Inspection Reports for Belmont Village Senior Living Sabre Springs
13075 Evening Crk S Dr, San Diego, CA 92128, United States, CA, 92128
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related to resident care, medication management, staffing, and safety, with several substantiated complaints over the past years. The facility faced repeated issues including delayed staff responses to resident calls, failure to administer medications as prescribed, insufficient food quality and quantity, and lapses in resident supervision, particularly involving elopements. Serious enforcement actions included multiple civil penalties totaling at least $20,000 for failures such as delayed emergency response and medication errors. The most recent report from October 20, 2025, found no deficiencies and indicated that facility representatives understood compliance requirements, with a new license issued under probationary status. This suggests some improvement, though earlier reports show ongoing challenges primarily in resident rights, medication administration, and staffing sufficiency.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Capacity: 184
Deficiencies: 0
Oct 20, 2025
Visit Reason
The visit was conducted as a Case Management - Other type of unannounced inspection to review the Stipulation and Waiver and Order adopted on September 18, 2025.
Findings
An office meeting was held to review and discuss the agreed upon and adopted Decision and Order. The facility representatives understood the requirements for compliance. A new license will be issued with probationary status indicated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Armstrong | Senior Vice President of Regulatory Affairs | Present during the review meeting and exit interview regarding the Stipulation and Waiver and Order. |
| Tracy Knepple | Executive Director | Present during the review meeting and exit interview regarding the Stipulation and Waiver and Order; acknowledged receipt of the report and rights. |
| Jerry Romero | Regional Manager | Reviewed and discussed the agreed upon and adopted Decision and Order. |
| Sabel Martinez | Licensing Program Manager | Present for the Department of Social Services during the meeting. |
Inspection Report
Annual Inspection
Census: 149
Capacity: 184
Deficiencies: 0
Aug 7, 2025
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies cited. All safety equipment and required postings were in place, and medications were properly stored and labeled.
Report Facts
Capacity: 184
Census: 149
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analysts during inspection and participated in exit interview |
| Nacole Patterson | Licensing Program Analyst | Conducted the inspection |
| Jose De La Cruz | Licensing Program Analyst | Conducted the inspection |
| Robyn Clark | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 184
Deficiencies: 1
Aug 5, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff forcefully administered medication to a resident in care.
Findings
The investigation substantiated that a nurse/area manager forcefully administered an insulin injection to Resident #1 on 06/10/2025 despite the resident's refusal, which posed a potential safety and personal risk to residents in care.
Complaint Details
The complaint was substantiated based on interviews and record review. It was found that staff forcefully administered medication to a resident who refused it. Resident #1 was not interviewed due to a Major Neurocognitive Disorder and had moved out of the facility on 06/12/2025.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To receive or reject medical care or other services. This requirement is not met as evidenced by the licensee not allowing 1 out of 149 residents to refuse their medications/insulin. | Type B |
Report Facts
Census: 150
Total Capacity: 184
Residents affected: 1
Plan of Correction Due Date: Sep 2, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 184
Deficiencies: 0
Aug 5, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff were falsifying medication administration documentation.
Findings
The investigation included a facility tour, record reviews, and interviews with staff and residents. The evidence did not support the allegation, and the complaint was deemed unsubstantiated.
Complaint Details
The complaint alleged that multiple medication technicians falsely documented medications as administered when they were not. Interviews and record reviews found medications were given as prescribed, and no leftover medications were observed. The allegation was unsubstantiated.
Report Facts
Capacity: 184
Census: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Tracy Knepple | Executive Director | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 184
Deficiencies: 0
May 14, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by multiple allegations including neglect resulting in pressure injuries and infections, failure to seek timely medical attention, lack of dignity in resident treatment, absence of activities, presence of rodents, and facility disrepair.
Findings
The investigation found all allegations to be unsubstantiated after reviewing records, conducting interviews, and facility observations. No deficiencies were cited, and the facility was found to provide appropriate care, activities, and maintain the premises without evidence of neglect or disrepair.
Complaint Details
The complaint investigation addressed allegations of neglect causing pressure injuries and mouth infections, failure to seek timely medical care, residents not treated with dignity, lack of activities, presence of rodents, and facility disrepair. The investigation included records review, interviews with staff, residents, and outside sources, and facility observations. All allegations were found unsubstantiated.
Report Facts
Capacity: 184
Census: 151
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with during investigation and discussed complaint elements |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Robyn Clark | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 151
Capacity: 184
Deficiencies: 0
Apr 10, 2025
Visit Reason
Licensing Program Analyst Natasha Persaud conducted a Case Management - Incident visit following a self-reported incident involving Resident #1 who had an unwitnessed fall resulting in injury.
Findings
The facility responded appropriately by providing medical care and contacting 911. Resident #1 was hospitalized, diagnosed with a hip fracture, and later returned to the facility under hospice care. The resident passed away on 03/28/2025 with family present. The care plan was updated and monitoring continued in partnership with hospice.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst during the visit and discussed the incident involving Resident #1. |
| Natasha Persaud | Licensing Program Analyst | Conducted the Case Management - Incident visit. |
Inspection Report
Complaint Investigation
Capacity: 184
Deficiencies: 2
Apr 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that medications were not given as prescribed, resident medication records were inaccurate, and staff cut resident's medication without an order.
Findings
The investigation substantiated that medications were not given as prescribed for two residents, and medication records were inaccurate, including discrepancies between the Medication Administration Record and Controlled Drug Record. It was unsubstantiated that staff cut medication without an order, as the medication technician had nurse approval. A civil penalty was assessed for repeat violations related to medication administration and documentation.
Complaint Details
The complaint investigation was substantiated for allegations that medications were not given as prescribed and medication records were inaccurate. The allegation that staff cut resident's medication without an order was unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee did not ensure medications were given as prescribed for 2 out of 152 residents, posing a potential health and safety risk. | Type B |
| Licensee did not ensure a complete and current Medication Administration Record was maintained for 1 out of 152 residents. | Type B |
Report Facts
Facility capacity: 184
Residents involved: 2
Residents involved: 1
Wasted morphine pills: 6
Medication doses discrepancy: 3
Medication doses discrepancy: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst during investigation and acknowledged receipt of report and rights |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Robyn Clark | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 184
Deficiencies: 1
Apr 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff did not respond timely to a resident's calls for assistance, along with allegations of neglect resulting in a Stage 3 pressure injury, neglect resulting in fracture, and failure to follow the resident's admission agreement.
