Most inspections found no deficiencies, with the facility consistently clean, well-maintained, and compliant in recent years. The most recent report from October 31, 2025, was perfect, showing no health or safety hazards and well-managed medication and staff records. Earlier reports included some deficiencies related to resident supervision and medication errors, notably a substantiated medication error in March 2022 and a fall incident in 2021 that led to a $500 fine and cited failures in resident supervision and post-fall care. Several complaint investigations were unsubstantiated, including allegations of abuse, medication mishandling, and inadequate resident care. Overall, the facility’s record shows improvement over time, with recent inspections free of deficiencies and no enforcement actions reported in the latest visits.
Deficiencies (last 5 years)
Deficiencies (over 5 years)2.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than California average
California average: 4 deficiencies/year
Deficiencies per year
86420
2021
2022
2023
2024
2025
Census
Latest occupancy rate63% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
The inspection visit was an unannounced continuation of the required 1 Year Annual Inspection conducted on 10/09/2025, focusing on remaining inspection domains including medications, outdoors, staff records, and resident records.
Findings
No immediate health and safety hazards were observed during the inspection. Medication rooms, outdoor areas, staff records, and resident records were reviewed and found to be secure, complete, and current.
Employees Mentioned
Name
Title
Context
Janelle Topete
Administrator
Met with during inspection and named in report narrative.
Raymond Comer
Licensing Program Analyst
Conducted the unannounced site visit and signed the report.
The inspection was an unannounced required 1-year annual inspection visit to evaluate the facility's compliance with licensing requirements.
Findings
The facility was inspected for physical plant conditions, fire safety systems, kitchen, laundry, bedrooms, bathrooms, and common areas. Overall, the facility was found clean, well-maintained, and compliant with safety and health standards. The fire alarm system and safety equipment were operational, and resident areas were safe and comfortable. Due to time constraints, the annual inspection was not fully completed and will be finished at a later date.
Report Facts
Fire extinguishers last serviced: 2025Fire drill last conducted: 2025Room temperature: 74Hot water temperature range: 108Hot water temperature range: 116Facility capacity: 150Resident census: 95Fire clearance capacity: 125Fire clearance capacity bedridden: 25Hospice waiver capacity: 15
Employees Mentioned
Name
Title
Context
Nathaniel Akyempon
Resident Care Director
Met with Licensing Program Analyst during inspection
The inspection visit was an unannounced continuation of the required 1 Year Annual Inspection conducted on 07/01/2024, focusing on remaining inspection domains including fire safety, kitchen, medications, laundry, common areas, bedrooms, bathrooms, and outdoor areas.
Findings
The facility was found to be in compliance with no immediate health and safety hazards observed. Fire safety systems were operational and maintained, kitchen and medication areas were clean and secure, laundry and common areas were clean and unobstructed, bedrooms and bathrooms were safe and sanitary, and outdoor areas were well maintained.
Report Facts
Fire extinguisher service date: Feb 8, 2024Fire drill date: Jun 12, 2024Hot water temperature: 118
Employees Mentioned
Name
Title
Context
Nathaniel Akyempon
Director
Met with Licensing Program Analyst during inspection and received exit interview
Raymond Comer
Licensing Program Analyst
Conducted the unannounced site visit and inspection
The inspection was an unannounced required annual visit to evaluate the facility's compliance with licensing regulations and assess the physical plant, resident and staff records, and infection control measures.
Findings
The facility was found to be clean and well-maintained with proper emergency exits and infection control measures in place. Resident and staff records were complete and current, and the facility's administrator certificate was valid. No deficiencies or violations were noted in the report.
Report Facts
Fire clearance capacity: 125Fire clearance capacity: 25Hospice waiver capacity: 15Hospice residents present: 4Room temperature: 73Disaster drills last conducted: Jun 12, 2024
Employees Mentioned
Name
Title
Context
Janelle Topete
Administrator
Met with Licensing Program Analyst during inspection
The inspection was conducted as a complaint investigation following allegations that a resident was diagnosed at the hospital for a drug overdose and that staff sometimes administer medications directly into residents' mouths.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews, observations, and record reviews indicated no health and safety hazards, and no deficiencies were cited.
