Inspection Reports for Belmont Village Senior Living Thousand Oaks
CA, 91360
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on June 24, 2025, which was clean with no citations. Earlier reports showed some serious issues, notably substantiated findings of neglect and lack of supervision that led to a resident’s injury and death, resulting in civil penalties totaling $15,000 in 2024 and 2023. Other deficiencies involved failure to notify responsible parties of condition changes and medication management errors, while several complaint investigations were unsubstantiated. The facility has shown improvement over time, with recent inspections free of deficiencies and no new enforcement actions. Minor or isolated issues from earlier years, such as unsecured cleaning supplies and staff association errors, have been addressed.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
65% occupied
Based on a June 2025 inspection.
Occupancy over time
Inspection Report
Annual Inspection
Census: 102
Capacity: 158
Deficiencies: 0
Date: Jun 24, 2025
Visit Reason
The inspection was an unannounced required annual visit to evaluate the facility's compliance with Title 22 regulations and ensure there are no health and safety hazards.
Findings
The facility was found to be in compliance with all applicable regulations, including infection control, emergency disaster planning, physical plant safety, medication management, and record keeping. No deficiencies or citations were issued during the inspection.
Report Facts
Residents interviewed: 13
Staff interviewed: 10
Family visitors interviewed: 1
Resident bedrooms observed: 15
Memory care bedrooms: 5
Assisted living bedrooms: 10
Personnel files reviewed: 10
Resident files reviewed: 6
Medications reviewed: 8
Fire extinguisher last serviced: Apr 4, 2025
Last fire inspection date: Sep 26, 2024
Last emergency disaster drill: Jun 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cyntia Dachenberg | Executive Director | Met with Licensing Program Analyst during inspection |
| Erica Mosley | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 158
Deficiencies: 1
Date: Feb 20, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff did not properly treat a resident's wound and did not notify the resident's responsible party of a change in condition.
Complaint Details
The complaint alleged that staff did not properly treat Resident #1's wound and did not notify Resident #1's responsible party of a change in condition. The wound treatment allegation was unsubstantiated due to insufficient evidence. The failure to notify the responsible party was substantiated based on care notes, interviews, and lack of documentation. No citations were issued for the wound treatment allegation; a deficiency was cited for failure to notify the responsible party.
Findings
The investigation found the allegation that staff did not properly treat the resident's wound to be unsubstantiated due to insufficient evidence. However, the allegation that staff did not notify the resident's responsible party of a change in condition was substantiated, with documentation and interviews supporting this finding. A deficiency was cited related to failure to notify the responsible party.
Deficiencies (1)
The licensee failed to ensure that residents are regularly observed for changes and that such changes are documented and brought to the attention of the resident's responsible person, as evidenced by failure to notify Resident #1's responsible person of a contusion on the left toe.
Report Facts
Capacity: 158
Census: 106
Deficiency count: 1
Plan of Correction Due Date: Mar 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Cyntia Drachenberg | Executive Director | Facility Executive Director involved in interviews and entrance/exit interviews |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 158
Deficiencies: 0
Date: Feb 14, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not seek medical attention in a timely manner for a resident's toe infection.
Complaint Details
The complaint alleged that Resident #1 had an infection in their toe and staff failed to obtain timely medical treatment. The investigation found that the resident had a podiatrist's plan of care and timely communication with medical providers. The resident was taken to the podiatrist/Emergency Department by family. The allegation was deemed unsubstantiated.
Findings
The investigation reviewed medical records, staff interviews, and correspondence with medical providers. The allegation was found to be unsubstantiated due to insufficient evidence to prove the alleged violation occurred. No citations were issued.
Report Facts
Complaint Control Number: 29-AS-20240726110738
Facility Capacity: 158
Census: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation and staff interviews |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Cyntia Drachenberg | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 158
Deficiencies: 0
Date: Nov 12, 2024
Visit Reason
The visit was a Case Management - Incident inspection triggered by a self-reported incident involving an allegation of sexual assault on Resident #1.