Findings
The investigation substantiated that facility staff failed to respond timely to Resident #1's calls for assistance, with documented delays up to six hours. However, allegations of neglect resulting in fracture and Stage 3 pressure injury, as well as failure to follow the resident's admission agreement, were found to be unsubstantiated. A civil penalty was assessed for the repeat violation related to response times.
Complaint Details
The complaint investigation was substantiated regarding delayed staff response to Resident #1's calls for assistance. The resident was bedridden with major neurocognitive disorder and required two-person assistance. Call Light History logs showed multiple instances of response delays ranging from 45 minutes to 6 hours. Other allegations including neglect resulting in fracture and Stage 3 pressure injury, and failure to follow admission agreement were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personnel Requirements – General. Facility personnel were not sufficient in numbers and competence to meet resident needs, evidenced by failure to respond timely to 1 out of 155 resident requests, with wait times up to 6 hours. | Type B |
Report Facts
Resident census: 151
Total capacity: 184
Resident requests not responded timely: 1
Maximum staff response delay: 6
Additional charge: 1150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tracy Knepple | Executive Director | Facility administrator met during investigation and named in findings |
| Robyn Clark | Licensing Program Manager | Oversaw licensing program, named in report |
Inspection Report
Follow-Up
Census: 152
Capacity: 184
Deficiencies: 1
Apr 8, 2025
Visit Reason
An unannounced inspection was conducted on April 8, 2025, to follow up on a previously reported incident investigation involving delayed medical care to a resident.
Findings
The Department concluded that a civil penalty is warranted for serious bodily injury due to the licensee's failure to immediately call 9-1-1 for a resident who had fallen and was in extreme physical pain. A civil penalty of $10,000 was issued.
Complaint Details
The visit was a follow-up to a complaint investigation regarding delayed medical care to resident (R1). The Department substantiated the complaint and determined serious bodily injury occurred.
Deficiencies (1)
| Description |
|---|
| Violation of California Code of Regulations § 87465(g) Incidental Medical and Dental Care related to delayed medical care to a resident. |
Report Facts
Civil penalty amount: 10000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst during inspection and was provided appeal rights |
| Juliana Barfield | Licensing Program Analyst | Conducted the unannounced inspection and signed the report |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 184
Deficiencies: 2
Mar 26, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff were not ensuring residents were provided with sufficient amounts of food and that staff provided dirty dishware to residents.
Findings
The investigation substantiated that residents in the memory care unit were sometimes served insufficient food portions, requiring staff to ration food, and that dirty dishware with lipstick stains was occasionally served due to dishwasher issues. Staff training on food quantity and dishware sanitation was planned.
Complaint Details
The complaint investigation was substantiated based on observations and interviews. Allegations included insufficient food portions and dirty dishware being served. The licensee did not ensure adequate food quantity and proper cleaning of dishware for 25 residents, posing health and safety risks.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Food quantity did not meet the needs for 25 out of 154 residents, posing a potential health and safety risk. | Type B |
| Cups and dishware were not properly cleaned for 25 out of 154 residents, posing a potential health and safety risk. | Type B |
Report Facts
Residents affected: 25
Residents affected: 25
Census: 154
Total Capacity: 184
Plan of Correction Due Date: Apr 23, 2025
Dishwasher downtime: 7
Food delivery delay: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Named in findings related to food quantity and dishware sanitation |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Robyn Clark | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 184
Deficiencies: 0
Jan 30, 2025
Visit Reason
The inspection was conducted as a Case Management - Incident visit following a self-reported incident where Resident #1 fell from the third floor balcony on July 7, 2024, resulting in the resident's death on July 12, 2024. The visit included investigation of the incident through facility tour, record review, and interviews.
Findings
The investigation found that Resident #1 had a Major Neurocognitive Disorder but was assessed as safe to remain in the Assisted Living unit rather than the secured memory care unit. There was no documented evidence of suicidal ideations by staff or physician, though an outside source reported hallucinations and suicidal statements that were not communicated to management. The cause of death was blunt force trauma with pelvic fractures, but there was insufficient evidence to deem the licensee culpable of violations.
Complaint Details
The visit was complaint-related due to the incident of Resident #1 falling from a balcony and subsequent death. The investigation found no substantiated violations of CCR Title 22 by the licensee.
Report Facts
Facility capacity: 184
Resident census: 154
Incident date: Jul 7, 2024
Resident death date: Jul 12, 2024
Number of appraisals conducted: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tacy Knepple | Executive Director | Met with Licensing Program Analyst during inspection and named in report |
| Natasha Persaud | Licensing Program Analyst | Conducted the Case Management - Incident visit |
| Robyn Clark | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 184
Deficiencies: 0
Nov 13, 2024
Visit Reason
An unannounced complaint investigation was conducted following an allegation that staff did not ensure supervision resulting in resident elopement on 11/04/2024.
Findings
The investigation included interviews, video footage review, and log checks, which found no evidence of resident elopement on the alleged date. The allegation was deemed unsubstantiated due to lack of corroborating evidence.
Complaint Details
The complaint alleged that staff failed to provide supervision leading to a resident elopement on 11/04/2024. The investigation found inconsistent statements and no preponderance of evidence to support the allegation. The complaint was unsubstantiated.
Report Facts
Capacity: 184
Census: 158
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Interviewed during complaint investigation and recipient of report and licensee rights |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Robyn Clark | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 155
Capacity: 184
Deficiencies: 1
Oct 28, 2024
Visit Reason
The inspection was a Case Management - Incident visit triggered by a self-reported incident where Resident #1 was found outside the facility without staff knowledge, posing a potential safety risk.
Findings
The facility failed to ensure the safety of one resident who eloped without staff knowledge. The concierge did not notice the resident leaving, and a deficiency was cited related to basic service requirements and resident whereabouts.
Complaint Details
The visit was complaint-related due to an incident involving Resident #1 eloping from the facility without staff knowledge. The complaint was substantiated by the cited deficiency.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Basic services requirements. Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by the licensee not ensuring the safety for 1 out of 155 residents when the resident eloped without staff knowledge, posing a potential health and safety risk. | Type B |
Report Facts
Residents present: 155
Total licensed capacity: 184
Deficiency count: 1
Plan of Correction due date: Nov 25, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met during inspection and discussed incident and corrective actions |
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection and cited the deficiency |
| Robyn Clark | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 158
Capacity: 184
Deficiencies: 0
Oct 15, 2024
Visit Reason
Licensing Program Analyst Natasha Persud conducted a Case Management - Incident visit to check on the health and safety of residents in care.
