Inspection Reports for
Belmont Village Senior Living Westwood

10475 Wilshire Blvd, Los Angeles, CA 90024, United States, CA, 90024

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Deficiencies (last 5 years)

Deficiencies (over 5 years) 1.2 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

70% better than California average
California average: 4 deficiencies/year

Deficiencies per year

4 3 2 1 0
2021
2022
2023
2024
2025

Census

Latest occupancy rate 73% occupied

Based on a December 2025 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Occupancy over time

50 100 150 200 250 Jun 2021 Mar 2023 Mar 2024 Nov 2024 May 2025 Dec 2025

Inspection Report

Census: 176 Capacity: 240 Deficiencies: 0 Date: Dec 12, 2025

Visit Reason
An unannounced Case Management visit was conducted to review compliance with licensing requirements and to address a Decision and Order received against an individual excluded from care facilities.

Findings
No deficiencies were observed during the visit, and no citations were issued. The facility was found to be in compliance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorMet with Licensing Program Analyst during the visit and discussed the Decision and Order.
Alfonso IniguezLicensing Program AnalystConducted the unannounced Case Management visit and inspection.

Inspection Report

Census: 174 Capacity: 240 Deficiencies: 0 Date: Jun 26, 2025

Visit Reason
An unannounced Case Management visit was conducted following receipt of a Decision and Order excluding an individual (S#1) from any care facility licensed by the department.

Findings
No deficiencies were observed during the visit; therefore, no citations were issued.

Report Facts
Capacity: 240 Census: 174

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorMet with Licensing Program Analyst during the visit and involved in review of personnel and guardian records.
Alfonso IniguezLicensing Program AnalystConducted the unannounced Case Management visit and inspection.
Eva M AlvarezLicensing Program ManagerNamed in the report as Licensing Program Manager.

Inspection Report

Census: 174 Capacity: 240 Deficiencies: 0 Date: Jun 26, 2025

Visit Reason
An unannounced Case Management visit was conducted to investigate a Decision and Order received against an individual excluded from care facilities licensed by the department.

Findings
No deficiencies were observed during the visit, and no citations were issued. The individual named in the Decision and Order was not found to be associated with the facility.

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorMet with Licensing Program Analyst during the visit and involved in review of personnel and guardian records.
Alfonso IniguezLicensing Program AnalystConducted the unannounced Case Management visit and reviewed facility records.

Inspection Report

Complaint Investigation
Census: 176 Capacity: 240 Deficiencies: 0 Date: Jun 4, 2025

Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff mishandle residents' medications.

Complaint Details
The allegation was that staff mishandle the residents' medications. Interviews with 11 staff members and 10 residents found 11 staff denied mishandling and 9 residents denied it, with 1 resident affirming. Based on the evidence, the allegation was determined to be unsubstantiated.
Findings
The investigation included record reviews, interviews with staff and residents, and a facility tour. No sufficient evidence was found to substantiate the allegation of medication mishandling, and no deficiencies were cited.

Report Facts
Capacity: 240 Census: 176 Staff interviewed: 11 Residents interviewed: 10

Employees mentioned
NameTitleContext
Daisy CeballosDirector of Resident CareMet with during the investigation and named in the report
Felisa ShirleyLicensing Program AnalystConducted the complaint investigation
Stephanie CifuentesLicensing Program ManagerNamed as Licensing Program Manager on the report

Inspection Report

Complaint Investigation
Census: 176 Capacity: 240 Deficiencies: 0 Date: Jun 4, 2025

Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to an allegation that staff mishandle the residents' medications.

Complaint Details
The complaint alleged that staff mishandle the residents' medications. The investigation included review of medication administration records, interviews with 11 staff and 10 residents, and a tour of the medication room. Of those interviewed, 11 staff denied mishandling and 9 of 10 residents denied mishandling. The allegation was unsubstantiated due to lack of sufficient evidence.
Findings
Based on records review, interviews with staff and residents, and observations, the Licensing Program Analyst did not find sufficient evidence to support the allegation of medication mishandling. The allegation was determined to be unsubstantiated and no deficiencies were cited.