Complaint Details
The complaint involved an allegation by Resident #1 that two men entered their room and sexually assaulted them on 11/06/2024. The allegation was reported to the Ventura County Sheriff, medical providers, and Long Term Care Ombudsman. Resident #1 has dementia, but no evidence supported the allegation, and the family expressed no concerns about care.
Findings
The investigation found no indication that the alleged assault occurred; Resident #1 felt safe, and medical examination revealed no signs of assault. No deficiencies were cited during the visit.
Report Facts
Facility capacity: 158
Resident census: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the Case Management - Incident visit and investigation |
| Cyntia Drachenberg | Executive Director | Met with Licensing Program Analyst and reported the incident |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 158
Deficiencies: 1
Date: Aug 21, 2024
Visit Reason
An unannounced Case Management visit was conducted to issue a civil penalty related to a substantiated complaint investigation regarding neglect and lack of supervision that resulted in injury and death of a resident.
Complaint Details
The complaint investigation was substantiated. The allegation was neglect and lack of supervision that resulted in injury and death of resident R1. An immediate civil penalty of $500 was previously assessed, and an additional civil penalty of $14,500 was issued for a total of $15,000.
Findings
The investigation found that on December 20, 2021, a resident (R1) was left unattended due to malfunctioning radios, resulting in a fall causing a subdural hematoma and eventual death. The licensee was cited for failing to provide adequate care and supervision.
Deficiencies (1)
Neglect and lack of supervision resulting in injury and death of a resident (R1) in violation of Health & Safety Code §1569.312(a) Basic Services Requirements.
Report Facts
Civil penalty amount: 15000
Civil penalty amount previously assessed: 500
Facility capacity: 158
Resident census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cyntia Drachenberg | Executive Director | Met with Licensing Program Analyst during the visit and acknowledged receipt of report and appeal rights. |
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced Case Management visit and signed the report. |
| Kristin Heffernan | Licensing Program Manager | Named in the report as Licensing Program Manager overseeing the case. |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 158
Deficiencies: 0
Date: Jul 15, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2024-01-11 regarding unsanitary conditions, malodorous environment, inadequate staff supervision, unsafe sanitation practices, and unmet resident needs at Belmont Village Thousand Oaks.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included facility unsanitary conditions, malodorous environment, staff not meeting residents' needs, unsafe sanitation practices, and inadequate supervision. The Department found insufficient evidence to support any of these claims.
Findings
The investigation found no evidence to substantiate the allegations. The facility was observed to be clean with no foul odors, staff followed safe sanitation practices including during a COVID outbreak, and residents were adequately supervised and their needs met. All allegations were deemed unsubstantiated.
Report Facts
Capacity: 158
Census: 114
Complaint control number: 29-AS-20240111143021
Number of staff interviewed: 6
Number of residents interviewed: 8
Dates of prior visits: Initial visit on 2024-01-17 and subsequent visit on 2024-05-16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Cyntia Drachenberg | Executive Director | Met with Licensing Program Analyst during inspection |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 106
Capacity: 158
Deficiencies: 0
Date: Jun 18, 2024
Visit Reason
The inspection was an unannounced required annual visit to evaluate the facility's compliance with health and safety regulations.
Findings
The facility was toured including common areas, resident rooms, restrooms, kitchen, and exterior. No health or safety hazards were observed, and the facility was found clean and in good repair. No deficiencies were cited at this time.
Report Facts
Food supply duration: 3
Food supply duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cyntia Drachenberg | Administrator | Met with Licensing Program Analyst during inspection |
| Zabel Chochian | Licensing Program Analyst | Conducted the annual inspection visit |
| Desaree Perera | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 158
Deficiencies: 0
Date: May 16, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the facility was trying to persuade residents and/or their responsible parties to change physicians or home health agencies to ones preferred by administration.
Complaint Details
The complaint alleged that the facility was persuading residents or their responsible parties to change physicians or home health agencies to those preferred by the administration. The investigation included interviews with staff, residents, and family members, and review of relevant documents. The allegation was found unsubstantiated.
Findings
The investigation found no sufficient evidence to support the allegation. Interviews with staff, residents, and family members indicated that residents and families make their own decisions regarding physicians and home health agencies without pressure from the facility. The allegation was deemed unsubstantiated.