Findings
No immediate health and/or safety violations were observed, and no complaints about resident health were received during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst during the visit and acknowledged receipt of report and licensee rights. |
| Natasha Persud | Licensing Program Analyst | Conducted the Case Management - Incident visit. |
Inspection Report
Census: 161
Capacity: 184
Deficiencies: 0
Sep 26, 2024
Visit Reason
Licensing Program Analyst Natasha Persaud conducted a Case Management - Other visit to evaluate the facility's secured perimeter status following a fire department clearance revision.
Findings
The facility's perimeter was observed to be locked and secured with no deficiencies noted during the visit.
Report Facts
Capacity: 184
Census: 161
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst during the visit and received Licensee Rights |
| Natasha Persaud | Licensing Program Analyst | Conducted the Case Management - Other visit |
Inspection Report
Complaint Investigation
Census: 161
Capacity: 184
Deficiencies: 0
Sep 26, 2024
Visit Reason
The visit was conducted to investigate complaints alleging the facility did not provide adequate food service resulting in resident illness and that the facility was not clean and in good repair.
Findings
The investigation found no evidence to support the allegations. Resident and staff interviews, observations, and record reviews indicated no foodborne illness or cleanliness issues. The facility was found to be clean and equipment in good repair, with the allegations deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included inadequate food service causing illness and poor facility cleanliness and repair. Investigation revealed inconsistent statements and no corroborating evidence.
Report Facts
Capacity: 184
Census: 161
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Tracy Knepple | Executive Director | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Census: 161
Capacity: 184
Deficiencies: 3
Sep 26, 2024
Visit Reason
The inspection visit was conducted to investigate a complaint received on 2021-05-13 regarding allegations that staff did not follow a resident's care plan, did not respond timely to the resident, and the licensee did not arrange appropriate medical care for the resident.
Findings
The investigation substantiated that staff did not follow the resident's care plan requiring two-person assistance, did not respond timely to the resident's calls for help with response times exceeding 30 minutes, and failed to arrange appropriate medical care for the resident's second COVID-19 vaccine dose. Additional allegations regarding unsafe environment and food service were unsubstantiated.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to follow resident's care plan requiring two-person assist, delayed staff response times to resident calls (up to 1 hour 30 minutes), and failure to arrange appropriate medical care for the resident's second COVID-19 vaccine dose. Other allegations about unsafe environment and food service were unsubstantiated.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility personnel were not competent with following through with care plan for 1 out of 123 residents, posing a potential health and safety risk. | Type B |
| Staff did not respond timely to 1 out of 123 residents' requests for assistance, with response times over 30 minutes, posing a potential health and safety risk. | Type B |
| Licensee did not arrange appropriate medical care for 1 out of 123 residents; resident was taken to multiple locations for vaccine due to staff not confirming appropriate appointment. | Type B |
Report Facts
Response times: 90
Deficiency count: 3
Resident census: 161
Facility capacity: 184
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Inan Linton | Executive Director | Provided statements regarding resident care needs and vaccine arrangements. |
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst during investigation and received report and licensee rights. |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Census: 156
Capacity: 184
Deficiencies: 1
Aug 28, 2024
Visit Reason
The visit was a Case Management - Other type conducted for an investigation related to infection control practices at the facility.
Findings
The Licensing Program Analyst observed a Covid-19 positive resident sitting in a common area with their apartment door open, indicating the facility did not follow infection control guidelines to isolate the resident. A deficiency was cited for failure to ensure isolation of Covid-19 positive residents.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure Covid positive residents are isolated, posing a potential health and safety risk. | Type B |
Report Facts
Residents present: 156
Total licensed capacity: 184
Deficiencies cited: 1
Plan of Correction due date: Sep 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst and involved in infection control deficiency |
| Natasha Persaud | Licensing Program Analyst | Conducted the Case Management visit and investigation |
| Lizzette Tellez | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 157
Capacity: 184
Deficiencies: 0
Aug 21, 2024
Visit Reason
Licensing Program Analyst Carmen Lopez conducted an unannounced collateral visit for an investigation unrelated to this facility.
Findings
No deficiencies were observed or cited during the visit. Records were requested and obtained, and an exit interview was conducted with the Executive Director.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carmen Lopez | Licensing Program Analyst | Conducted the unannounced collateral visit. |
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst and participated in exit interview. |
Inspection Report
Complaint Investigation
Census: 157
Capacity: 184
Deficiencies: 0
Aug 21, 2024
Visit Reason
The inspection was an unannounced complaint investigation regarding an allegation that facility staff did not follow a resident's physician's orders related to dietary requirements.
Findings
The investigation found that the facility was complying with the physician's orders by providing a low carbohydrate and no added salt diet as required. The resident had the cognitive ability to make their own food choices, and the facility offered appropriate diet options. The allegation was deemed unsubstantiated due to inconsistent statements and lack of evidence.
Complaint Details
The complaint alleged that facility staff did not follow physician's orders for Resident #1's diet, specifically regarding a low carbohydrate and no added salt diet. The allegation was investigated and found unsubstantiated.
Report Facts
Capacity: 184
Census: 157
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Tracy Knepple | Executive Director | Facility representative interviewed during investigation |
Inspection Report
Annual Inspection
Census: 157
Capacity: 184
Deficiencies: 1
Jul 30, 2024
Visit Reason
An unannounced required annual inspection was conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was generally clean, sanitary, and in good repair with compliant safety measures; however, a deficiency was cited for locking the entire perimeter, which violates fire clearance regulations. A civil penalty was assessed and a plan of correction was submitted.
Deficiencies (1)
| Description |
|---|
| Facility locked the entire perimeter for safety reasons, which is a violation of the fire clearance requirement. |
Report Facts
Residents affected: 157
Capacity: 184
Census: 157
Plan of Correction Due Date: Jul 31, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst during inspection and named in relation to the fire clearance violation. |
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Lizzette Tellez | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 159
Capacity: 184
Deficiencies: 0
Jul 16, 2024
Visit Reason
An unannounced Case Management - Incident visit was conducted following a self-reported incident where a resident fell from the third floor balcony and subsequently passed away.
Findings
The facility was toured briefly, records were requested, and interviews were conducted. No deficiencies were issued during this visit.
Complaint Details
The visit was triggered by a self-reported incident involving Resident #1 who fell from the third floor balcony on 07/12/2024, was transported to the hospital, and passed away the same day.
