Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. However, some reports did identify issues, primarily related to staff supervision, facility maintenance, and staff qualifications. The most serious events included immediate civil penalties of $500 issued in May 2024 for unqualified staff and administrator, and substantiated findings of inadequate supervision leading to resident elopements in late 2024. Deficiencies also involved unsecured hazardous items, delayed response to residents’ calls, and maintenance problems such as water leaks and a broken refrigerator. The most recent report from September 29, 2025 had no deficiencies, showing improvement compared to earlier substantiated complaints.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
11.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
188% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
69% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 82
Capacity: 119
Deficiencies: 0
Date: Sep 29, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that facility staff were not properly turning a resident resulting in pressure injury and that staff were leaving the resident in bed for extended periods of time.
Complaint Details
The complaint alleged that staff were not properly turning resident R1, resulting in a pressure injury, and that staff left the resident in bed for extended periods. The investigation included interviews with staff and residents, review of medical and care records, and a physical assessment by a SCAN Nurse Practitioner. The allegations were found unsubstantiated due to lack of evidence.
Findings
The investigation found insufficient evidence to support the allegations. Staff and residents denied the claims, and a SCAN Nurse Practitioner confirmed no current pressure injury. The resident's bedridden status and care routine were consistent with medical reports, leading to the allegations being unsubstantiated.
Report Facts
Capacity: 119
Census: 82
Staff interviewed: 7
Residents interviewed: 5
Complaint receipt date: Sep 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation |
| Laura Garcia | Executive Director | Met with Licensing Program Analyst during investigation |
| Lisa Hicks | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 119
Deficiencies: 0
Date: Aug 21, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that the licensee did not ensure the facility was kept in good repair and that staff did not maintain residents' rooms in a sanitary condition.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included a water leak in the kitchen ceiling and poor sanitary conditions in residents' rooms involving blood, vomit, and feces soaked garments left for seven or more days. The investigation found no corroborating evidence for these claims.
Findings
The investigation found no evidence to substantiate the allegations. Staff and resident interviews, observations, and record reviews did not corroborate claims of water leaks or unsanitary conditions in residents' rooms. The facility's plumbing was found to be in good condition and laundry procedures were timely and effective.
Report Facts
Staff interviewed: 8
Resident interviewed: 6
Resident rooms inspected: 10
Laundry rooms inspected: 3
Soiled linen closets inspected: 2
Days complaint received to visit: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mayra Cota | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Guerrero | Wellness Nurse | Met with during the visit and facilitated the investigation |
| Chad Coleman | Administrator | Facility administrator named in the report |
| Wei Siew Ho | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Laura Sanchez | Director | Contacted via phone during the investigation |
| Plant Operations Director | Interviewed staff member (S3) who explained the water leak was condensation related and resolved |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 119
Deficiencies: 0
Date: Aug 7, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate multiple allegations including disrepair of resident pull cords, untimely leak repairs, malfunctioning alarmed exit doors, unexplained bruises on residents, lack of supervision leading to resident elopement, failure to report incidents, and failure to safeguard residents' personal property.
Complaint Details
The complaint investigation was triggered by allegations received on 11/19/2024. The investigation found the allegation of lack of supervision leading to a resident elopement substantiated, while all other allegations including disrepair of pull cords, leaks, alarmed exit doors, unexplained bruises, failure to report incidents, and failure to safeguard personal property were unsubstantiated.
Findings
Most allegations were found to be unsubstantiated based on interviews, facility tours, and evidence gathered, except for the allegation of lack of supervision leading to a resident elopement, which was substantiated. No deficiencies were issued at this visit, though prior investigations had substantiated some findings and issued deficiencies.
Report Facts
Capacity: 119
Census: 80
Memory care residents: 19
Caregivers: 7
Med techs: 3
Caregivers during elopement: 2
Med techs during elopement: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Laura Sanchez | Health Services Director | Interviewed during investigation and provided information on facility operations and incident reporting |
| Chad Coleman | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 119
Deficiencies: 1
Date: Aug 5, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff inappropriately took a resident's call pendant away.
Complaint Details
The complaint was substantiated. It was found that staff took the resident's call pendant away due to excessive pressing, which was confirmed by interviews with staff and residents. The resident reported the pendant was lost and staff did not know its location.
Findings
The investigation found that the resident's call pendant was taken away due to excessive pressing, which posed an immediate health, safety, and personal rights risk. The allegation was substantiated based on interviews and record review.
Deficiencies (1)
87468.1 Personal Rights of Residents in All Facilities: Residents must be accorded safe, healthful and comfortable accommodations, furnishings and equipment. R1's call pendant was taken away due to excessive pushing, posing an immediate health, safety, and personal rights risk.
Report Facts
Capacity: 119
Census: 78
Deficiency count: 1
Plan of Correction Due Date: Aug 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christian Gutierrez | Licensing Program Analyst | Conducted the complaint investigation |
| David Sicairos | Licensing Program Manager | Oversaw the complaint investigation |
| Chad Coleman | Administrator | Interviewed during investigation |
| Tammy Garcia | Activity Director | Met with Licensing Program Analyst during investigation |
| Laura Sanchez | Health Services Director | Participated in exit interview and agreed to plan of correction |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 119
Deficiencies: 1
Date: Aug 5, 2025
Visit Reason
This was an unannounced complaint investigation visit conducted due to an allegation that staff did not fix the leak in the roof timely or properly.
Complaint Details
The complaint was substantiated. The allegation was that staff did not fix the leak in the roof timely or properly. Evidence from staff interviews and observations confirmed frequent ceiling leaks and water damage in the Memory Care Activity Room and Dining Room.
