Deficiencies (last 3 years)
Deficiencies (over 3 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
275% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
85% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 106
Capacity: 125
Deficiencies: 0
Date: Sep 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-05-30 regarding medication administration, care plan adherence, and modified diet compliance for a resident.
Complaint Details
The complaint alleged that staff did not administer medication as prescribed, did not follow the resident's care plan, and did not follow the resident's modified diet. The investigation concluded these allegations were unsubstantiated.
Findings
The investigation found no preponderance of evidence to substantiate the allegations that staff failed to administer medication as prescribed, follow the resident's care plan, or adhere to the modified diet. The allegations were determined to be unsubstantiated based on records review, interviews, and observations.
Report Facts
Capacity: 125
Census: 106
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hannah Rodgers | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jeremy Danenhauer | Executive Director | Facility representative met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 125
Deficiencies: 0
Date: Jul 8, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff did not meet a resident's incontinence care needs and did not follow PPE protocol when providing care.
Complaint Details
The complaint alleged that Resident #1 was left in soiled incontinence briefs for extended periods and that staff used the same gloves and cloth for incontinence care after cleaning the floor. The investigation found these allegations unsubstantiated.
Findings
The investigation, including interviews and records review, did not find sufficient evidence to substantiate the allegations. It was concluded that staff met the resident's incontinence care needs and followed PPE protocols.
Report Facts
Capacity: 125
Census: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hannah Rodgers | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzie De La Fuente Mistica | Resident Services Director | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Annual Inspection
Census: 91
Capacity: 125
Deficiencies: 0
Date: Feb 25, 2025
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing regulations and facility standards.
Findings
The facility was found to have sufficient space, equipment, and safety measures in place. No deficiencies were cited during the inspection, but the annual inspection could not be completed due to time constraints, requiring a return visit.
Report Facts
Hospice waiver capacity: 17
Bedridden resident capacity: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeremy Danenhauer | Executive Director | Met with Licensing Program Analyst during inspection |
| Lizzie De La Fuente Mistica | Resident Service Director | Met with Licensing Program Analyst during inspection and participated in facility tour |
| Hannah Rodgers | Licensing Program Analyst | Conducted the unannounced required annual inspection |
| Lizzette Tellez | Licensing Program Manager | Named in report signature section |
Inspection Report
Routine
Deficiencies: 2
Date: Feb 21, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding the initiation of baseline care plans and appropriate pressure ulcer care for residents with actual pressure ulcers.
Findings
The facility failed to initiate baseline care plans within 48 hours for two residents with actual pressure ulcers, resulting in delayed treatment and potential worsening of pressure ulcers. The facility also failed to accurately assess and stage pressure ulcers on admission and provide timely treatment and preventative measures.
Deficiencies (2)
Failed to initiate a baseline care plan within 48 hours for residents with actual pressure ulcers.
Failed to accurately assess and stage an actual pressure ulcer on admission and provide appropriate treatment and preventative measures.
Report Facts
Residents sampled: 43
Pressure ulcer risk assessment score: 17
Brief Interview for Mental Status (BIMS) score: 10
Pressure ulcer care plan initiation delay: 3
Pressure ulcer measurements: 1.5
Pressure ulcer measurements: 1.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse (LN 1) | Provided statements regarding pressure ulcer staging and care plan initiation delays | |
| Minimum Data Set (MDS) Nurse | Provided statements regarding pressure ulcer assessment and care plan importance | |
| Director of Nursing (DON) | Provided statements on expectations for admission assessments and pressure ulcer care plans |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Dec 12, 2024
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to meet professional standards of care, including medication administration, personal care, infection control, and dietary safety.
Complaint Details
The visit was complaint-related, triggered by allegations of substandard care including medication errors, inadequate personal care, infection control lapses, and dietary safety violations. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to check gastrostomy tube placement before medication administration, inadequate nail care for a resident, untimely dressing changes for a PICC line, unclear medication indications, improper psychotropic medication use, unsafe food handling practices, and poor infection control related to urinary catheter care.
Deficiencies (7)
Failure to check gastrostomy tube placement and residual before medication administration for one resident.
Failure to provide nail care to one resident, resulting in risk for skin injury and infection.
Failure to change dressing for a peripherally inserted central catheter (PICC) in a timely manner for one resident.
Failure to indicate appropriate indication for anticoagulant medication for one resident.
Failure to indicate appropriate use and behavioral monitoring for anti-anxiety medication for one resident.
Failure to ensure safe and sanitary food handling practices including unlabeled opened food, moldy food, personal belongings in food prep area, and boxes on ice machine.
Failure to ensure safe infection control practices when urinary catheter bag and dignity bag were lying on the floor for one resident.