Report Facts
Capacity: 184
Census: 159
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst during the visit and named in the report |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager in the report |
Inspection Report
Complaint Investigation
Census: 159
Capacity: 184
Deficiencies: 2
Jul 16, 2024
Visit Reason
An unannounced Case Management - Incident visit was conducted following self-reported incidents involving Resident #1, including concerns about staff behavior and medication administration.
Findings
The facility failed to ensure Resident #1 was treated with dignity and did not receive prescribed medications due to staff misconduct. Two staff members were terminated and deficiencies were cited related to medication management and personal rights.
Complaint Details
The visit was complaint-related based on self-reported incidents involving Resident #1. The complaint was substantiated by interviews and record review confirming staff misconduct including rude behavior and falsification of medication records.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The licensee did not ensure 1 out of 159 residents received medications as prescribed, posing a potential health and safety risk. | Type B |
| The licensee did not ensure 1 out of 159 residents was treated with dignity, posing a potential health and safety risk. | Type B |
Report Facts
Census: 159
Total Capacity: 184
Deficiencies cited: 2
Plan of Correction Due Date: Aug 13, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst; involved in interview confirming expectations and actions taken |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
| Lizzette Tellez | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 163
Capacity: 184
Deficiencies: 2
Jun 27, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-02-02 regarding food quality and resident record currency, among other complaints.
Findings
The investigation substantiated that the facility did not ensure food quality, serving burnt and undercooked food, and failed to maintain current medical assessments for residents with Major Neurocognitive Disorder. Other allegations related to resident treatment and dignity were found unsubstantiated after interviews and observations.
Complaint Details
The complaint investigation was substantiated for allegations related to poor food quality and outdated resident medical records. Other allegations including rough handling, punishment, dignity violations, denial of personal possessions, and hygiene neglect were unsubstantiated based on interviews, observations, and record reviews.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee did not ensure good quality of food for 21 of 147 residents, posing a potential health and safety risk. | Type B |
| Licensee did not ensure current medical assessments for 2 out of 147 residents with dementia, posing a potential health and safety risk. | Type B |
Report Facts
Residents affected by food quality deficiency: 21
Residents affected by medical assessment deficiency: 2
Facility capacity: 184
Census: 163
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keisha Bean | Director of Resident Care Service | Met during investigation and named in findings related to food quality and medical assessments |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager overseeing investigation |
Inspection Report
Complaint Investigation
Census: 163
Capacity: 184
Deficiencies: 1
Jun 27, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that residents were not receiving medications, staff were not properly checking on residents, staff were not properly trained on transferring residents, and residents' pendants were in disrepair.
Findings
The investigation substantiated that residents were not receiving medications as prescribed due to lack of documentation for missed doses and unadministered medications. However, allegations that residents were not being checked on by staff, staff were not properly trained on transfers, and pendants were in disrepair were found to be unsubstantiated based on interviews, record reviews, and observations.
Complaint Details
The complaint investigation was substantiated for the allegation that residents were not receiving medications as prescribed. Other allegations regarding resident checks, staff training on transfers, and pendant disrepair were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee did not ensure medications were given as prescribed to 4 out of 151 persons in care, posing a potential health and safety risk. | Type B |
Report Facts
Residents affected: 4
Total residents in care: 151
Facility census: 163
Facility capacity: 184
Pendants reported in disrepair: 15
Plan of Correction due date: Jul 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keisha Bean | Director of Resident Care Service | Met with during investigation and named in findings |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager |
| Tracy Knepple | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 163
Capacity: 184
Deficiencies: 1
Jun 27, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff do not respond timely to residents’ calls for assistance, leave residents in wet and soiled diapers for extended periods, and did not provide breakfast to residents.
Findings
The investigation substantiated that staff did not respond timely to some resident calls for assistance, with response times ranging from 1 minute to 1 hour and 40 minutes, posing a potential health and safety risk. The allegations that staff left residents in wet and soiled diapers for extended periods and did not provide breakfast were found to be unsubstantiated based on interviews and record reviews.
Complaint Details
The complaint investigation was substantiated for the allegation that staff do not respond timely to residents’ calls for assistance. The allegations that staff left residents in wet and soiled diapers for extended periods and did not provide breakfast to residents were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personnel Requirements – General. Facility personnel were not sufficient in numbers and competent to provide necessary services, evidenced by failure to respond timely to 5 out of 161 resident requests for assistance, with some wait times over 30 minutes. | Type B |
Report Facts
Resident requests not responded to timely: 5
Facility capacity: 184
Census: 163
Caregiver to resident ratio: 1
Response time range: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keisha Bean | Director of Resident Care Service | Met with Licensing Program Analyst during investigation and named in findings. |
| Tracy Knepple | Administrator | Named as facility administrator. |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation. |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 157
Capacity: 184
Deficiencies: 0
Jun 20, 2024
Visit Reason
The visit was conducted in response to an LIC 624 Incident Report regarding a resident who exited the facility unassisted and was returned safely. The purpose was to investigate the incident and assess compliance with care requirements.
Findings
The resident was found to have Mild Cognitive Impairment and required staff assistance with medications and was not to leave unassisted. The resident was safely returned after leaving unassisted and expressed understanding of the rules. No injuries were noted and staff interviewed.
Complaint Details
The visit was triggered by a complaint incident report of a resident leaving the facility unassisted on 06/11/2024. The incident was self-reported by the licensee and investigated during the visit.
Report Facts
Capacity: 184
Census: 157
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keisha Bean | Director of Resident Care | Interviewed during the visit and involved in the incident discussion |
| Tiffany Holmes | Licensing Program Analyst | Conducted the unannounced Case Management – Incident visit |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 184
Deficiencies: 4
Jun 7, 2024
Visit Reason
Unannounced case management visit to follow up on a substantiated complaint investigation regarding multiple pressure injuries sustained by a resident due to staff neglect.
Findings
The Department found that the licensee failed to contact 9-1-1 or obtain emergency medical services when an imminent threat to a resident's health was observed, failed to obtain a written plan of care, failed to conduct a reappraisal, failed to train and supervise staff, and failed to ensure staff followed physician's orders, contributing to serious bodily injury requiring hospitalization and maggot debridement therapy.
Complaint Details
The complaint was substantiated involving multiple pressure injuries resulting in hospitalization due to staff neglect. An immediate civil penalty of $500 was assessed on June 23, 2022, and an additional civil penalty of $9,500 was issued on June 7, 2024 for serious bodily injury.