Complaint Details
The complaint involved two allegations: 1) a resident was diagnosed at the hospital for a drug overdose, and 2) staff sometimes administered medications directly into residents' mouths. Both allegations were found to be unsubstantiated based on interviews, observations, and record reviews.
Report Facts
Complaint Control Number: 31-AS-20220310132329Number of residents interviewed: 8
Employees Mentioned
Name
Title
Context
LaQueena Lacy
Licensing Program Analyst
Conducted the complaint investigation and interviews
The visit was an unannounced complaint investigation triggered by an allegation that a resident was tested positive for drugs he was not taking.
Findings
The investigation found that medications were securely stored and administered only by staff, with no evidence residents shared medications. The toxicology report was positive for Tricyclic Antidepressants, but concerns for human or lab error were noted and no follow-up testing was requested. Based on interviews, observations, and record review, there was insufficient evidence to substantiate the allegation.
Complaint Details
The complaint alleged that resident #1 tested positive for drugs he was not prescribed. The allegation was unsubstantiated after investigation.
Report Facts
Capacity: 150Census: 84
Employees Mentioned
Name
Title
Context
LaQueena Lacy
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Naira Margaryan
Licensing Program Manager
Named as Licensing Program Manager on report
Janelle Topete
Facility representative met during the investigation
The visit was an unannounced complaint investigation conducted in response to allegations received on 2023-04-25 regarding staff not assisting residents with toileting needs, not ensuring residents' showering needs are met, and a lack of water supply at the facility.
Findings
After interviews with residents and staff, observations, and record reviews, there was insufficient evidence to substantiate the allegations. Residents confirmed they receive toileting assistance and showers as needed, and staff confirmed no issues with water supply. No health and safety hazards or deficiencies were cited.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not assisting residents with toileting, not ensuring showering needs, and lack of water supply. Interviews with seven out of eight incontinent residents and staff confirmed assistance and no water supply issues. Records showed residents received care every two hours and showers three times per week. No corroborating evidence was found to prove violations.
The inspection was conducted as a complaint investigation following allegations received on 01/17/2020 regarding sexual abuse of Resident #1 by staff and uncleared adults working in the facility.
Findings
The investigation found insufficient evidence to substantiate the sexual abuse allegation and the presence of uncleared adults. However, the facility was substantiated for failing to meet reporting requirements, failing to seek timely medical attention for the resident, and failing to protect the resident from harm by allowing the alleged staff to continue care after allegations.
Complaint Details
The complaint alleged sexual abuse of Resident #1 by Staff #1 and the presence of uncleared adults working in the facility. The sexual abuse allegation was unsubstantiated based on forensic exam results, police reports, and interviews. The uncleared adult allegation was also unsubstantiated after review of employee files and interviews.
Severity Breakdown
Type A: 1Type B: 2
Deficiencies (3)
Description
Severity
Failure to comply with reporting requirements for suspected physical abuse within 24 hours.
Type A
Failure to arrange or assist in arranging medical examination after suspicions of sexual abuse.
Type B
Failure to protect resident from punishment, humiliation, or interference with daily living functions.
Type B
Report Facts
Capacity: 150Census: 80Staff interviewed: 16Plan of Correction Due Date: Jun 28, 2022Plan of Correction Due Date: Jul 1, 2022
Employees Mentioned
Name
Title
Context
Allyson Young
Administrator
Met with during inspection and explained reason for visit
Brian Balisi
Licensing Program Analyst
Conducted complaint investigation and authored report
Desaree Perera
Licensing Program Manager
Oversaw complaint investigation
Sonia Sandoval
Investigator
Reviewed forensic exam records and police report
Deborah Kroeplin
Building Engineer
Accompanied LPA during initial complaint visit
Staff #1
Alleged staff involved in sexual abuse allegations
The visit was a one-year required infection control inspection conducted unannounced to evaluate the facility's compliance with infection control and safety standards.