Findings
The investigation found that ceiling tiles in the Memory Care Activity Room and Dining Room had water damage due to leaks that occur frequently during the summer when the HVAC is used. The allegation was substantiated based on interviews, observations, and record review.
Deficiencies (1)
Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Evidence showed water damage on ceiling tiles due to leaks.
Report Facts
Capacity: 119
Census: 78
Plan of Correction Due Date: Aug 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Irra | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Wei Siew Ho | Licensing Program Manager | Oversaw the complaint investigation |
| Laura Sanchez | Health Services Director | Facility representative present during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 119
Deficiencies: 0
Date: Aug 4, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit regarding an allegation that facility staff is not allowing residents to select their own hospice agency and forces responsible parties/residents to choose a specific hospice agency which does not provide proper care.
Complaint Details
The complaint alleged that facility staff did not allow residents to select their own hospice agency and forced them to choose a specific agency. The investigation found mixed awareness among residents and responsible parties about hospice agency choice. There was no sufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Findings
The investigation included interviews with residents, staff, and responsible parties, as well as review of resident files and death reports. It was found that some residents and responsible parties were unaware of their choice in hospice agencies, but multiple hospice agencies were providing services. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Residents interviewed: 8
Staff interviewed: 6
Resident files reviewed: 6
Residents currently in hospice: 27
Hospice agencies providing services: 8
Death reports reviewed: 7
Hospice agencies noted at time of death: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Wei Siew Ho | Licensing Program Manager | Named as Licensing Program Manager on report |
| Laura Sanchez | Health-Wellness Director | Participated in exit interview |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 119
Deficiencies: 2
Date: Jun 26, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2025-06-20 regarding staff not ensuring resident's dietary needs were met resulting in choking, failure to provide resident's advance directive to emergency personnel, and failure to report resident's incident to appropriate parties.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not ensure the resident's dietary needs were met resulting in choking and did not provide the resident's advance directive to emergency personnel. The allegation that staff did not report the resident's incident to appropriate parties was unsubstantiated.
Findings
The investigation substantiated that a resident was served the wrong diet plate causing choking and that emergency personnel were not provided necessary advance directive documents due to equipment issues. However, the allegation that staff failed to notify appropriate parties about the incident was unsubstantiated as staff notified the responsible party and hospice nurse within a reasonable time.
Deficiencies (2)
Failure to provide modified diets prescribed by a resident's physician as a medical necessity, resulting in a resident choking after being served the wrong diet plate.
Failure to immediately present advance directive and/or request regarding resuscitative measures to emergency medical personnel.
Report Facts
Residents interviewed: 5
Staff interviewed: 5
Plan of Correction due dates: Jul 1, 2025
Plan of Correction due dates: Jul 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Named in report as Licensing Program Manager |
| Laura Sanchez | Health Services Director | Met with during investigation |
| Nadia Batista | Human Resources Director | Participated in exit interview |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 119
Deficiencies: 0
Date: May 13, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate multiple allegations regarding staff performance, facility conditions, and compliance with safety and reporting requirements at Bayshire San Dimas.
Complaint Details
The complaint investigation was triggered by multiple allegations including untimely response to resident calls, improper disposal of soiled diapers, insufficient staff training, lack of emergency evacuation drills, facility cleanliness issues, window screen disrepair, failure to follow reporting requirements, unsafe chemical and sharp object storage, and improper hand hygiene. All allegations were found unsubstantiated after investigation.
Findings
All allegations investigated were found to be unsubstantiated based on interviews, observations, documentation review, and resident feedback. The facility was found to respond timely to resident calls, properly dispose of soiled diapers, provide sufficient staff training, conduct emergency evacuation drills, maintain cleanliness, keep window screens in good repair, follow reporting requirements, secure chemicals and sharp objects, and ensure proper hand hygiene.
Report Facts
Capacity: 119
Census: 74
Resident Interviews: 7
Rooms Inspected: 13
Special Incident Reports: 20
Fire Drill Dates: 3
Staff Training Dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Laura Sanchez | Health Services Coordinator | Met with Licensing Program Analyst during the investigation and provided information |
| Chad Coleman | Administrator | Facility administrator named in the report |
| Wei Siew Ho | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 42
Capacity: 119
Deficiencies: 4
Date: Mar 27, 2025
Visit Reason
The inspection was a required, unannounced annual inspection to evaluate compliance with licensing requirements for the facility serving older adults.
Findings
The inspection found several deficiencies including unlocked cleaning supplies posing immediate risk, a broken bathroom sink faucet, missing pre-admission needs and service plans for some residents, and missing admission agreement for one resident. The facility was otherwise clean, safe, and well-maintained with proper medication storage and emergency equipment.
Deficiencies (4)
Cleaning supplies and scissors left in unlocked drawers in kitchen area in activity room posing immediate health, safety or personal rights risk.
Broken bathroom sink faucet in room #151 posing potential health, safety or personal rights risk.
Two out of five residents missing LIC 603 Pre admission needs and service plans posing potential health, safety or personal rights risk.
One resident missing admission agreement.
Report Facts
Residents receiving hospice care: 30
Licensed capacity: 119
Current census: 42
Residents missing pre-admission plans: 2
Residents files reviewed: 7
Staff files missing training: 2
Staff files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Sanchez | Health Service Director | Met with Licensing Program Analyst during inspection and responsible for submitting training log and pre-admission documentation. |
| Christian Gutierrez | Licensing Program Analyst | Conducted the annual inspection and signed the report. |
| Tony Vasallo | Licensing Program Manager | Supervisor of the licensing program and signed the report. |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 119
Deficiencies: 0
Date: Mar 14, 2025
Visit Reason
An unannounced complaint investigation visit was conducted regarding allegations of staff neglect resulting in a resident's death and unauthorized access to a resident's personal funds.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff neglect resulting in a resident's death and unauthorized access to a resident's personal funds. Interviews with staff, residents, and the resident's family, as well as record reviews, did not corroborate the allegations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents interviewed denied the allegations, and review of records did not corroborate the claims. Therefore, both allegations were determined to be unsubstantiated.