Deficiencies (4)
| Description |
|---|
| Failure to immediately telephone 9-1-1 when an injury or other circumstance resulted in an imminent threat to a resident’s health. |
| Failure to provide supporting care and supervision needed to meet the needs of the resident receiving home health care. |
| Facility personnel were not sufficient in numbers and competent to provide necessary services to meet resident needs. |
| Failure to submit a written exception request for a resident with a prohibited and/or restrictive health condition. |
Report Facts
Civil penalty amount: 9500
Immediate civil penalty amount: 500
Facility capacity: 184
Resident census: 158
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keisha Bean | Director of Residential Care Services | Met with Licensing Program Manager during the inspection and acknowledged receipt of appeal rights. |
| Simon Jacob | Licensing Program Analyst | Conducted the unannounced case management visit and signed the report. |
| Kimberly Lyon | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 157
Capacity: 184
Deficiencies: 2
May 31, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-03-30 regarding unclean facility bathrooms, inoperable resident alarm systems, and failure to administer medication as prescribed.
Findings
The allegation regarding unclean bathrooms was unsubstantiated after interviews and observations confirmed cleanliness. However, allegations that the resident alarm system was inoperable and that medications were not administered as prescribed were substantiated based on interviews, records review, and observations. Deficiencies were cited related to medication administration and alarm system maintenance.
Complaint Details
The complaint investigation addressed three allegations: 1) Facility bathroom was not maintained cleaned (unsubstantiated), 2) Residents alarm system was not operable (substantiated), and 3) Facility did not administer medication as prescribed (substantiated). The investigation included interviews with residents, staff, and outside sources, records review, and observations. The medication administration issues involved missed doses, incorrect discontinuations, and failure to assist with self-administration. The alarm system was found to have been repaired in 2022 but was initially inoperable.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff did not assist resident #1 with self-administration of medications as prescribed, posing a potential health risk. | Type B |
| Residents' call signal system was inoperable, posing a potential safety risk. | Type B |
Report Facts
Residents affected by medication administration deficiency: 5
Residents affected by alarm system deficiency: 1
Plan of Correction Due Date: Jun 28, 2024
Plan of Correction Due Date: Jun 14, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carmen Lopez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Tracy Knepple | Executive Director | Facility representative met during investigation and exit interview |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 184
Deficiencies: 0
May 31, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 01/20/2022 regarding resident falls due to lack of supervision, unmet resident care needs, and insufficient staff training.
Findings
The investigation found insufficient evidence to support the allegations. Interviews with residents, staff, and outside sources, as well as record reviews, indicated no concerns regarding resident falls, care needs being unmet, or lack of staff training during the relevant periods.
Complaint Details
The complaint involved allegations that a resident sustained a fall due to lack of supervision, staff did not meet residents' assessed needs, and care staff lacked required training. The investigation concluded these allegations were unsubstantiated due to lack of corroborating evidence.
Report Facts
Facility capacity: 184
Census: 134
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liliana Silveira | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Jennifer Lott | Licensing Program Manager | Named in report as Licensing Program Manager |
| Inan Linton | Administrator | Facility Administrator named in report |
Inspection Report
Plan of Correction
Census: 151
Capacity: 184
Deficiencies: 0
Mar 28, 2024
Visit Reason
The visit was an unannounced Plan of Correction (POC) to verify correction of a previously cited deficiency regarding an air conditioning unit leak.
Findings
The air conditioning unit that was previously cited for disrepair had been replaced, and the deficiency was corrected. No deficiencies were observed during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst during the Plan of Correction visit and discussed the purpose of the visit. |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced Plan of Correction visit. |
| Lizzette Tellez | Licensing Program Manager | Named in the report header and narrative. |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 184
Deficiencies: 0
Mar 28, 2024
Visit Reason
The visit was a Case Management - Incident investigation triggered by a timely reported incident involving alleged abuse of Resident #1 by Staff #1 on 2024-03-09.
Findings
The facility assessed the resident and found no injuries sustained. The facility followed protocols and no deficiencies were issued. Staff #1 was suspended pending investigation.
Complaint Details
The complaint involved alleged abuse of Resident #1 by Staff #1. The resident has Major Neurocognitive Disorder and was unable to recall the incident. The facility investigated and found no injuries or deficiencies.
Report Facts
Suspension duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst and received report and Licensee Rights |
| Natasha Persaud | Licensing Program Analyst | Conducted the Case Management - Incident visit |
| Lizzette Tellez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 184
Deficiencies: 1
Feb 29, 2024
Visit Reason
The visit was conducted in response to an LIC624 Incident Report regarding a medication error where a resident (R1) received medications prescribed to another resident (R2) on 2024-02-07.
Findings
The investigation found that a newer staff member (S1) mistakenly gave R1 medications intended for R2, causing R1 to vomit but not suffer serious illness. One deficiency and one technical violation were cited, and a plan of correction was developed.
Complaint Details
The complaint was substantiated. The incident involved a medication error by staff leading to a resident ingesting incorrect medications, causing vomiting but no serious illness. Staff provided remedial training following the incident.
Deficiencies (1)
| Description |
|---|
| Licensee’s staff did not assist 1 of 152 residents (R1) with self-administered medications as needed/prescribed, which posed a potential health risk to persons in care. |
Report Facts
Residents present during inspection: 152
Total licensed capacity: 184
Medications ingested in error: 4
Deficiencies cited: 1
Technical Violations issued: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met during visit and involved in exit interview |
| Keisha Bean | Director of Resident Care | Met during visit and involved in exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection visit |
| Lizzette Tellez | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 148
Capacity: 184
Deficiencies: 0
Dec 29, 2023
Visit Reason
The inspection was a Case Management - Incident visit conducted due to a self-reported incident involving a resident with unexplained injuries.
Findings
The Licensing Program Analyst reviewed records and interviewed staff and the resident, finding no indications of a violation or deficiencies during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst during the incident visit and named in the report. |
| Natasha Persaud | Licensing Program Analyst | Conducted the Case Management - Incident visit. |
| Lizzette Tellez | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 153
Capacity: 184
Deficiencies: 0
Oct 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-08-21 regarding lack of supervision, staff treatment of residents, communication barriers, medication mismanagement, and unmet medical needs at the facility.