Report Facts
Deficiencies cited: 7
Brief Interview for Mental Status (BIMS) score: 11
Brief Interview for Mental Status (BIMS) score: 15
Date of survey completion: Dec 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Observed and interviewed during medication administration; admitted to forgetting to check gastrostomy tube placement. |
| Director of Nursing | Director of Nursing (DON) | Interviewed multiple times regarding expectations for nursing care, medication verification, and infection control. |
| CNA 11 | Certified Nursing Assistant | Interviewed regarding nail care and behavioral monitoring for Resident 96. |
| LN 12 | Licensed Nurse | Interviewed about medication orders and behavioral monitoring for Resident 96 and Resident 22. |
| LN 14 | Licensed Nurse | Observed administering medication and noted catheter bag was on the floor. |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Interviewed regarding food safety violations including unlabeled food and personal belongings in food prep area. |
| Registered Dietician | Registered Dietician (RD) | Interviewed regarding dietary staff expectations and food safety. |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding infection control practices related to urinary catheter care. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 8, 2024
Visit Reason
The inspection was conducted due to allegations of inappropriate sexual comments made by a resident towards a staff member, prompting a complaint investigation.
Complaint Details
The complaint involved allegations that Resident 1 made inappropriate sexual comments to a Certified Nursing Assistant. The investigation was not documented as required, and the facility did not classify the incident as abuse.
Findings
The facility failed to implement policies and procedures by not conducting a comprehensive investigation into the allegations of inappropriate comments made by Resident 1. The Director of Nursing acknowledged the investigation was not documented as required by facility policy.
Deficiencies (1)
Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft, specifically failing to conduct a comprehensive investigation of allegations of inappropriate comments involving one resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acknowledged failure to document investigation of inappropriate comments. |
| Director of Staff Development | Director of Staff Development | Reported the allegation made by CNA 1 regarding inappropriate comments by Resident 1. |
| Administrator | Administrator | Stated expectation for facility to follow abuse policy and noted the incident was not classified as abuse. |
Inspection Report
Original Licensing
Census: 89
Capacity: 125
Deficiencies: 0
Date: Mar 25, 2024
Visit Reason
The visit was a pre-licensing inspection with Component III to observe the facility’s physical plant for compliance with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code, as the facility is undergoing a change of ownership.
Findings
The facility was found to be clean, sanitary, and in good repair with all required furnishings and safety features in place. All safety equipment including fire extinguishers, smoke and carbon monoxide detectors were operational and compliant. Medications and hazardous materials were properly secured. The facility was deemed ready for licensure pending management final review and approval.
Report Facts
Fire extinguishers: 21
Non-perishable food supply: 7
Perishable food supply: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jermey Danenhauer | Executive Director | Met with during inspection and participated in exit interview |
| Veronica Merlos | Assistant Administrator | Met with during inspection |
Inspection Report
Capacity: 125
Deficiencies: 0
Date: Mar 8, 2024
Visit Reason
The visit was an office evaluation involving a telephone interview with the applicant/administrator to verify identification and confirm understanding of California Code Title 22 regulations and licensing requirements.
Findings
The applicant/administrator demonstrated understanding of facility operation, admission policies, staffing and training requirements, restricted health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness. Signed documentation and photo ID were obtained.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Scott Kirby | Administrator | Participated in the telephone interview and confirmed understanding of licensing regulations. |
| Jude De La Concepcion | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Bethany Hunter | Licensing Program Analyst | Conducted the licensing program analyst role and signed the report. |
Inspection Report
Routine
Deficiencies: 5
Date: Jan 11, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident dignity, resident assessments, catheter care, food preparation, and food safety in the nursing home.
Findings
The facility was found deficient in multiple areas including failure to treat a resident with dignity during feeding, failure to complete and transmit discharge assessments for residents, unsafe handling of urine collection containers increasing risk of urinary tract infections, failure to follow standardized recipes for pureed diets risking nutritional deficits, and failure to properly label and date food items in the kitchen risking foodborne illness.
Deficiencies (5)
Failure to treat a resident with dignity when a Certified Nursing Assistant stood while assisting with breakfast.
Failure to develop and transmit Discharge Minimum Data Set assessments for two residents, resulting in discharge status not communicated to CMS.
Failure to utilize urine collection containers in a safe, clean manner for two residents, potentially causing urinary tract infections.
Failure to ensure residents received foods in measured amounts when standardized recipes were not followed for pureed diets, risking decreased nutrition and weight loss.
Failure to ensure food safety in the kitchen when multiple food items were not dated or were dated in the future, risking foodborne illness.