Report Facts
Capacity: 119
Census: 65
Staff interviewed: 4
Residents interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
| Nadia Batista | Human Resources Manager | Met with Licensing Program Analyst during the visit |
Inspection Report
Census: 73
Capacity: 119
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
The visit was an unannounced office meeting conducted to discuss the oversight of the facility, specifically addressing the number of complaints received since licensing, Title 22 violations, administrator hours, and hospice waiver increase requests.
Findings
The report discusses multiple topics including a hospice waiver increase request, administrator qualifications and hours, designation of responsible staff for each shift, staff scheduling requirements, a high volume of complaints, and citations issued for various Title 22 regulation violations. The facility representatives explained internal procedures to mitigate complaints and agreed to provide updated documentation as requested.
Report Facts
Hospice waiver increase request: 38
Hospice waiver increase current: 30
Capacity: 119
Census: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chad Coleman | Administrator / Director | Named in relation to oversight and exit interview |
| Tanner Peterson | Operation Manager | Present during meeting and explained internal procedures |
| Laura Sanchez | Health Services Director | Provided hospice waiver increase letter |
| Fernando Fierros | License Program Manager | Conducted the informal conference and discussed citations |
| Luis DeLeon | Licensing Evaluator | Conducted licensing evaluation and signed report |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 119
Deficiencies: 0
Date: Mar 11, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations including staff preventing residents from having family councils, staff not responding timely to residents' alerts, and staff allowing a resident to be soiled while in care.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff preventing family councils, delayed response to call pendants, and leaving a resident soiled causing a rash. Interviews with residents and staff, and review of records did not support these claims.
Findings
The investigation found no corroboration of the allegations from residents or staff interviews, review of records, and reports. The allegations were determined to be unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 119
Census: 66
Call pendant response rate: 90
Number of residents interviewed: 8
Number of staff interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik Zaragoza | Licensing Program Analyst | Conducted the complaint investigation visit |
| David Sicairos | Licensing Program Manager | Named as Licensing Program Manager on report |
| Laura Sanchez | Health Services Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Census: 70
Capacity: 119
Deficiencies: 0
Date: Feb 11, 2025
Visit Reason
The visit was an unannounced Case Management visit to evaluate the residents' displacement caused by the Eaton Fire.
Findings
Seven residents were relocated from another facility due to the fire. Four displaced residents were interviewed and reported feeling safe and comfortable, receiving good care, timely medication administration, and good food. No health or safety concerns were observed during the facility tour.
Report Facts
Number of displaced residents relocated: 7
Residents interviewed: 4
Residents not available for interview: 3
Water temperature range (°F): 105
Water temperature range (°F): 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Sanchez | Health Services Director | Met with during the visit and received a copy of the report |
| Sanjay Vaid | Program Analyst (LPA) | Conducted the unannounced Case Management visit |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 119
Deficiencies: 1
Date: Feb 4, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-01-30 regarding staff not ensuring sharp objects are inaccessible to residents, delayed response to residents' call buttons, and failure to update residents' physician reports.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not ensure sharp objects were inaccessible to residents. The allegations that staff were not responding to residents' call buttons in a timely manner and that residents' physician reports were not being updated were unsubstantiated.
Findings
The allegation that staff did not ensure sharp objects were inaccessible was substantiated based on observation of unlocked cleaning supplies and a caulk gun accessible to residents. The allegations regarding delayed response to call buttons and failure to update physician reports were unsubstantiated based on interviews, file reviews, and observations.
Deficiencies (1)
The licensee failed to ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items were in locked storage and not left unattended outside locked storage, as evidenced by an unlocked spray bottle of cleaning supply and Heavy Duty Construction Caulk Gun accessible to residents in the kitchen cabinet.
Report Facts
Capacity: 119
Census: 69
Plan of Correction Due Date: Feb 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nune Margaryan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Wei Siew Ho | Licensing Program Manager | Oversaw the complaint investigation |
| Laura Sanchez | Health Services Director | Interviewed during investigation and assisted with the visit |
| Chad Coleman | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 119
Deficiencies: 0
Date: Dec 17, 2024
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff did not prevent a resident from developing pressure injuries while in care.
Complaint Details
The complaint alleged staff failed to prevent pressure injuries in a resident. The investigation included interviews with staff and hospice, review of medical and care records, and found no preponderance of evidence to substantiate the allegation. The complaint was determined to be unsubstantiated.
Findings
The investigation found that the resident required full assistance and frequent repositioning, with staff providing care and notifying hospice as needed. Physician and hospice records indicated the wounds were likely unavoidable due to the resident's condition, and there was insufficient evidence to prove staff neglect. Therefore, the allegation was unsubstantiated.
Report Facts
Facility capacity: 119
Resident census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Guerrero | LVN | Interviewed during investigation |
| Tony Vasallo | Licensing Program Manager | Named in report as licensing program manager |
| Laura Sanchez | Health Care Director | Participated in exit interview |
| Chad Coleman | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 119
Deficiencies: 1
Date: Dec 10, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-10-01 regarding inadequate supervision of a resident resulting in the resident wandering from the facility.
Complaint Details
The complaint was substantiated. The allegation was that staff did not adequately supervise a resident, resulting in the resident wandering from the facility. Interviews and observations confirmed that the resident wandered out through a back gate whose alarm was not properly secured, and there were insufficient staff on duty at the time.