Findings
The investigation found no preponderance of evidence to support the allegations. Staff maintained supervision of the resident who wandered, residents were treated with dignity, no language barriers were found, no medication errors occurred, and medical needs were met as prescribed. The allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included lack of supervision resulting in resident wandering, staff not treating residents with dignity, language barriers, medication mismanagement, and unmet medical needs. The investigation included interviews, record reviews, and observations, concluding no violations were found.
Report Facts
Facility capacity: 184
Resident census: 153
Complaint receipt date: Aug 21, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Tracy Knepple | Executive Director | Facility administrator met during investigation and recipient of report |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 151
Capacity: 184
Deficiencies: 0
Sep 28, 2023
Visit Reason
An unannounced Case Management - Health Checks visit was conducted to perform a health and safety welfare check on residents and discuss the purpose of the visit with the Executive Director.
Findings
No deficiencies were observed or cited during the visit. The Licensing Program Analyst toured the facility, checked on residents' health and safety, and spoke with staff.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst during the visit |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management - Health Checks visit |
| Lizzette Tellez | Licensing Program Manager | Named in report header |
Inspection Report
Census: 161
Capacity: 184
Deficiencies: 0
Jun 1, 2023
Visit Reason
The visit was an unannounced Case Management visit focused on legal and non-compliance issues, including evaluation of the licensee's ongoing compliance with actions agreed to during a prior Non-Compliance Conference.
Findings
The facility was found to be clean, safe, sanitary, and in good repair with no immediate health or safety concerns. No deficiencies were observed or issued during this compliance visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst during the visit |
| Christina Witcher | Director of Resident Care Services | Met with Licensing Program Analyst during the visit |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Lizzette Tellez | Licensing Program Manager | Named in report header |
Inspection Report
Follow-Up
Census: 159
Capacity: 184
Deficiencies: 2
Apr 17, 2023
Visit Reason
An unannounced Case Management visit was conducted to cite a deficiency identified during a prior visit related to an AWOL incident involving a resident with dementia who exited the facility unassisted.
Findings
The inspection found that the facility lacked an auditory device or staff alert feature to monitor one exit door, and two delayed-egress doors in the memory care unit were missing required signage, posing potential safety risks to residents. Two Type B deficiencies were cited and plans of correction were developed.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The licensee did not have an auditory device or other staff alert feature to monitor one of its exits, posing a potential safety risk to 1 resident. | Type B |
| The licensee did not have a sign reading 'KEEP PUSHING. THIS DOOR WILL OPEN IN ___ SECONDS. ALARM WILL SOUND' on two of its four delayed egress doors within the memory care unit, posing a potential safety risk to 24 residents. | Type B |
Report Facts
Residents at risk: 1
Residents at risk: 24
Deficiencies cited: 2
Capacity: 184
Census: 159
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met during inspection and exit interview |
| Christina Witcher | Director of Resident Care Services | Met during inspection and exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lizzette Tellez | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Complaint Investigation
Census: 169
Capacity: 184
Deficiencies: 0
Mar 14, 2023
Visit Reason
The visit was conducted in response to an LIC624 Incident Report submitted by the licensee regarding an AWOL (absent without leave) event involving Resident #1.
Findings
During the unannounced Case Management visit, no deficiencies were observed or cited. The resident involved in the incident was located by law enforcement and returned unharmed.
Complaint Details
The visit was complaint-related due to an incident report of a resident absent without leave. The resident was found unharmed and returned to the facility. No deficiencies were cited.
Report Facts
Capacity: 184
Census: 169
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst during the visit and involved in exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management visit |
Inspection Report
Complaint Investigation
Census: 163
Capacity: 184
Deficiencies: 1
Feb 8, 2023
Visit Reason
The visit was conducted to issue deficiencies identified during a complaint investigation regarding the lack of a current Medical Assessment for Resident #1 with Major Neurocognitive Disorder.
Findings
The facility failed to have a current annual Medical Assessment on file for Resident #1, which posed a potential health and safety risk. The last assessment was dated September 2021 and lacked required updated medical conditions and care needs.
Complaint Details
The visit was triggered by a complaint investigation that found Resident #1 did not have a current Medical Assessment on file, violating requirements for annual reassessment of dementia care needs.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure Resident #1 had a current annual Medical Assessment on file as required for persons with dementia. | Type B |
Report Facts
Resident census: 163
Total capacity: 184
Residents affected: 1
Plan of Correction due date: Mar 8, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst during the visit and named in relation to deficiency findings |
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lizzette Tellez | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 163
Capacity: 184
Deficiencies: 0
Feb 8, 2023
Visit Reason
An unannounced complaint investigation was conducted following allegations that medications were not given as prescribed, the facility did not meet a resident's incontinent needs, and the facility did not provide basic laundry services.
Findings
The investigation included interviews, record reviews, and a facility tour. Evidence did not support the allegations; medications were confirmed given as prescribed, incontinent needs were met, and laundry services were provided according to facility policy. The allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated after review of medication administration records, resident and staff interviews, and outside source confirmations. No evidence supported the allegations regarding medication administration, incontinent care, or laundry services.
Report Facts
Facility capacity: 184
Resident census: 163
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with during investigation and discussed findings |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Plan of Correction
Census: 159
Capacity: 184
Deficiencies: 0
Nov 18, 2022
Visit Reason
The visit was conducted as a Plan of Correction (POC) follow-up to verify correction of a previously issued deficiency related to resident supervision and notification systems.
Findings
The facility had corrected the previously issued deficiency regarding resident supervision and notification systems. No deficiencies were observed during this visit.
Report Facts
Resident eloped: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst during Plan of Correction visit and named in relation to deficiency correction |
| Natasha Persaud | Licensing Program Analyst | Conducted the Plan of Correction visit |
| Lizzette Tellez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 184
Deficiencies: 0
Nov 15, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 09/26/2022 regarding medication security, incontinent care needs, and staffing sufficiency at the facility.
Findings
The investigation found no confirmable evidence to support the allegations. Interviews, record reviews, and observations indicated that medication carts were locked, residents' incontinent care needs were met according to plans, and staffing levels were generally sufficient despite occasional shortages.
Complaint Details
The complaint included allegations that the licensee did not keep centrally stored medications locked, did not meet residents' incontinent care needs, and did not have sufficient staff to meet resident needs. The investigation concluded these allegations were unsubstantiated due to lack of confirmable evidence.