Report Facts
Facility capacity: 158
Resident census: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation |
| Desaree Perera | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Cyntia Drachenberg | Executive Director | Met with Licensing Program Analyst during the investigation |
| Nancy D Nelson | Administrator | Facility Administrator named in the report |
Inspection Report
Annual Inspection
Census: 111
Capacity: 158
Deficiencies: 4
Date: Jun 14, 2023
Visit Reason
The visit was an unannounced continuation of a required annual inspection to evaluate compliance with licensing requirements and assess facility operations.
Findings
The inspection identified multiple deficiencies including missing first aid certifications and tuberculosis test results for staff, incomplete verification of required training hours, medication errors involving residents, and documentation issues with medication administration. The facility reported medication errors and implemented corrective measures including staff retraining.
Deficiencies (4)
2 out of 5 staff records were missing first aid certification at the time of the visit.
4 out of 5 staff records had unverified required training hours at the time of the visit.
1 out of 5 staff records were missing tuberculosis test results at the time of the visit.
Medication errors observed for 4 out of 5 residents, including missing PRN medication, improper documentation, and incorrect dosages administered.
Report Facts
Staff missing first aid certification: 2
Staff with unverified training hours: 4
Staff missing tuberculosis test results: 1
Residents with medication errors: 4
Facility capacity: 158
Resident census: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nancy D Nelson | Administrator | Named in relation to agreeing to plans of correction for deficiencies |
| Elsie Campos | Licensing Program Analyst | Conducted inspection and authored report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing inspection |
| Cyntia Drachenberg | Executive Director | Facility representative met during inspection |
Inspection Report
Annual Inspection
Census: 111
Capacity: 158
Deficiencies: 3
Date: May 24, 2023
Visit Reason
The inspection was an unannounced required annual visit to evaluate compliance with health, safety, and regulatory standards at the assisted living and memory care facility.
Findings
The inspection identified multiple deficiencies including unsecured dangerous items accessible to residents with dementia, expired food products, unkempt resident bathrooms, unsecured cleaning supplies, and minor safety hazards in outdoor areas. Plans of correction were agreed upon to address these issues.
Deficiencies (3)
Knives, scissors, shaving razors, and gardening supplies were found accessible to residents with dementia, posing an immediate health and safety risk.
Two resident bathrooms (rooms 407 and 416) were unkempt, posing a potential health and safety risk.
Expired breads, expired Ensure nutritional drinks, and expired grits were observed, posing a potential health and safety risk.
Report Facts
Capacity: 158
Census: 111
Plan of Correction Due Date: May 25, 2023
Plan of Correction Due Date: May 26, 2023
Water Temperature Range: 105-114.8
Fire Extinguisher Last Service Date: 202303
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elsie Campos | Licensing Program Analyst | Conducted inspection and signed report |
| Nancy D Nelson | Administrator | Facility administrator present during inspection |
| Cyntia Drachenberg | Executive Director | Met with Licensing Program Analysts during inspection |
| Fabian Munoz | Chef Manager | Observed expired food items during kitchen inspection |
| Alejandra Martinez | Activities Program Coordinator | Met with Licensing Program Analysts during inspection |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing inspection |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 158
Deficiencies: 0
Date: Apr 20, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2022-01-03 regarding inadequate lighting during power outage, inadequate back-up power supply for healthcare devices, and inadequate staffing to ensure resident safety.
Complaint Details
The complaint investigation was unsubstantiated for all allegations: inadequate lighting during power outage, inadequate back-up power supply for healthcare devices, and inadequate staffing to ensure resident safety.
Findings
The investigation found insufficient evidence to support any of the allegations. The facility had emergency lighting in hallways but not in bedrooms, with natural light and flashlights available. Backup power outlets and portable oxygen tanks were available for medical devices. Staffing levels were maintained through permanent and agency staff, with measures to ensure resident safety despite power outage conditions. All allegations were deemed unsubstantiated.