Findings
The investigation substantiated the allegation that staff did not adequately supervise a resident with dementia who wandered out of the facility through a back gate whose alarm was not properly secured. The facility had insufficient staff on duty at the time of the incident, leading to the resident wandering into traffic and posing an immediate risk.
Deficiencies (1)
Failure to ensure an adequate number of direct care staff to support and maintain necessary supervision of residents with dementia, resulting in a resident wandering into traffic and posing an immediate risk.
Report Facts
Memory care residents: 19
Caregivers on duty: 2
Med techs on duty: 1
Caregivers assigned: 7
Med techs assigned: 3
Plan of Correction Due Date: Dec 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bennette Pena | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| David Sicairos | Licensing Program Manager | Oversaw the complaint investigation |
| Laura Sanchez | Health Services Director | Facility representative met during the investigation and exit interview |
| Chad Coleman | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 119
Deficiencies: 2
Date: Nov 13, 2024
Visit Reason
The visit was an unannounced case management inspection conducted during a complaint investigation to assess health and safety conditions at the facility.
Complaint Details
The visit was conducted as part of a complaint investigation. Deficiencies were substantiated as noted in the report.
Findings
The inspection found deficiencies including accessible large scissors and a knife in the dementia kitchenette, a cabinet door in disrepair, and water temperatures in residents' rooms not consistently within the required 105-120 degrees Fahrenheit range.
Deficiencies (2)
Knife and scissors were stored accessible to residents with dementia, posing an immediate risk to health and safety.
Dementia unit kitchenette cabinet was not in good repair and water temperatures in residents' rooms were below the required 105-120 degrees Fahrenheit, posing a potential risk.
Report Facts
Water temperature readings: 71.5
Water temperature readings: 109.4
Deficiency due dates: Nov 14, 2024
Deficiency due dates: Nov 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lisa Gomez | Administrator | Met with Licensing Program Analyst during inspection |
| Tony Vasallo | Supervisor | Named as supervisor in the report |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 119
Deficiencies: 0
Date: Oct 21, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2024-10-11 regarding staff working under the influence, facility cleanliness, disrepair, and expired CPR certificates.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff working under the influence, facility dirtiness, disrepair, and expired CPR certificates. Interviews with staff and residents, observations, and document reviews did not corroborate the allegations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents denied the claims of intoxicated staff, dirty facility, unlocked doors at night, and expired CPR certificates. Observations and documentation supported compliance with operational and training requirements.
Report Facts
Capacity: 119
Census: 71
Staff interviewed: 6
Residents interviewed: 6
Date complaint received: Oct 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Reyes | Licensing Program Analyst | Conducted the complaint investigation |
| Fernando Fierros | Licensing Program Manager | Oversaw the complaint investigation |
| Lisa Gomez | Administrator | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 119
Deficiencies: 0
Date: Oct 7, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2024-09-30 regarding inadequate activities for residents, insufficient staff care, and failure to address residents' skin breakdown.
Complaint Details
The complaint investigation addressed three allegations: 1) staff not providing activities to residents, 2) inadequate staff care including diaper changes, and 3) failure to address skin breakdown. After interviews and observations, the allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that the allegations were unsubstantiated. Observations and interviews with staff and residents confirmed that residents received adequate activities, sufficient staff care including timely diaper changes, and proper monitoring and intervention for skin breakdown.
Report Facts
Capacity: 119
Census: 59
Residents interviewed: 6
Incontinent residents interviewed: 5
Staff shifts: 3
Diaper change frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nune Margaryan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Laura Sanchez | Health Service Director | Interviewed during investigation and assisted with the visit |
| Lisa Gomez | Administrator | Interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 119
Deficiencies: 1
Date: Oct 3, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff did not adequately supervise a resident, resulting in the resident wandering from the facility.
Complaint Details
The complaint was substantiated based on interviews, observations, and record reviews. The resident wandered out of the facility due to staff not properly securing the back gate alarm, leading to a potential safety risk.
Findings
The investigation substantiated the allegation that Resident #1 wandered out of the facility through a back gate whose alarm did not sound due to improper securing. Staff interviews and observations confirmed the incident occurred on 09/30/2024, and the resident was found without injury after wandering near a freeway.
Deficiencies (1)
The facility failed to ensure proper supervision of Resident #1, resulting in the resident wandering into traffic, posing a potential risk to residents in care.
Report Facts
Capacity: 119
Census: 41
Deficiency Plan of Correction Due Date: Oct 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bennette Pena | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| David Sicairos | Licensing Program Manager | Oversaw the complaint investigation |
| Lisa Gomez | Administrator | Facility administrator who assisted during the investigation and received the report |
| Laura Sanchez | Health Services Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 119
Deficiencies: 0
Date: Sep 12, 2024
Visit Reason
An unannounced complaint investigation was conducted to determine the validity of allegations that the facility air conditioner was in disrepair and staff did not provide comfortable room temperature for residents.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included facility air conditioner disrepair and inadequate room temperature. Interviews with staff, residents, and a third party AC contractor, along with temperature observations, did not confirm violations.
