inventory of personal effects. Additionally, the facility failed to administer medications according to physician orders, resulting in medication errors and a medication error rate of 5.71%.
Citations (3)
F 0600: The facility failed to protect a resident from financial abuse by not properly inventorying the resident's personal belongings upon admission, resulting in missing cash.
F 0755: The facility failed to administer medication according to a physician's order for one resident, resulting in the resident receiving un-prescribed medication and subsequent hospitalization.
F 0759: The facility failed to ensure the medication error rate was less than 5 percent, with an observed error rate of 5.71% during medication administration for two residents.
Report Facts
Medication error rate: 5.71
Medication errors observed: 2
Medication administration opportunities: 35
Residents sampled for medication error: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Named in medication error findings related to improper medication administration |
| DON | Director of Nursing | Interviewed regarding medication errors and facility policies |
| Adm | Administrator | Interviewed regarding failure to follow policy on inventorying resident belongings |
Inspection Report
Census: 73
Capacity: 125
Citations: 0
Date: Sep 23, 2021
Visit Reason
The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan including disinfection, testing, vaccination, screening protocols, and use of personal protective equipment (PPE).
Findings
No deficiencies were cited during the visit. A walk-through of the facility was conducted and a debriefing was held with the Executive Director.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Phan | Executive Director | Met with during the visit and participated in debriefing. |
| Lizzette Tellez | Licensing Program Analyst | Conducted the on-site HAI assessment visit. |
| Ramon Serrano | Licensing Program Analyst | Conducted the on-site HAI assessment visit. |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 125
Citations: 0
Date: Jul 13, 2021
Visit Reason
An unannounced virtual visit was conducted to investigate a complaint received on 2021-07-08 regarding personal rights allegations at the facility.
Complaint Details
The complaint investigation was regarding personal rights allegations. The complaint was determined to be unfounded because the resident involved did not reside at the newly licensed facility.
Findings
The investigation found that the resident mentioned in the allegations did not reside at the newly licensed facility, which had a change of ownership on June 1, 2021. Therefore, the complaint was determined to be unfounded.
Report Facts
Complaint Control Number: 08-AS-20210708142631
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristina Ryan | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Sasha Hightower | Administrator | Met with the Licensing Program Analyst during the investigation. |
| Simon Jacob | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Original Licensing
Census: 76
Capacity: 125
Citations: 0
Date: Jun 2, 2021
Visit Reason
The visit was an announced pre-licensing inspection to evaluate Title 22 compliance for change of ownership and to assess the facility's readiness to serve elderly residents aged 60 and over.
Findings
The inspection found the facility to be in compliance with physical plant requirements, including sanitary bathrooms, operable lighting and windows, unobstructed passageways, and proper storage of hazardous items. Fire safety equipment was present and operational, and required postings were displayed. Technical assistance was provided, and no deficiencies were explicitly cited.
Report Facts
Capacity: 125
Census: 76
Hospice Waiver: 17
Bedridden residents capacity: 15
Water temperature range: 106-113
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sasha Hightower | Executive Director | Met during inspection and discussed operational requirements |
| Alexandre Vo | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Simon Jacob | Licensing Program Manager | Oversaw the inspection process |
Inspection Report
Census: 79
Capacity: 125
Citations: 0
Date: May 10, 2021
Visit Reason
The visit was an office evaluation related to a change of ownership application for the facility. The applicant and administrator participated in a COMP II telephone interview to verify identification and confirm understanding of California Code Title 22 regulations.
Findings
The applicant and administrator demonstrated understanding of facility operation, admission policies, staffing requirements and training, restrictive/prohibited health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness. Signed LIC 809 with photo ID copies were obtained.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Gonzalez | Administrator | Named as facility administrator |
| Scott Kirby | President | Participant in COMP II interview |
| Sasha Hightower | Administrator | Participant in COMP II interview |
| Bethany Hunter | Licensing Evaluator | Conducted evaluation and signed report |
| Jude De La Concepcion | Supervisor | Supervisor of licensing evaluation |
Inspection Report
Original Licensing
Census: 79
Capacity: 125
Citations: 0
Date: May 10, 2021
Visit Reason
The visit was conducted as a Change of Ownership application evaluation for the facility, including verification of applicant and administrator identification and confirmation of understanding of California Code Title 22 regulations.
Findings
The applicant and administrator participated in a telephone interview confirming their understanding of facility operation, admission policies, staffing requirements, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness. Signed documentation and photo ID copies were obtained.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Scott Kirby | President | Participant in the Change of Ownership application interview |
| Sasha Hightower | Administrator | Participant in the Change of Ownership application interview |
| Jeff Gonzalez | Administrator | Facility Administrator |
| Jude De La Concepcion | Licensing Program Manager | Named in report header |
| Bethany Hunter | Licensing Program Analyst | Named in report header and analyst conducting the interview |
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