Report Facts
Capacity: 184
Census: 154
Staffing numbers: 5
Staffing numbers: 6
Staffing numbers: 3
Staffing numbers: 4
Staffing numbers: 1
Staffing numbers: 2
Staffing numbers: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vicky Williamson | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Tracy Knepple | Executive Director | Met with the Licensing Program Analyst during the investigation and provided information on staffing and facility operations |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Inan Linton | Administrator | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Census: 148
Capacity: 184
Deficiencies: 3
Oct 13, 2022
Visit Reason
The visit was an unannounced Case Management - Incident inspection to follow up on incident reports involving two residents, including an elopement and a fall with injuries.
Findings
The facility failed to ensure the safety of Resident #1 who eloped from the facility despite known exit-seeking behavior and lack of safety measures. Resident #2 was found on the floor with multiple injuries and required hospital evaluation. Deficiencies were cited related to basic services and dementia care assessments.
Complaint Details
The visit was complaint-related, triggered by incidents involving Resident #1 eloping from the facility and Resident #2 sustaining injuries from a fall. The complaint was substantiated by observed deficiencies.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Basic services requirements. Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met. | Type B |
| Based on interviews, the licensee did not ensure the safety for Resident #1 who eloped from the facility. Staff were unaware of the elopement, posing an immediate health and safety risk. | Type B |
| Care of Persons with Dementia. Each resident with dementia shall have an annual medical assessment and reappraisal. The licensee did not ensure Resident #1 had a current Medical Assessment on file. | Type B |
Report Facts
Residents present: 148
Total licensed capacity: 184
Deficiencies cited: 3
Plan of Correction due date: Nov 10, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lizzette Tellez | Licensing Program Manager | Supervisor overseeing the inspection |
| Tracy Knepple | Executive Director | Facility representative met during inspection |
Inspection Report
Census: 148
Capacity: 184
Deficiencies: 0
Oct 13, 2022
Visit Reason
The visit was an unannounced Case Management - Legal/Non-compliance inspection to ensure ongoing compliance with regulations and laws and to ensure the health and safety of residents in care.
Findings
During the inspection, the Licensing Program Analyst toured the facility, observed residents, and provided consultation on Title 22 requirements. No deficiencies were cited at this time in the areas evaluated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Knepple | Executive Director | Met with Licensing Program Analyst during inspection and debriefed on regulations. |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced Case Management - Legal/Non-compliance visit. |
| Lizzette Tellez | Licensing Program Manager | Named in report header and signature section. |
Inspection Report
Census: 148
Capacity: 184
Deficiencies: 0
Aug 9, 2022
Visit Reason
The visit was an unannounced Case Management - Other conducted by Licensing Program Analyst Natasha Persaud to perform a health and safety check and discuss the purpose of the visit with facility leadership.
Findings
During the visit, a brief tour and observation of residents were conducted, and no deficiencies were observed. The report confirms no deficiencies were issued.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Inan Linton | Executive Director | Met with Licensing Program Analyst during the visit and received the report and Licensee Rights. |
| Tracy Knepple | Assistant Executive Director | Met with Licensing Program Analyst during the visit. |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced Case Management visit and authored the report. |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager overseeing the visit. |
Inspection Report
Annual Inspection
Census: 152
Capacity: 184
Deficiencies: 0
Jul 1, 2022
Visit Reason
An unannounced annual required licensing inspection was conducted to verify compliance with statutes, regulations, and other written requirements relevant to protecting the health of residents and staff, including infection control practices.
Findings
No deficiencies were observed during the visit. The Licensing Program Analyst provided consultation and evaluated the facility's COVID-19 Mitigation Plan including disinfection, testing, vaccination, screening protocols, and use of personal protective equipment.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Inan Linton | Executive Director | Met with Licensing Program Analyst during inspection and received report and Licensee Rights. |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced annual inspection and evaluation. |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 152
Capacity: 184
Deficiencies: 0
Jul 1, 2022
Visit Reason
An unannounced Case Management visit was conducted following a self-reported elopement incident involving a resident who was not allowed to leave the facility unassisted.
Findings
The facility followed their Absentee Notification Plan after the elopement, the resident was located and returned without injuries, and no deficiencies were issued during the visit.
Report Facts
Capacity: 184
Census: 152
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Inan Linton | Executive Director | Met with Licensing Program Analyst during the visit and acknowledged receipt of report and licensee rights |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Lizzette Tellez | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 157
Capacity: 184
Deficiencies: 1
Jul 1, 2022
Visit Reason
An unannounced Case Management visit was conducted related to a complaint received by the Department on January 24, 2022.
Findings
An amended report was issued to the Executive Director correcting a previously cited Type A deficiency to a Type B deficiency related to the complaint.
Complaint Details
Complaint received on January 24, 2022; deficiency originally Type A, amended to Type B; visit was related to this complaint.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiency originally cited as Type A for a complaint received on January 24, 2022, amended to Type B. | Type B |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Inan Linton | Executive Director | Met with Licensing Program Analyst during the visit and received the amended report. |
| Esther Miller | Licensing Program Analyst | Conducted the unannounced Case Management visit related to the complaint. |
| Denise Powell | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 153
Capacity: 184
Deficiencies: 1
Jun 23, 2022
Visit Reason
An unannounced Case Management visit was conducted following a substantiated complaint alleging neglect/lack of supervision of Resident #1 (R1). The visit was to assess compliance and address deficiencies related to this complaint.
Findings
The Department found that the licensee failed to contact 911 or obtain emergency medical services for Resident #1 when they developed a Stage II pressure injury that progressed to unstageable, posing an immediate health and safety risk. A $500 civil penalty was issued for this violation resulting in injury to the resident.
Complaint Details
The complaint alleging neglect/lack of supervision of Resident #1 was substantiated on 05/06/2021. The Department determined the violation resulted in injury to the resident and issued a $500 civil penalty under HSC 1569.49(c)(1).
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to contact 911 or obtain emergency medical services for Resident #1 who developed a Stage II pressure injury that progressed to unstageable. | Type A |
Report Facts
Civil penalty amount: 500
Resident count: 121
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Toupin | Director of Resident Care Services | Met during the visit and received report and civil penalty assessment form |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced Case Management visit and authored the report |
| Lizzette Tellez | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Census: 153
Capacity: 184
Deficiencies: 0
Jun 23, 2022
Visit Reason
The visit was an unannounced Case Management - Legal/Non-Compliance inspection to ensure ongoing compliance with regulations and laws and to ensure the health and safety of residents in care.