Findings
The investigation found that although some AC issues occurred due to a recent heat wave, the facility promptly contacted a third party contractor who provided portable AC units to affected residents. Most residents reported comfortable temperatures, and observed temperatures were within regulatory limits. Therefore, the allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Residents interviewed: 8
Dates of contractor visits: 5
Residents reporting no AC issues: 6
Residents reporting some AC issues: 2
Residents comfortable with dining room temperature: 5
Residents reporting warm/hot dining room: 3
Temperature range in residents' rooms: Between 72 and 78 degrees Fahrenheit
Temperature range in dining room: Observed between 78 and 83 degrees Fahrenheit
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Luis Mora | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Wei Siew Ho | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Chad Coleman | Administrator | Facility Administrator interviewed during investigation |
| Lisa Gomez | Manager | Facility Manager interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 119
Deficiencies: 1
Date: Aug 27, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 07/24/2024 regarding staff response times to residents' calls for assistance and meeting residents' dental hygiene and toileting needs.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not respond to residents' calls for assistance in a timely manner and did not meet residents' dental hygiene and toileting needs. The allegation that staff were pushing residents who do not require hospice care to agree to hospice care was unsubstantiated.
Findings
The investigation substantiated that staff took more than 30 minutes to respond to residents' pendant calls and did not meet residents' oral care and toileting needs in a timely manner. Another allegation that staff were pushing residents to agree to hospice care was found to be unsubstantiated.
Deficiencies (1)
Personnel Requirements-General (a): Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Staff took more than 30 minutes to respond to residents’ pendant calls and to meet residents’ oral care and/or toileting needs in a timely manner.
Report Facts
Resident interviews: 5
Pendant alarms: 14
Hospice agencies: 7
Deficiency count: 1
Plan of Correction due date: Sep 6, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Irra | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Tony Vasallo | Licensing Program Manager | Oversaw the complaint investigation |
| Laura Sanchez | Staff (S-1) | Assisted with the investigation and was present during exit interview |
| Chad Coleman | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 119
Deficiencies: 0
Date: Aug 26, 2024
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 08/19/2024 regarding multiple allegations including facility disrepair, equipment maintenance, staff training and qualifications, forced change of hospice companies, and timely resident care.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included facility disrepair, improper equipment maintenance, untrained staff on Hoyer lift operation, unqualified staff, forced hospice company changes, and delayed resident care response. None of these allegations were supported by evidence gathered during the investigation.
Findings
The investigation found no evidence to substantiate any of the allegations. Interviews with residents and staff, review of records, and physical observations confirmed that the facility was not in disrepair, equipment was properly maintained, staff were trained and qualified, residents were not forced to change hospice companies, and resident care needs were met in a timely manner.
Report Facts
Capacity: 119
Census: 55
Response time: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bonnie Tao | Licensing Program Analyst | Conducted the complaint investigation |
| Laura Sanchez | Health Service Director | Met with investigator and participated in exit interview |
| Fernando Fierros | Licensing Program Manager | Oversaw complaint investigation |
| Chad Coleman | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 119
Deficiencies: 1
Date: Aug 22, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit triggered by allegations received on 2024-05-23 regarding staff not being fingerprint cleared prior to working with residents and issues with staff records and qualifications.
Complaint Details
The complaint alleged that staff were not fingerprint cleared prior to working with residents in care, staff records were not properly maintained, and staff were not properly qualified. The fingerprint clearance allegation was substantiated, while the other allegations were unsubstantiated.
Findings
The investigation substantiated that one staff member (Staff #3) started working prior to obtaining background clearance, posing an immediate health and safety concern. Other allegations regarding staff records and qualifications were found to be unsubstantiated due to lack of preponderance of evidence.
Deficiencies (1)
Staff #3 started working prior to obtaining verification of background clearance, posing an immediate health and safety concern to residents in care.
Report Facts
Capacity: 119
Census: 56
Civil penalty: 1
Plan of Correction Due Date: Aug 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Tony Vasallo | Licensing Program Manager | Oversaw the complaint investigation |
| Chad Coleman | Administrator | Facility administrator named in the report |
| Nadia Bautista | HR Staff | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 119
Deficiencies: 0
Date: Aug 20, 2024
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff were mishandling residents' medications.
Complaint Details
The allegation was that staff did not document medication destruction, failed to ensure medications and narcotics were centrally stored and inaccessible to unauthorized persons, and that medications were missing. Five staff and five residents interviewed denied the allegation. Medication destruction logs for 20 residents and narcotic shift logs for July and August 2024 were reviewed with no discrepancies found. The allegation was unsubstantiated.
Findings
The investigation found no preponderance of evidence to substantiate the allegation. Medication destruction logs and narcotic shift logs were reviewed and found accurate, medication storage was secure, and interviews with staff and residents denied the allegation. No deficiencies were cited.
Report Facts
Capacity: 119
Census: 53
Staff interviews: 5
Resident interviews: 5
Medication destruction logs reviewed: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
| Laura Sanchez | Resident Services Director | Assisted with facility tour during investigation |
| Nadia Batista | Human Resources Manager | Explained purpose of visit to Licensing Program Analyst |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 119
Deficiencies: 1
Date: Aug 20, 2024
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation based on allegations received on 08/14/2024 regarding food quality and refrigerator disrepair at the facility.
Complaint Details
The complaint investigation was triggered by allegations that facility staff did not provide food of good quality to residents and that the facility refrigerator was in disrepair. The food quality allegation was unsubstantiated, while the refrigerator disrepair allegation was substantiated.
Findings
The allegation that facility staff did not provide food of good quality was unsubstantiated based on staff and resident interviews and observations. However, the allegation that the facility refrigerator was in disrepair was substantiated, with the refrigerator being broken since July 2024 and used for storage, posing a potential risk to residents.
Deficiencies (1)
The refrigerator in the main kitchen has been broken since July 2024, currently not yet scheduled to be fixed and being used as storage which posed a potential risk for residents in care.
Report Facts
Capacity: 119
Census: 55
Deficiency Type: 1
Plan of Correction Due Date: Sep 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bennette Pena | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| David Sicairos | Licensing Program Manager | Oversaw the complaint investigation |
| Lisa Gomez | General Manager | Facility representative met during the investigation and exit interview |
| Chad Coleman | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 119
Deficiencies: 0
Date: Aug 13, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the licensee was not ensuring the personal property of residents in care was being safeguarded, specifically that money had been stolen from residents' rooms.