Report Facts
Staff interviewed: 11 Residents interviewed: 10 Capacity: 240 Census: 176

Employees mentioned
NameTitleContext
Daisy CeballosDirector of Resident CareMet with Licensing Program Analyst during investigation and named in report
Felisa ShirleyLicensing Program AnalystConducted the complaint investigation visit
Stephanie CifuentesSupervisorSupervisor overseeing the investigation

Inspection Report

Annual Inspection
Census: 174 Capacity: 240 Deficiencies: 2 Date: May 22, 2025

Visit Reason
The inspection was an unannounced annual required visit conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements for the facility.

Findings
The facility was generally clean, sanitary, and appropriately furnished with adequate storage and safety measures. However, deficiencies were found including water temperatures exceeding the regulatory maximum and medication administration discrepancies.

Deficiencies (2)
Water temperature over 125°F, 124°F and 123°F, exceeding the maximum allowed 120°F.
Resident without medication for a couple of days.
Report Facts
Residents' service files reviewed: 10 Staff personnel files reviewed: 5 Medication Administration Records reviewed: 10 Fire/Disaster Drills last conducted: Apr 17, 2025 Capacity: 240 Census: 174

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorMet with Licensing Program Analyst during inspection and named in findings
Alfonso IniguezLicensing Program AnalystConducted the inspection and authored the report
Eva M AlvarezLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Annual Inspection
Census: 174 Capacity: 240 Deficiencies: 2 Date: May 22, 2025

Visit Reason
The inspection was an unannounced annual required visit conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements for the facility.

Findings
The facility was found to be generally clean, sanitary, and appropriately furnished with adequate food supplies and operational safety equipment. However, deficiencies were cited related to water temperature exceeding regulatory limits and medication management issues.

Deficiencies (2)
Water temperature over 125F°, 124F° and 123F°.
Resident without medication for a couple of days.
Report Facts
Deficiencies cited: 2 Fine amount: 100 Units inspected: 10 Units inspected: 10 Residents' service files reviewed: 10 Staff personnel files reviewed: 5 Medication Administration Records reviewed: 10 Fire/Disaster Drills date: Apr 17, 2025

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorMet with Licensing Program Analyst during inspection and named in findings
Alfonso IniguezLicensing Program AnalystConducted the inspection and authored the report
Eva M AlvarezLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Complaint Investigation
Census: 175 Capacity: 240 Deficiencies: 0 Date: Mar 6, 2025

Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2025-02-18 regarding allegations of inadequate food service, unsafe food handling, discouragement of residents from reporting, yelling at residents, and lack of cleanliness in the facility.

Complaint Details
The complaint included allegations that facility staff did not provide adequate food service, did not ensure safe food handling, discouraged residents from reporting, yelled at residents, and did not keep the facility clean. After interviews with residents, staff, witnesses, and review of documents and observations, the allegations were found to be unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found that the facility provides adequate and well-balanced meals, staff are certified in safe food handling, residents and witnesses reported no discouragement from reporting or yelling by staff, and the facility is kept clean according to schedules and observations. Therefore, all allegations were found to be unsubstantiated.

Report Facts
Residents interviewed: 13 Witnesses interviewed: 14 Staff interviewed: 15 Resident rooms inspected: 15 Public restrooms inspected: 5 Facility capacity: 240 Facility census: 175

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorInterviewed regarding allegations and findings
Alfonso IniguezLicensing Program AnalystConducted the complaint investigation
Eva M AlvarezLicensing Program ManagerOversaw the complaint investigation

Inspection Report

Complaint Investigation
Census: 175 Capacity: 240 Deficiencies: 0 Date: Mar 6, 2025

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2025-02-18 regarding inadequate food service, unsafe food handling, discouragement of residents from reporting, yelling at residents, and cleanliness issues at the facility.