Report Facts
Capacity: 158
Census: 111
Battery operated flashlights: 35
Emergency power outlets per floor: 2
Staff on morning shift: 4
Staff on afternoon/evening shift: 5
Staff in Memory Care unit: 4
Staff in Memory Care unit: 5
Staff placed on each end of Memory Care unit: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted complaint investigation and visits |
| Keith Payne | Administrator | Facility administrator named in report header |
| Cyntia Drachenberg | Executive Director | Met with Licensing Program Analyst during investigation |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on report |
| Guzman Chavez | Licensing Program Analyst | Conducted initial complaint visit on 2022-01-11 |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 158
Deficiencies: 0
Date: Apr 20, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2022-11-08 regarding resident falls, personal hygiene, room odor, and cleanliness at Belmont Village Thousand Oaks.
Complaint Details
The complaint involved multiple allegations including resident falls, failure to maintain personal hygiene, failure to maintain resident room odor free, and failure to clean the resident room. All allegations were deemed unsubstantiated based on interviews, observations, and record reviews.
Findings
The investigation found insufficient evidence to substantiate the allegations. Although the resident sustained multiple falls, staff were responsive and communicated with the resident's physician. The resident declined assistance with personal hygiene and room cleaning, and staff efforts to maintain cleanliness and odor control were ongoing but limited by resident refusal.
Report Facts
Facility Capacity: 158
Resident Census: 111
Complaint Receipt Date: Nov 8, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Dina Davis | Administrator | Facility administrator named in the report |
| Cyntia Drachenberg | Executive Director | Met with Licensing Program Analyst during the investigation |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 158
Deficiencies: 1
Date: Apr 20, 2023
Visit Reason
The visit was conducted as a Case Management - Deficiencies visit in conjunction with a complaint investigation to issue a citation for a deficiency observed during the complaint investigation.
Complaint Details
The visit was conducted in conjunction with complaint #29-NP-20220311163324. The deficiency was substantiated as the facility did not report the power outage within the required timeframe.
Findings
The facility failed to report a power outage that occurred on 12/31/2021 within 24 hours to Community Care Licensing or the persons responsible for the residents, as required by California Code of Regulations, posing a potential health and safety risk.
Deficiencies (1)
Failure to report the power outage on 12/31/2021 within 24 hours either by telephone or facsimile to the licensing agency as required.
Report Facts
Deficiency Type B: 1
Plan of Correction Due Date: Apr 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the Case Management - Deficiencies visit and complaint investigation. |
| Desaree Perera | Licensing Program Manager | Supervisor and Licensing Program Manager named in the report. |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 158
Deficiencies: 1
Date: Apr 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation received on 12/29/2021 regarding neglect/lack of supervision that resulted in injury and death of a resident.
Complaint Details
The complaint was substantiated. It alleged neglect/lack of supervision that resulted in Resident #1 falling and sustaining a traumatic subdural hematoma which resulted in death. The investigation confirmed the allegation.
Findings
The investigation found that facility staff failed to provide appropriate supervision to Resident #1, who fell and sustained a traumatic subdural hematoma resulting in death. The allegation of neglect/lack of supervision was substantiated.
Deficiencies (1)
Failure to provide care and supervision to Resident #1, resulting in a fall and traumatic subdural hematoma leading to death, violating Health and Safety Code §1569.312(a) Basic services requirements.
Report Facts
Immediate civil penalty: 500
Capacity: 158
Census: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings. |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Cyntia Drachenberg | Executive Director | Met with Licensing Program Analyst during the visit and was informed of findings. |
| Robert Kujawa | Investigator | Conducted interviews and reviewed records related to the complaint. |
| Dina Davis | Administrator | Met with Licensing Program Analyst during initial complaint visit. |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 158
Deficiencies: 1
Date: Apr 13, 2023
Visit Reason
The visit was an unannounced case management incident investigation conducted to investigate an incident of elopement involving Resident #1 that occurred on 2023-04-09.
Complaint Details
The visit was triggered by a complaint regarding an unusual incident report of Resident #1 eloping from the facility on 2023-04-09. The incident was substantiated with a repeat deficiency citation and civil penalty.