Complaint Details
The complaint was unsubstantiated due to lack of sufficient evidence to prove that money was stolen from the resident's room. Interviews and document reviews did not confirm the allegation.
Findings
The investigation included interviews with residents and staff and a review of documents. Five out of six residents stated their belongings had not gone missing, while one resident reported missing money on one occasion. Staff and administrators reported only one such incident in the last four months. There was insufficient evidence to prove the alleged theft occurred, and the allegation was determined to be unsubstantiated.
Report Facts
Residents interviewed: 6
Staff interviewed: 5
Resident census: 53
Facility capacity: 119
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
| Laura Sanchez | Health Services Coordinator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 119
Deficiencies: 0
Date: Jul 30, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility did not update physicians reports for residents with a change in condition.
Complaint Details
The complaint alleged that the facility did not update physicians reports for residents with a change in condition. The allegation was unsubstantiated after investigation, with no preponderance of evidence to prove the violation occurred.
Findings
The investigation included interviews with staff and residents, a tour of the facility, and review of resident files. The allegation was found to be unsubstantiated due to lack of sufficient evidence, with staff and documentation indicating that physicians reports are updated regularly and residents' needs are addressed.
Report Facts
Capacity: 119
Census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chad Coleman | Administrator | Met with Licensing Program Analyst and assisted with the investigation |
| Bennette Pena | Licensing Program Analyst | Conducted the complaint investigation visit |
| David Sicairos | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 119
Deficiencies: 0
Date: Jul 18, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-05-23 regarding hazardous chemicals accessible to residents, staff not monitoring residents with sharp objects, staff leaving residents unattended, staff interfering with family council meetings, and failure to follow up on family council meeting concerns in a timely manner.
Complaint Details
The complaint investigation was unsubstantiated as there was no preponderance of evidence to prove the alleged violations occurred. Allegations included hazardous chemicals accessible to residents, lack of monitoring with sharp objects, residents left unattended, interference with family council meetings, and untimely follow-up on family concerns.
Findings
The investigation found no evidence supporting the allegations. Hazardous chemicals and sharp objects were secured, residents were supervised during walks and activities, and family council meetings were held monthly with concerns addressed promptly. Therefore, the allegations were unsubstantiated.
Report Facts
Capacity: 119
Census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Lisa Gomez | Manager | Facility manager met during investigation and exit interview |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 119
Deficiencies: 0
Date: Jul 16, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the facility did not update Needs and Services Plans for residents and did not update physicians reports for residents with a change in condition.
Complaint Details
The complaint investigation was unsubstantiated based on interviews with staff and residents, review of resident files, and observations. There was no preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff and residents denied the allegations, and file reviews showed that Needs and Services Plans and physician reports were updated as required. Therefore, the allegations were determined to be unsubstantiated.
Report Facts
Capacity: 119
Census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Villalobos | Licensing Program Analyst | Conducted the complaint investigation visit |
| Fernando Fierros | Licensing Program Manager | Named in report as Licensing Program Manager |
| Lisa Gomez | Facility Manager | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 119
Deficiencies: 0
Date: Jul 2, 2024
Visit Reason
An unannounced complaint investigation was conducted to investigate the allegation that staff were preventing residents from receiving telephone calls.
Complaint Details
The complaint alleged that staff were preventing residents from receiving telephone calls, including claims that the facility was not opened at 8am and calls were unanswered. Interviews with staff and residents, observations, and documentation review did not support the allegation. The complaint was unsubstantiated.
Findings
The investigation found insufficient evidence to corroborate the allegation. Staff and residents stated that residents have reasonable access to telephones, primarily using cell phones, and calls are answered appropriately. The allegation was determined to be unsubstantiated.
Report Facts
Residents interviewed: 6
Staff interviewed: 5
After hours phone numbers posted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bennette Pena | Licensing Program Analyst | Conducted the complaint investigation visit |
| David Sicairos | Licensing Program Manager | Named in report as Licensing Program Manager |
| Lisa Gomez | General Manager | Met with Licensing Program Analyst during investigation and received report |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 119
Deficiencies: 0
Date: Jun 20, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the air conditioner in room #166 was not working and that the facility's HVAC system had been nonfunctional for a month.
Complaint Details
The complaint was unsubstantiated based on staff and resident interviews, observations, and file reviews. There was no preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found that the air conditioner in room #166 and other rooms in the memory care unit were operating properly. Staff and residents interviewed denied the allegation, and file reviews showed only one room (#240) had AC issues in June which were addressed. There was insufficient evidence to substantiate the complaint, so the allegations were deemed unsubstantiated.
Report Facts
Staff interviewed: 6
Residents interviewed: 4
Rooms inspected: 7
Rooms with AC issues in June: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Villalobos | Licensing Program Analyst | Conducted the complaint investigation visit |
| Fernando Fierros | Licensing Program Manager | Named in report as Licensing Program Manager |
| Lisa Gomez | Manager | Facility manager met during the investigation |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 119
Deficiencies: 0
Date: Jun 18, 2024
Visit Reason
An unannounced complaint investigation visit was conducted regarding allegations that staff were not meeting residents' dietary needs and not providing an adequate amount of food to residents.
Complaint Details
The complaint was unsubstantiated. Allegations included staff not following residents' diets, adding salt to no salt diets, not following food allergies, and providing inadequate food portions. Interviews and observations did not corroborate these claims.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff and residents interviews, review of dietary records, and observations indicated that residents' dietary needs were met and adequate food quantities were provided.