Complaint Details
The complaint included allegations that facility staff did not provide adequate food service, did not ensure safe food handling, discouraged residents from reporting, yelled at residents, and did not keep the facility clean. After investigation including interviews and document reviews, all allegations were found to be unsubstantiated.
Findings
The investigation found that the facility provides adequate and well-balanced meals with proper food handling certifications and training. Interviews with residents, staff, and witnesses confirmed no discouragement from reporting, no yelling by staff, and that the facility is kept clean. The allegations were found to be unsubstantiated based on the evidence gathered.

Report Facts
Residents interviewed: 13 Staff interviewed: 15 Witnesses interviewed: 14 Residents rooms inspected: 15 Public restrooms inspected: 5

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorMet with during investigation and named in multiple allegation responses
Alfonso IniguezLicensing Program AnalystEvaluator conducting the complaint investigation

Inspection Report

Complaint Investigation
Census: 175 Capacity: 240 Deficiencies: 0 Date: Mar 4, 2025

Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations regarding medication assistance timeliness, cleanliness of resident rooms, and quality of food provided to residents.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not providing timely medication assistance, failure to keep resident rooms clean, and providing poor quality food with small portions. After interviews, observations, and record reviews, the department found no preponderance of evidence to prove the alleged violations.
Findings
The investigation found no sufficient evidence to substantiate any of the allegations. Interviews with staff and residents, observations, and record reviews indicated that medication was administered timely, rooms and facility were kept clean, and food quality and portions were adequate.

Report Facts
Staff interviewed: 8 Residents interviewed: 10 Rooms inspected: 9 Medication Administration Records reviewed: 31

Employees mentioned
NameTitleContext
Elvira GonzalezLicensing Program AnalystConducted the complaint investigation and interviews
Chris SchroederExecutive DirectorFacility representative met during investigation and exit interview

Inspection Report

Complaint Investigation
Census: 175 Capacity: 240 Deficiencies: 0 Date: Mar 4, 2025

Visit Reason
An unannounced complaint investigation was conducted to investigate allegations that staff did not provide timely medication assistance, did not keep residents' rooms clean, and did not provide good quality food to residents.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included untimely medication assistance, unclean resident rooms, and poor quality food. Interviews with staff and residents, medication administration record reviews, and facility inspections did not find sufficient evidence to support the allegations.
Findings
The investigation included interviews with staff and residents, record reviews, and facility inspections. No sufficient evidence was found to substantiate any of the allegations; all were determined to be unsubstantiated.

Report Facts
Staff interviewed: 8 Residents interviewed: 10 Rooms inspected: 9 Medication Administration Records reviewed: 31

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorMet with Licensing Program Analyst during investigation and named in findings
Elvira GonzalezLicensing Program AnalystConducted the complaint investigation

Inspection Report

Census: 177 Capacity: 240 Deficiencies: 0 Date: Nov 21, 2024

Visit Reason
The visit was a Case Management visit conducted to review compliance with privacy regulations regarding surveillance cameras and adherence to admission requirements under section 1569.153 of the Health and Safety Code.

Findings
No deficiencies were observed during the visit. The facility's surveillance system was confirmed to have no audio capabilities, and the facility was found to be in compliance with admission regulations.

Report Facts
Residents' files reviewed: 17

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorMet with Licensing Program Analyst during the Case Management visit and reviewed surveillance system and residents' files
Alfonso IniguezLicensing Program AnalystConducted the Case Management visit and reviewed compliance with regulations
Eva M AlvarezLicensing Program ManagerNamed in the report as Licensing Program Manager

Inspection Report

Census: 177 Capacity: 240 Deficiencies: 0 Date: Nov 21, 2024

Visit Reason
The visit was a Case Management visit conducted by Licensing Program Analyst Alfonso Iniguez to review an incident involving a resident pushing another resident, causing a fall, and to assess the facility's response and compliance.

Findings
No deficiencies were observed during the visit, and no citations were issued. The facility promptly assisted the residents involved in the incident and followed up with the primary care physician and families. The Executive Director stated this was the first time the resident exhibited aggressive behavior.