Findings
The licensee did not comply with the requirement for care and supervision as Resident #1 was able to elope and walk out of the facility unassisted, posing an immediate health and safety risk. The deficiency was cited as a repeat violation and a civil penalty of $250 was assessed.
Deficiencies (1)
Licensee did not comply with care and supervision requirements as Resident #1 was able to elope and walk out of the facility unassisted, posing an immediate health and safety risk.
Report Facts
Civil penalty amount: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the unannounced case management incident visit and authored the report |
| Desaree Perera | Licensing Program Manager | Supervisor of the licensing evaluation |
| Cyntia Drachenberg | Executive Director | Met with Licensing Program Analyst during the visit and provided information about the incident |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 158
Deficiencies: 1
Date: Jan 26, 2023
Visit Reason
The visit was an unannounced case management incident investigation conducted to investigate incidents of residents eloping from the facility on 01/16/2023 and 01/26/2023.
Complaint Details
The investigation was triggered by an unusual incident report regarding Resident #1 eloping on 01/16/2023. The complaint was substantiated as the facility failed to supervise the residents leading to elopements on 01/16/2023 and 01/26/2023.
Findings
The facility failed to supervise Resident #1 on 01/16/2023 and both Resident #1 and Resident #2 on 01/26/2023, allowing them to elope from the facility unassisted, posing an immediate health and safety risk.
Deficiencies (1)
Basic Services 'Care and Supervision' requirement was not met as Residents #1 and #2 were able to elope and walk out of the facility unassisted, posing an immediate health and safety risk.
Report Facts
Census: 108
Total Capacity: 158
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the unannounced case management incident visit and authored the report |
| Cyntia Drachenberg | Executive Director | Met with Licensing Program Analyst during the visit and provided information about the incidents |
| Desaree Perera | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 158
Deficiencies: 0
Date: Sep 20, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 08/16/2021 regarding illegal eviction and a resident eloping from the facility.
Complaint Details
The complaint involved allegations of illegal eviction of Resident #1 and that the resident was able to elope from the facility. The investigation included interviews with staff and family, review of incident reports, and facility records. The allegations were found unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found insufficient evidence to support the allegations of illegal eviction and resident elopement. Both allegations were deemed unsubstantiated after interviews, record reviews, and incident report analysis.
Report Facts
Complaint Control Number: 29-AS-20210816143842
Incident duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Keith Payne | Administrator | Facility administrator mentioned in the report header |
| Collette Philipp | Memory Program Director | Met with during the investigation and involved in incident response |
| Cindy Carrillo | Customer Service Specialist | Met with during the investigation |
Inspection Report
Census: 113
Capacity: 158
Deficiencies: 0
Date: Sep 20, 2022
Visit Reason
The inspection was conducted to follow up on a confirmation of removal and Decision and Order (D&O) issued on 8/24/22 for staff #1 (S1), an excluded individual, to ensure S1 does not work at the facility.
Findings
The inspection confirmed that staff #1 (S1) does not work at the facility as S1 was hired but never started working and is not on the terminated list. Management understands the restrictions imposed by the D&O and the effective date of 9/6/22. No citations were issued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the inspection and reviewed the Decision and Order. |
| Collette Philipp | Memory Program Director | Met with the Licensing Program Analyst during the inspection. |
| Cindy Carrillo | Customer Service Specialist | Met with the Licensing Program Analyst during the inspection. |
Inspection Report
Plan of Correction
Census: 103
Capacity: 158
Deficiencies: 1
Date: Sep 1, 2022
Visit Reason
The visit was a Plan of Correction (POC) unannounced visit to evaluate compliance with previously cited deficiencies related to staff association with the facility.
Findings
The facility failed to associate the Interim Executive Director and Regional Vice President of Resident Care to the facility as required, resulting in civil penalties. A deficiency was cited for not ensuring staff were properly associated prior to working, posing an immediate safety risk.
Deficiencies (1)
Failure to ensure staff (S1 and S2) were associated with the facility prior to working, violating criminal record clearance requirements.