Report Facts
Residents interviewed: 12
Residents on special diet: 5
Staff interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bennette Pena | Licensing Program Analyst | Conducted the complaint investigation |
| David Sicairos | Licensing Program Manager | Oversaw the complaint investigation |
| Lisa Gomez | General Manager | Assisted with the investigation and received the exit interview |
| Nadia Batista | Human Resources Director | Met with Licensing Program Analyst and assisted with the investigation |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 119
Deficiencies: 0
Date: Jun 13, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to determine the validity of allegations that staff were violating residents' personal rights by discouraging complaints to CCLD and that staff did not treat residents with dignity and respect.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff violating residents' personal rights by telling them not to file complaints with CCLD and staff not treating residents with dignity and respect. Interviews and observations did not corroborate these allegations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. The manager denied the allegations, staff and residents interviewed denied the claims, and the CCLD complaint hotline poster was confirmed to be visibly posted in the main lobby.
Report Facts
Capacity: 119
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Luis Mora | Licensing Program Analyst | Conducted the complaint investigation |
| Wei Siew Ho | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Chad Coleman | Administrator | Facility Administrator |
| Lisa Gomez | Manager | Met with Licensing Program Analyst during investigation and denied allegations |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 119
Deficiencies: 1
Date: Jun 13, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to determine the validity of allegations received on 2024-05-29 regarding food service sanitation practices, hygiene item availability, facility odors, and toilet maintenance at Bayshire San Dimas.
Complaint Details
The complaint investigation was substantiated for the allegation related to food service sanitation practices due to lack of training. Other allegations about hygiene items, mal odors, and toilet repair were unsubstantiated.
Findings
The allegation that staff did not ensure food service sanitation practices were followed was substantiated due to lack of required on-the-job training for memory care caregivers in food handling. Allegations regarding hygiene item availability, facility odors, and toilet repair were unsubstantiated based on observations and interviews.
Deficiencies (1)
Memory care caregivers do not have the training in regards to preparing and handling food as required by Title 22 Section 87411(d)(1).
Report Facts
Capacity: 119
Census: 54
Plan of Correction Due Date: Jun 27, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Luis Mora | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Wei Siew Ho | Licensing Program Manager | Oversaw the complaint investigation |
| Lisa Gomez | Manager | Facility manager interviewed during investigation |
| Chad Coleman | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 119
Deficiencies: 0
Date: Jun 4, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff do not give residents medication as prescribed.
Complaint Details
The complaint alleged that staff do not give residents medication as prescribed. After review of medication records, interviews with staff and residents, and observation, the allegation was found to be unsubstantiated.
Findings
The investigation found that all medication for residents R1-R6 was given as prescribed with no missed doses. Interviews with residents and staff confirmed that medication administration was done according to physician's orders, and no complaints against staff were found. The allegation was determined to be unsubstantiated due to lack of evidence.
Report Facts
Facility capacity: 119
Census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Gomez | Manager | Met with Licensing Program Analyst during investigation and participated in interviews |
| Chad Coleman | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 119
Deficiencies: 0
Date: May 30, 2024
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2024-05-21 regarding facility disrepair resulting in leaks and concerns about carpet cleanliness and sanitation.
Complaint Details
The complaint involved allegations of facility disrepair causing leaks and staff not ensuring the carpet was clean and sanitized. The investigation included tours, staff and resident interviews, and found no corroboration of the allegations. The complaint was unsubstantiated.
Findings
The investigation found no evidence of leaks or facility disrepair, and residents and staff confirmed the carpet was clean and sanitized. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 119
Census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Rea | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Gomez | Manager | Facility manager who assisted with the investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw the licensing program |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 119
Deficiencies: 1
Date: May 30, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the licensee did not complete an admission agreement for a resident.
Complaint Details
The complaint alleged that resident R1 moved into the facility on May 14, 2024 without a signed admission agreement. The investigation corroborated this allegation and found the deficiency substantiated.
Findings
The investigation found that resident R1 moved in without a signed admission agreement and the facility failed to obtain signed copies of R1's admission agreement. Resident R2's agreement was signed within seven days following admission. The allegation was substantiated and a deficiency was cited.
Deficiencies (1)
Admission agreements were not signed and dated by the resident or representative and the licensee within seven days following admission, specifically for resident R1.
Report Facts
Capacity: 119
Census: 53
New residents moved in: 2
Deficiency Plan of Correction Due Date: Jun 6, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lisa Gomez | Manager | Facility manager interviewed and participated in exit interview |
| Chad Coleman | Administrator | Facility administrator interviewed telephonically and acknowledged failure to obtain signed admission agreement |
| Lisa Hicks | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 119
Deficiencies: 0
Date: May 30, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff were under the influence while on shift and that staff yelled at residents in care.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff being under the influence of alcohol and drugs while on shift and staff yelling at residents. Interviews with staff and residents did not support these allegations sufficiently to substantiate them.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents denied the allegations of staff being under the influence and yelling at residents, though one resident stated one caregiver handled them roughly. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 119
Census: 53
Number of staff interviewed: 3
Number of residents interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Gomez | Manager | Met with Licensing Program Analyst during the investigation and denied allegations |
| Jewel Baptiste | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 119
Deficiencies: 2
Date: May 21, 2024
Visit Reason
An unannounced complaint visit was conducted to issue citations related to staff qualifications and criminal background clearance.
Complaint Details
The visit was complaint-related, focusing on staff qualifications and criminal background clearance. The complaint was substantiated by findings of unqualified administrator and staff without clearance.
Findings
The facility was found to have deficiencies including an administrator who does not meet qualifications for managing an RCFE and a staff member working without appropriate criminal background clearance. Immediate civil penalties of $500 were issued.