Findings
No deficiencies were cited at the time of the inspection. The Licensing Program Analyst toured the facility, observed residents, and provided consultation regarding Title 22 requirements.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Toupin | Director of Resident Care Services | Met with during the inspection and debriefed on regulations. |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced Case Management - Legal/Non-Compliance visit. |
| Lizzette Tellez | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 184
Deficiencies: 1
Jun 10, 2022
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that the facility was not following COVID-19 guidelines, specifically not requiring negative COVID tests for visitors to enter the facility.
Findings
The investigation found that the facility did not require negative COVID tests from visitors between January 18, 2022 and February 7, 2022, which substantiated the allegation. The licensee failed to provide safe and healthful accommodations to all 154 residents, posing a potential personal rights risk.
Complaint Details
The complaint was substantiated. The allegation was that the facility was not following COVID-19 guidelines by not requiring negative COVID tests for visitors. The investigation confirmed that visitors were allowed entry without negative tests during the specified period.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews, observations, and record reviews, the licensee did not provide safe and healthful accommodations in 154 of 154 residents which posed a potential personal rights risk to residents in care. | Type B |
Report Facts
Visitors logged: 248
Antigen COVID test entries: 109
Residents affected: 154
Total capacity: 184
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Inan Linton | Executive Director | Named in relation to the complaint investigation and findings |
| Esther Miller | Licensing Program Analyst | Conducted the complaint investigation |
| Denise Powell | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 145
Capacity: 184
Deficiencies: 0
Mar 22, 2022
Visit Reason
The visit was an unannounced Case Management - Legal/Non-Compliance inspection to ensure ongoing compliance with regulations and laws and to ensure the health and safety of residents in care.
Findings
During the inspection, the Licensing Program Analyst toured the facility, observed residents, and provided consultation on Title 22 requirements. No deficiencies were cited at this time in the areas evaluated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Inan Linton | Executive Director | Met with Licensing Program Analyst during inspection |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced Case Management - Legal/Non-Compliance visit |
| John Rante | Licensing Program Manager | Named in report header |
Inspection Report
Census: 129
Capacity: 184
Deficiencies: 0
Jan 11, 2022
Visit Reason
The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's disinfection, screening protocols as well as the use of personal protective equipment during the COVID-19 pandemic.
Findings
No deficiencies were issued during the visit. The Executive Director was interviewed and a walk-through of the facility was conducted, followed by a debriefing and exit interview.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Inan Linton | Executive Director | Interviewed and met during the visit |
| Natasha Persaud | Licensing Program Analyst | Conducted the on-site visit |
| Sandra Brackman | County of San Diego Nurse Contractor | Conducted the on-site visit |
| Ann Wood | Regional VP of Operations | Discussed the purpose of the visit |
Inspection Report
Census: 129
Capacity: 184
Deficiencies: 0
Oct 5, 2021
Visit Reason
The visit was an unannounced Case Management visit conducted following receipt of a self-reported incident and a death report involving two residents.
Findings
During the visit, staff interviews and record reviews were conducted. The incident involved one resident found on the floor with injury and another resident who fell, was hospitalized, and later passed away. No deficiencies were issued during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Inan Linton | Executive Director | Met with during the visit and discussed the purpose of the visit. |
| Amy Salvador | Director of Care Services | Discussed the purpose of the visit. |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| John Rante | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Census: 129
Capacity: 184
Deficiencies: 0
Aug 24, 2021
Visit Reason
An unannounced annual required licensing inspection was conducted to verify compliance with statutes, regulations, and other written requirements relevant to protecting the health of residents and staff, including infection control practices.
Findings
The facility was found to be in compliance with infection control practices, including COVID-19 mitigation measures, and no deficiencies were observed during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Inan Linton | Executive Director | Met with Licensing Program Analyst during inspection and named in report. |
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection and authored the report. |
| John Rante | Licensing Program Manager | Named in report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 184
Deficiencies: 3
Aug 24, 2021
Visit Reason
The visit was an unannounced Case Management inspection to issue deficiencies identified during a complaint investigation involving Resident #1 who sustained five pressure injuries resulting in hospitalization due to neglect by facility staff.
Findings
The investigation found that the facility failed to obtain a plan of care from the Home Health Agency, did not follow physician's orders to off-load pressure on the resident's legs, and did not request a prohibited health condition exception for unstageable pressure injuries. These failures posed an immediate health risk to the resident.
Complaint Details
The complaint investigation revealed that Resident #1 sustained five pressure injuries resulting in hospitalization due to neglect by facility staff. The injuries were documented by Home Health and Mobile Wound Care services. The facility failed to obtain a plan of care, follow physician's orders, and request required exceptions for prohibited health conditions.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Did not provide the supporting care and supervision needed to meet the needs of Resident #1 receiving home health care. | Type A |
| Facility personnel were not competent to provide the services necessary to meet resident needs, including failure to follow physician's orders for Resident #1. | Type A |
| Did not request an exception for a prohibited health condition regarding unstageable pressure injuries for Resident #1. | Type B |
Report Facts
Pressure injuries sustained: 5
Resident census: 129
Facility capacity: 184
Plan of Correction due date: Aug 25, 2021
Plan of Correction due date: Aug 31, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Inan Linton | Executive Director | Met during inspection and named in relation to findings. |
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection and authored the report. |
| John Rante | Licensing Program Manager | Supervisor and cited in the report. |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 184
Deficiencies: 1
May 6, 2021
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that a resident sustained multiple pressure injuries resulting in hospitalization due to neglect.
Findings
The investigation found that the facility failed to follow physician's orders and did not obtain or follow a plan of care from Home Health and Mobile Wound Care, contributing to the progression of multiple pressure injuries on Resident #1, resulting in hospitalization. The facility also failed to provide immediate medical attention and did not contact emergency services as required.
Complaint Details
The complaint was substantiated. Resident #1 sustained multiple pressure injuries resulting in hospitalization due to neglect. The facility failed to follow physician's orders, did not obtain a plan of care from Home Health and Mobile Wound Care, and delayed medical attention. The preponderance of evidence supported the allegation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee did not contact 911 or obtain emergency medical services for 1 out of 121 residents, posing an immediate health and safety risk. | Type A |
Report Facts
Resident census: 121
Total capacity: 184
Pressure injuries: 5
Plan of Correction due date: May 7, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Inan Linton | Executive Director | Met with during investigation and named in findings |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| John Rante | Licensing Program Manager | Named in report as Licensing Program Manager |
| Rebecca Hedgecock | Licensing Program Manager | Named in report as Licensing Program Manager |
Report
January 30, 2025
File
report_35_374603279_inx34_2025-01-30.pdf
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