Report Facts
Civil penalties assessed: 400
Civil penalty per day: 100
Days penalty assessed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Colleen Papp | Interim Executive Director | Named in deficiency for not being associated with the facility. |
| Sharlene Gephart | Regional Vice President of Resident Care | Named in deficiency for not being associated with the facility. |
| Collette Phillips | Memory Program Director | Authorized to review and sign reports during the inspection. |
Inspection Report
Census: 103
Capacity: 158
Deficiencies: 1
Date: Aug 29, 2022
Visit Reason
The visit was a Case Management - Deficiencies unannounced inspection conducted to evaluate compliance with licensing requirements and address identified deficiencies.
Findings
A deficiency was cited for failure to ensure that an individual (S1) was properly associated with the facility prior to working, posing an immediate safety risk. A civil penalty of $500 was issued related to this deficiency.
Deficiencies (1)
Failure to ensure that S1 was associated with the facility prior to working, violating criminal record clearance requirements.
Report Facts
Civil penalty amount: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Colleen Papp | Interim Executive Director | Met during inspection and discussed staffing association issues. |
| Roger Alaba | Director of Resident Care Services | Met during inspection and authorized to review and sign reports. |
| Ann Wood | Senior Vice President of Operations | Authorized staff to review and sign reports via telephone. |
Inspection Report
Annual Inspection
Census: 105
Capacity: 158
Deficiencies: 1
Date: Jun 25, 2022
Visit Reason
The inspection was an unannounced required annual visit with a specific emphasis on infection control practices and procedures.
Findings
The facility was generally in compliance with health and safety regulations, including infection control, food storage, and sanitation. However, a deficiency was cited for storing cleaning supplies and toxins on an unattended housekeeping cart accessible to residents, posing an immediate health risk.
Deficiencies (1)
Cleaning supplies and toxic substances were observed on an unattended housekeeping cart accessible to residents, posing an immediate health risk.
Report Facts
Water temperature: 114.8
Water temperature: 113.5
Water temperature: 118
Water temperature: 111.2
Facility capacity: 158
Census: 105
Fire extinguisher last serviced: 5
Plan of Correction Due Date: Jul 1, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the inspection and authored the report |
| Desaree Perera | Licensing Program Manager | Supervisor overseeing the inspection |
| Roger Alaba | Staff member met during inspection |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 158
Deficiencies: 0
Date: Jun 25, 2022
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit following allegations that facility staff failed to seek timely medical attention resulting in the death of Resident #1 and failed to report change of condition to the responsible party in a timely manner.
Complaint Details
The complaint alleged that facility staff failed to seek timely medical attention resulting in the death of Resident #1 and failed to report change of condition to the responsible party in a timely manner. Both allegations were deemed unsubstantiated based on interviews, record reviews, and family statements.
Findings
The investigation found insufficient evidence to substantiate the allegations. Resident #1 was monitored throughout the day, and staff called 911 when oxygen levels dropped. The resident had a DNR on file, and family members were aware and did not want to override it. No citations were issued.
Report Facts
Facility capacity: 158
Resident census: 105
Complaint receipt date: Mar 11, 2022
Paramedic arrival time: 1913
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Roger Alaba | Staff member met with during the investigation | |
| Peter Zertuche | Investigator | Conducted additional interviews during the investigation |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation |
| Guzman Chavez | Licensing Program Analyst | Conducted initial 10-day visit and interviews |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 158
Deficiencies: 0
Date: Feb 11, 2021
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that a resident sustained hip fractures as a result of physical abuse while in care.
Complaint Details
The complaint alleged physical abuse causing hip fractures to a resident. The investigation included interviews, medical record reviews, and police notes. The claim was unsubstantiated as evidence supported a medical cause for the injuries.
Findings
The investigation found that the resident's injuries were consistent with a medical issue related to a seizure, osteoporosis, and generalized weakness, with no evidence of physical abuse. The allegation was deemed unsubstantiated and no deficiencies were cited.
Report Facts
Facility capacity: 158
Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation visit |
| Keith Payne | Executive Director | Interviewed during the investigation |
| Douglas Real | Investigator | Reviewed medical records, police notes, and conducted staff interviews |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation report |
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