Report Facts
Capacity: 240 Census: 177

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorMet during the visit and provided information about the incident and resident behavior
Alfonso IniguezLicensing Program AnalystConducted the Case Management visit and reviewed documentation
Eva M AlvarezLicensing Program ManagerNamed in the report as Licensing Program Manager

Inspection Report

Census: 177 Capacity: 240 Deficiencies: 0 Date: Nov 21, 2024

Visit Reason
The visit was a Case Management visit conducted by Licensing Program Analyst Alfonso Iniguez to review compliance with prior issues related to surveillance camera audio capabilities and admission of new residents.

Findings
No deficiencies were observed during the visit. The facility was found to be in compliance with the Health and Safety Code regarding surveillance cameras and admission of new residents, and no citations were issued.

Report Facts
Residents' files reviewed: 17

Employees mentioned
NameTitleContext
Alfonso IniguezLicensing Program AnalystConducted the Case Management visit and reviewed compliance issues
Chris SchroederExecutive DirectorMet with Licensing Program Analyst during the visit and reviewed surveillance system and residents' files

Inspection Report

Census: 177 Capacity: 240 Deficiencies: 0 Date: Nov 21, 2024

Visit Reason
The visit was a Case Management visit conducted by Licensing Program Analyst Alfonso Iniguez to address an incident reported on 11/7/24 involving a resident pushing another resident, causing a fall.

Findings
No deficiencies were observed during the visit, and no citations were issued. The Executive Director stated this was the first time the resident exhibited aggressive behavior, and a new physician's report will be completed.

Report Facts
Facility capacity: 240 Resident census: 177

Employees mentioned
NameTitleContext
Alfonso IniguezLicensing Program AnalystConducted the Case Management visit and reviewed the physician's report
Chris SchroederExecutive DirectorMet with Licensing Program Analyst during the visit and provided information about the incident and resident behavior

Inspection Report

Census: 174 Capacity: 240 Deficiencies: 0 Date: Aug 30, 2024

Visit Reason
An unannounced Case Management visit was conducted following reports of a male dressed as a service worker entering community care facilities in the Westwood area.

Findings
The Licensing Program Analysts conducted a health and safety check, reviewed staff and resident rosters, observed video footage of the intruder, and reviewed staff in-service training. No deficiencies were observed and no citations were issued.

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorMet with Licensing Program Analysts during the visit and provided information about the incident and facility procedures.
Alfonso IniguezLicensing Program AnalystConducted the inspection and signed the report.
Yolanda RosserLicensing Program AnalystConducted the inspection.
Eva M AlvarezLicensing Program ManagerNamed as Licensing Program Manager on the report.

Inspection Report

Census: 174 Capacity: 240 Deficiencies: 0 Date: Aug 30, 2024

Visit Reason
An unannounced Case Management visit was conducted following reports of a male dressed as a service worker entering community care facilities in the Westwood area.

Findings
The Licensing Program Analysts conducted a health and safety check, reviewed staff and resident rosters, observed video recordings of the intruder event, and reviewed staff in-service training. No deficiencies or citations were observed or issued at this time.

Report Facts
Capacity: 240 Census: 174

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorMet with Licensing Program Analysts during the visit and provided information about the incident and facility procedures.
Alfonso IniguezLicensing EvaluatorConducted the inspection visit.
Eva M AlvarezSupervisorSupervisor overseeing the licensing evaluation.

Inspection Report

Annual Inspection
Census: 174 Capacity: 240 Deficiencies: 0 Date: May 23, 2024

Visit Reason
The inspection was an unannounced annual required visit conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations.

Findings
The facility was found to be clean, sanitary, and appropriately furnished with no observed deficiencies. All safety equipment was operable, infection control practices were followed, and medication administration records showed no discrepancies.

Report Facts
Units inspected: 10 Units inspected: 10 Fire/Disaster Drill date: Apr 25, 2024 Fire department inspection date: Mar 29, 2024

Employees mentioned
NameTitleContext
Alfonso IniguezLicensing Program AnalystConducted the inspection and authored the report
Chris SchroederExecutive DirectorFacility representative met during inspection and received report
Eva M AlvarezLicensing Program ManagerNamed in the report as Licensing Program Manager

Inspection Report

Annual Inspection
Census: 174 Capacity: 240 Deficiencies: 0 Date: May 23, 2024

Visit Reason
The inspection was an unannounced annual required visit conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations.