Report Facts
BIMS score: 12
BIMS score: 11
BIMS score: 13
Discharge MDS assessments due: 2
Portions cut: 7
Containers without dates: 7
Items with future received dates: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in dignity deficiency for feeding Resident 108 |
| Director of Nursing | Director of Nursing | Interviewed regarding dignity, MDS completion, catheter care, food safety, and recipe adherence |
| Minimum Data Set Coordinator | MDS Coordinator | Admitted to missing Discharge MDS assessments for Residents 5 and 8 |
| Licensed Nurse 1 | Licensed Nurse | Interviewed about improper placement of urine collection containers |
| Infection Preventionist 1 | Infection Preventionist | Interviewed about infection risks related to urine collection container placement |
| Culinary Director | Culinary Director | Observed preparing pureed food without measuring portions or following recipes |
| Dietary Services Manager | Dietary Services Manager | Interviewed about importance of recipe adherence and food labeling |
| Registered Dietitian | Registered Dietitian | Interviewed about nutritional importance of following recipes and food safety |
| Administrator | Facility Administrator | Interviewed about risks of expired and unlabeled food |
Inspection Report
Deficiencies: 1
Date: Dec 21, 2023
Visit Reason
The inspection was conducted to evaluate the nursing facility's compliance with professional standards of quality, specifically regarding the administration of blood pressure medication to residents.
Findings
The facility failed to ensure the acceptable standard of care for blood pressure medication was followed for one of two sampled residents, with medication administered despite low blood pressure readings and lack of documented parameters. The standard practice was to hold medication if systolic blood pressure was below 110 mmHg and pulse below 60 beats per minute, but this was not consistently followed.
Deficiencies (1)
Failure to follow acceptable standard of care for blood pressure medication administration, including administering medication despite low blood pressure readings and lack of documented parameters.
Report Facts
Blood pressure readings: 104
Blood pressure readings: 90
Blood pressure readings: 103
Medication dosage: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 2 | Licensed Nurse | Interviewed regarding blood pressure medication administration and standard of practice |
| LN 3 | Licensed Nurse | Interviewed regarding blood pressure medication administration and facility policy |
| LN 4 | Licensed Nurse | Interviewed regarding blood pressure medication administration and standard of practice |
| Director of Nursing | Director of Nursing | Interviewed regarding staff adherence to medication administration standards |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Nov 2, 2023
Visit Reason
The inspection was conducted to assess compliance with care standards, specifically focusing on the provision of activities of daily living such as regular showers for residents.
Findings
The facility failed to provide regular showers to two sampled residents, Resident 1 and Resident 2, resulting in an increased risk of skin infections. Documentation was missing for several scheduled showers, and the Director of Nursing confirmed the lack of proper shower documentation.
Deficiencies (1)
Failure to provide regular showers to two sampled residents as scheduled, with missing documentation for multiple shower days.
Report Facts
Scheduled showers missed for Resident 1: 4
Scheduled showers missed for Resident 2: 8
Scheduled showers provided to Resident 1: 7
Scheduled showers provided to Resident 2: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding missing shower documentation for Residents 1 and 2 |
Inspection Report
Deficiencies: 24
Date: Mar 8, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, dietary services, infection control, medication management, and other health and safety standards.
Findings
The facility had multiple deficiencies including failure to ensure safe medication administration, inadequate resident care and assessment, failure to provide timely and appropriate dietary services, poor infection control practices, and lack of competent oversight in dietary and infection prevention services. Several residents were affected by these deficiencies, with potential risks for harm, infection, and compromised care.
Deficiencies (24)
Failure to perform interdisciplinary team assessment and obtain physician order for resident self-administration of topical medications.
Failure to reasonably accommodate resident needs and preferences, including call light accessibility and medication administration timing.
Failure to inform resident's representative of significant change in physical status and failure to provide written bed hold notice upon hospital transfer.
Failure to conduct comprehensive assessments for residents with significant change in condition.
Failure to ensure accurate Minimum Data Set (MDS) assessments and coding.
Failure to develop and communicate baseline care plans within 48 hours of admission for residents.
Failure to revise and update care plans based on comprehensive assessments for residents.
Failure to provide necessary care to maintain good grooming and personal hygiene for residents.
Failure to provide care and services for residents with skin conditions, including monitoring and dressing changes.
Failure to provide timely bowel and bladder incontinence care.
Failure to provide necessary care and services for resident with incorrect tube feeding formula.
Failure to ensure system of receipt, disposition, and periodic reconciliation of controlled substances.
Failure to ensure Medication Regimen Review recommendations were communicated and acted upon.
Failure to implement gradual dose reductions and non-pharmacological interventions for psychotropic medications.
Failure to ensure drugs and biologicals were labeled and stored according to professional principles and facility policies.
Failure to ensure food and nutrition services were managed and overseen by a qualified full-time dietitian or dietary services supervisor.
Failure to ensure kitchen staff competently carried out food and nutrition service functions, including use of standardized recipes, therapeutic menus, food thermometer calibration, dish machine operation, sanitation, and proper food preparation.