Findings
The facility was found to have an approved mitigation plan, proper fire clearance, adequate COVID-19 prevention measures, clean and well-maintained physical plant including kitchen, bedrooms, bathrooms, medication storage, laundry, and common areas. No deficiencies were cited during the inspection.
Report Facts
Fire clearance capacity: 125Fire clearance capacity: 25Hospice waiver capacity: 15Number of floors: 4Water temperature range: 106.7Water temperature range: 119.1Number of rooms observed: 12Number of bathrooms observed: 12Number of first aid kits: 2
The visit was an unannounced complaint investigation conducted in response to an allegation that a toilet was in disrepair and unusable by a resident.
Findings
The investigation included interviews with staff and residents, observation of multiple bathrooms, and review of repair records. Although some concerns were raised, all toilets inspected were operational, and there was insufficient evidence to substantiate the complaint. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that a toilet was broken and unusable. The investigation found no substantiated violation after interviews, observations, and record review. The allegation was unsubstantiated.
The visit was conducted as a Case Management investigation regarding an incident reported on 09/11/2021 involving a resident receiving an additional dose of a prescribed medication.
Findings
The investigation confirmed that a nurse administered an additional dose of medication to a resident without using the facility's Accuflow system, posing an immediate health and safety hazard. The resident did not experience complications and was monitored hourly. A deficiency was cited for failure to follow medication dispensing procedures.
Complaint Details
The complaint involved a medication error where a nurse administered an additional dose of prescribed medication to resident #1. The nurse resigned prior to the investigation. The complaint was substantiated based on interviews and record review.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Failure to ensure staff follow procedures when dispensing medications, resulting in an immediate health and safety hazard to residents.
Type A
Report Facts
Deficiencies cited: 1Plan of Correction Due Date: Mar 10, 2022
Employees Mentioned
Name
Title
Context
LaQueena Lacy
Licensing Program Analyst
Conducted the investigation and authored the report
An unannounced complaint investigation was conducted due to an allegation that the facility did not have hot water for the residents.
Findings
The investigation found that a section of the building had fluctuating hot water temperatures for about three weeks. The facility offered affected residents alternative solutions such as moving rooms or using vacant rooms' bathrooms and provided some compensation. The allegation was deemed unsubstantiated as the facility was actively addressing the issue.
Complaint Details
The complaint was unsubstantiated. The facility was found to be taking appropriate actions to resolve the hot water issue and offered alternatives and compensation to residents.
Report Facts
Water temperature range in affected rooms: 105Water temperature range in non-affected rooms: 116.2Complaint received date: Jan 27, 2022Complaint control number: 31
Employees Mentioned
Name
Title
Context
Jose Gary Tan
Licensing Program Analyst
Conducted the complaint investigation
Allyson Young
Executive Director
Met with Licensing Program Analyst and involved in investigation
The visit was an unannounced case management visit regarding a serious incident report that occurred on 09/11/2021, specifically related to a staff member's positive COVID-19 test reported on 12/22/2021.
Findings
The Licensing Program Analyst obtained relevant documents and determined that further investigation is required at this time. Mass testing for staff began on 12/22/21 and for residents on 12/23/21.
Employees Mentioned
Name
Title
Context
Adriana Sais
Director of Resident Services
Met with Licensing Program Analyst during the visit and provided information about the incident.
LaQueena Lacy
Licensing Program Analyst
Conducted the unannounced case management visit and obtained documents relevant to the incident.
An unannounced case management visit was conducted to deliver an immediate exclusion order to the facility on behalf of the Monterey Park Adult and Senior Care Office.
Findings
The Licensing Program Analyst met with the Resident Services Director to review the Immediate Exclusion Order. An exit interview was conducted.