Deficiencies (2)
Staff member S2 did not have appropriate criminal record clearance prior to working at the facility, posing an immediate health, safety, or personal rights risk.
The listed administrator (S1) does not meet the qualifications required to manage the facility, posing a potential health, safety, or personal rights risk.
Report Facts
Civil Penalty Amount: 500
Plan of Correction Due Date: May 22, 2024
Plan of Correction Due Date: May 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather O'Neel | Health Services Director | Met with Licensing Program Analyst during inspection |
| Valeria Maldonado | Licensing Evaluator | Conducted the inspection and issued citations |
| Fernando Fierros | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 119
Deficiencies: 2
Date: May 21, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that the licensee does not ensure the facility has an administrator present a sufficient number of hours to adequately manage the facility, and that staff are preventing residents from receiving telephone calls.
Complaint Details
The complaint was substantiated based on interviews with staff and residents, and observations by the Licensing Program Analyst. The allegations involved insufficient administrator presence and failure to answer telephones during business hours.
Findings
The investigation substantiated both allegations. It was found that the administrator was present only sporadically, with some staff and residents corroborating the lack of administrator presence. Additionally, the facility telephone was not consistently answered during business hours, impacting residents' ability to receive calls.
Deficiencies (2)
Licensee failed to ensure the administrator is at the facility a sufficient amount of hours to address operational concerns, posing a potential Health, Safety, or Personal Rights risk.
Licensee failed to ensure the facility telephone is answered during normal business hours so that residents may be contacted, posing a potential Health, Safety, or Personal Rights risk.
Report Facts
Staff corroboration for administrator presence allegation: 6
Resident corroboration for administrator presence allegation: 3
Staff corroboration for telephone calls allegation: 4
Resident corroboration for telephone calls allegation: 1
Plan of Correction Due Date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chad Coleman | Executive Director | Named in relation to administrator presence allegation and assisted with the visit |
| Heather O'Neel | Health Services Director | Met with Licensing Program Analyst and involved in investigation |
| Valeria Maldonado | Licensing Program Analyst | Conducted the complaint investigation visit |
| Fernando Fierros | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 119
Deficiencies: 0
Date: Apr 16, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations including facility disrepair, inadequate meal quality, insufficient laundry supplies, and lack of a qualified administrator.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included facility disrepair, poor meal quality, inadequate laundry supplies, and unqualified administrator. Interviews, observations, and records review did not support these claims.
Findings
The investigation found no substantiated evidence supporting the allegations. The facility was observed to be in good condition, meals were adequate in quality and variety, laundry supplies were sufficient, and the administrator met all qualification requirements.
Report Facts
Capacity: 119
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chad Coleman | Administrator | Named in relation to qualification allegation; holds a Bachelor's Degree and active Administrator Certificate |
| Heather O'Neel | Health Services Director | Assisted with the visit and provided information on facility operations and administrator qualifications |
| Nune Margaryan | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 119
Deficiencies: 0
Date: Apr 11, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility's communication devices, including resident pendants, were not properly operating during the last weekend of March through April 1st, 2024.
Complaint Details
The complaint alleged that communication devices, including resident pendants, were non-operational during the last weekend of March through April 1st, preventing residents from calling for assistance. The allegation was unsubstantiated after investigation.
Findings
The investigation found that during the transition of facility ownership on April 1st, internet and communication systems were temporarily down for approximately 4-5 hours. Staff conducted safety checks every 30 minutes to 1 hour during this time. Residents confirmed their pendants were operational during the visit. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 119
Census: 57
Duration of communication outage: 4.5
Resident safety check interval: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nune Margaryan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Wei Siew Ho | Licensing Program Manager | Named as Licensing Program Manager on report |
| Heather O'Neel | Health Services Director | Met with Licensing Program Analyst and assisted with the investigation |
| Chad Coleman | Administrator | Facility Administrator named in report header |
Inspection Report
Original Licensing
Census: 58
Capacity: 114
Deficiencies: 1
Date: Mar 28, 2024
Visit Reason
The visit was a pre-licensing inspection conducted as part of a Change of Ownership application to operate as a Residential Care Facility for the Elderly. The purpose was to evaluate the facility's compliance with applicable regulations prior to licensing.
Findings
The inspection found that the facility generally met physical plant and operational requirements, including resident room furnishings, safety features, infection control, and medication management. However, the facility had not yet received an approved fire clearance, which prevented final clearance of the physical plant during this inspection.
Deficiencies (1)
An approved Fire Clearance has not been received by the department
Report Facts
Resident medications reviewed: 5
Resident files reviewed: 5
Staff files reviewed: 5
Resident bedrooms in assisted living: 90
Resident bedrooms in dementia unit: 23
Residents receiving hospice services: 12
Requested fire clearance capacity: 114
Requested non-ambulatory residents: 104
Requested bedridden residents: 10
Requested hospice waiver residents: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Valeria Maldonado | Licensing Program Analyst | Conducted the pre-licensing inspection and met with applicant |
| Fernando Fierros | Supervisor | Supervisor overseeing the licensing evaluation |
| Scott Kirby | Applicant/Licensee | Met with Licensing Program Analyst during inspection |
Inspection Report
Original Licensing
Capacity: 114
Deficiencies: 0
Date: Mar 19, 2024
Visit Reason
The visit was conducted as part of the initial licensing process (CHOW application) for the facility, including verification of applicant and administrator identification and understanding of licensing laws.
Findings
The applicant and administrator demonstrated understanding of community care facility licensing laws, including facility operation, admission policies, staffing requirements, restrictive health conditions, emergency preparedness, complaints and reporting, and pre-licensing readiness.
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