Failure to ensure meals and snacks were served at appropriate times and temperatures, and residents received palatable and nutritive food.
Failure to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including proper labeling, dating, refrigeration, sanitation, and ice machine maintenance.
Failure to maintain ongoing quality assessment and assurance program to identify and correct dietary service deficiencies.
Failure of Medical Director to ensure dietary policies and procedures and facility assessment were implemented to provide meals in accordance with physician orders.
Failure to implement infection prevention and control program, including proper use of PPE, hand hygiene, equipment sanitation, and isolation precautions.
Failure to designate a qualified full-time Infection Preventionist to oversee infection control practices.
Failure to keep essential equipment, including dish machines and ice machines, working safely and maintained according to manufacturer guidelines.
Report Facts
Residents reviewed: 39
Residents affected: 38
Expired renal supplements: 18
Dish machine sanitizer concentration: 0
Ice machine cleaning frequency: 6
Meal service times: Breakfast at 7:30 AM, Lunch at 11:15 AM, Dinner at 4:15 PM
Temperature of milk in satellite kitchen refrigerator: 44.8
Tray line food holding temperature: 124.6
Number of therapeutic diet pureed meals prepared: 2
Number of mechanical soft diet meals prepared: 5
Number of ground diet meals prepared: 6
Number of regular diet meals prepared: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 32 | Licensed Nurse | Acknowledged failure to assess resident for medication self-administration and failure to honor medication timing requests |
| LN 36 | Licensed Nurse | Observed not washing hands during wound care and improper PPE use |
| LN 1 | Licensed Nurse | Administered nebulizer treatment without proper monitoring |
| CNA 11 | Certified Nursing Assistant | Registry CNA started working without complete file |
| DSD | Director of Staff Development | Responsible for registry CNA oversight and staff education |
| ADM | Administrator | Provided removal plan for dietary deficiencies and acknowledged lack of full-time dietitian |
| EC | Executive Chef | Newly hired, lacked CDM credential, unable to confirm dish machine sanitizer levels |
| IP | Infection Preventionist | Part-time, lacked full-time oversight, observed performing medication pass |
| RD | Registered Dietitian | Part-time consultant, lacked oversight of kitchen sanitation and staff training |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 23, 2023
Visit Reason
The inspection was conducted due to an allegation of sexual abuse involving one resident, to investigate the facility's response and compliance with abuse policies.
Complaint Details
The complaint involved an allegation of sexual abuse of one resident. The facility did not notify the resident's Responsible Party, and the Social Services Director failed to follow up or assess the resident. The complaint was substantiated with findings of noncompliance.
Findings
The facility failed to notify the resident's Responsible Party of the alleged sexual abuse and did not have the Social Services Director assess, evaluate, or follow up with the resident. Additionally, the facility failed to initiate a resident-centered care plan addressing the sexual abuse allegation, which could lead to repeated incidents and staff being unaware of the situation.
Deficiencies (3)
Failed to follow abuse policy by not notifying the resident's Responsible Party of an alleged sexual abuse.
Social Services Director did not assess, evaluate, or follow up with the resident after the sexual abuse allegation.
Failed to initiate a resident-centered care plan for the resident involved in the sexual abuse allegation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Did not notify resident's Responsible Party or follow up with resident after sexual abuse allegation. |
| Licensed Nurse 1 | Licensed Nurse | Stated that the Social Services Director should follow up and document after sexual abuse allegation. |
| Licensed Nurse 2 | Licensed Nurse | Stated that the Social Services Director should be notified and should see the resident after any kind of abuse. |
| Director of Nursing | Director of Nursing | Confirmed no documentation or follow up investigation was done regarding the sexual abuse allegation. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 16, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to develop a resident-centered pressure ulcer care plan for Resident 1.
Complaint Details
Complaint investigation regarding failure to develop a pressure ulcer care plan for Resident 1. The deficiency was substantiated with findings of no care plan despite documented pressure ulcer and treatment orders.
Findings
The facility failed to develop and implement a complete care plan for Resident 1's stage 2 pressure ulcer, resulting in potential impact on treatment and coordination of care. Interviews and record reviews confirmed the absence of a wound care plan despite documented pressure ulcer diagnoses and treatments.
Deficiencies (1)
Failure to develop a resident-centered pressure ulcer care plan for Resident 1.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) | Interviewed and stated Resident 1 did not have any pressure ulcer | |
| Wound Care Nurse (WCN) | Interviewed and confirmed Resident 1 had a stage two pressure ulcer and no care plan was present | |
| Licensed Nurse (LN) | Interviewed and confirmed Resident 1 had skin issues and care plans were started on admission and updated as needed |
Report
February 4, 2026
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