Employees Mentioned
Name
Title
Context
Wendell Smith
Licensing Program Analyst
Conducted the unannounced case management visit and delivered the immediate exclusion order.
Adrianna Sais
Resident Services Director
Met with the Licensing Program Analyst during the visit.
One (1) Year Required - Infection Control visit for this facility as part of the annual inspection.
Findings
The facility was generally clean and well-maintained with proper infection control measures in place, including PPE availability and signage. However, several deficiencies were noted including hot water temperature issues, unlocked biohazard room, improper use of bed rails without physician orders, broken grab bars and dresser, and delayed staff response to emergency pull cords.
Severity Breakdown
Type A: 3Type B: 2
Deficiencies (5)
Description
Severity
Hot water temperature controls were not maintained within the required range of 105°F to 120°F.
Type A
Biohazard room was observed to be unlocked during the visit.
Type A
Resident in room 338 had full bed rails without hospice care plan specifying need.
Type A
Grab bars in rooms 101, 123, 222, 420, and 413 were loose; dresser in room 101 was broken.
Type B
Resident in room 225 had half bed rails without a written physician's order.
Type B
Report Facts
Capacity: 150Census: 74Hot water temperature: 109.6Hot water temperature: 109.7Hot water temperature: 111.7Fire extinguisher last serviced: Sep 21, 2020Care staff response time: 12
Employees Mentioned
Name
Title
Context
Jose Gary Tan
Licensing Program Analyst
Licensing evaluator who conducted the inspection and signed the report.
Naira Margaryan
Licensing Program Manager
Supervisor and Licensing Program Manager overseeing the inspection.
An unannounced case management follow-up visit was conducted regarding an incident on 03/31/2021 where a resident (R1) fell and sustained injuries requiring hospitalization and surgery.
Findings
The investigation concluded that R1 fell due to being left unattended on a wheelchair without footrests while staff went to ask for assistance. R1 was not assessed for pain prior to being moved from the floor to bed, and complained of pain after staff lifted R1 by pulling under the arms. Deficiencies related to supervision and assistance after the fall were cited, and a $500 civil penalty was issued with potential for additional penalties.
Severity Breakdown
Type A: 2
Deficiencies (2)
Description
Severity
The licensee did not ensure that the resident was supervised as required, resulting in a fall and injury.
Type A
The licensee did not provide required assistance to the resident after the fall.
Type A
Report Facts
Civil penalty amount: 500
Employees Mentioned
Name
Title
Context
Jose Gary Tan
Licensing Program Analyst
Conducted investigation and signed report.
Naira Margaryan
Licensing Program Manager
Conducted investigation and signed report.
Allyson L Young
Administrator
Facility administrator named in report header.
Adriana Sais
Resident Care Director
Met with during inspection and informed of findings.
The visit was conducted as an unannounced Case Management follow-up to obtain more information regarding a fall incident involving facility resident #1 (R1) that occurred on 03/31/2021.
Findings
The investigation revealed that R1 fell due to being left unattended on a wheelchair without footrests while staff went to ask for assistance. R1 was not assessed for pain prior to being moved from the floor to bed, and staff lifted R1 by holding under the arms, which may have contributed to injuries. The incident report was incomplete and required additional clarification.
Complaint Details
The complaint involved a fall incident of resident #1 on 03/31/2021 resulting in fractured clavicle and humerus. The complaint investigation found that staff left R1 unattended on the wheelchair without footrests, failed to assess pain before moving R1, and improperly lifted R1 from the floor. The complaint is substantiated based on the findings.
Report Facts
Capacity: 150Census: 74Date of incident: Mar 31, 2021Number of caregivers per shift: 3Radios broken: 1Party assistance required: 2
Employees Mentioned
Name
Title
Context
Allyson Young
Executive Director
Met during visit and involved in incident explanation
Naira Margaryan
Licensing Program Analyst
Conducted the unannounced Case Management visit and investigation
Nichelle Gillyard
Licensing Program Manager
Named in report as Licensing Program Manager
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