Findings
The facility was found to be clean, sanitary, and appropriately furnished with no observed deficiencies. All safety equipment was operable, infection control practices were followed, and resident and staff files were maintained in order. No citations were issued.

Report Facts
Units inspected: 10 Units inspected: 10 Residents' service files reviewed: 10 Staff personnel files reviewed: 10 Medication Administration Records reviewed: 10 Facility capacity: 240 Current census: 174 Fire/Disaster Drill date: Apr 25, 2024 Fire department inspection date: Mar 29, 2024

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorMet with Licensing Program Analyst during inspection and received report
Alfonso IniguezLicensing Program AnalystConducted the inspection visit
Eva M AlvarezSupervisorSupervisor overseeing the inspection

Inspection Report

Complaint Investigation
Census: 56 Capacity: 240 Deficiencies: 0 Date: Mar 27, 2024

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff did not assist residents with wearing clean clothing, incontinence care, showering, meeting dietary needs, and using hearing aids.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to assist residents with wearing clean clothing, incontinence care, showering, dietary needs, and hearing aid use. Interviews and record reviews showed residents were either independent or received appropriate assistance, and refusals were documented and communicated to family and physicians.
Findings
The investigation included interviews with the administrator, staff, residents, and review of records. The evidence did not substantiate the allegations; residents and staff confirmed that assistance was provided as needed, and residents were generally independent or received appropriate support. The allegations were found to be unsubstantiated.

Report Facts
Capacity: 240 Census: 56 Number of allegations: 5 Number of residents interviewed: 6 Number of staff interviewed: 5

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorAdministrator interviewed regarding complaint allegations and findings
Alfonso IniguezLicensing Program AnalystInvestigator who conducted the complaint investigation
Eva M AlvarezLicensing Program ManagerManager overseeing the complaint investigation report

Inspection Report

Complaint Investigation
Census: 56 Capacity: 240 Deficiencies: 0 Date: Mar 27, 2024

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff did not assist residents with wearing clean clothing, incontinence care, showering, meeting dietary needs, and using hearing aids.

Complaint Details
The complaint alleged failures by facility staff to assist residents with wearing clean clothing, incontinence care, showering, dietary needs, and hearing aid use. After investigation, these allegations were found to be unsubstantiated due to insufficient evidence.
Findings
The investigation included interviews with the administrator, staff, residents, and review of records. The evidence did not substantiate the allegations; residents generally manage their own care or receive appropriate assistance, and the facility has procedures in place to support resident needs.

Report Facts
Capacity: 240 Census: 56

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorAdministrator interviewed regarding complaint allegations and findings
Alfonso IniguezLicensing EvaluatorConducted the complaint investigation

Inspection Report

Annual Inspection
Census: 181 Capacity: 240 Deficiencies: 1 Date: Jun 14, 2023

Visit Reason
An unannounced Annual visit was conducted as part of case management to evaluate compliance with licensing requirements and infection control practices.

Findings
The facility was found to have proper infection control practices, adequate resident accommodations, and proper medication management. Several staff files were missing required records, resulting in technical assistance deficiencies issued during the visit.

Deficiencies (1)
Several staff files were missing required records: LIC508, LIC503, LIC501, LIC9052.
Report Facts
Residents on hospice: 7 Units in facility: 176 Two-bedroom units: 31

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorMet with Licensing Program Analyst during inspection and named in findings
David EspañaLicensing Program AnalystConducted the inspection
Ulysses CoronelLicensing Program ManagerNamed in report header and signature

Inspection Report

Annual Inspection
Census: 181 Capacity: 240 Deficiencies: 1 Date: Jun 14, 2023

Visit Reason
An unannounced annual case management visit was conducted to evaluate compliance with licensing requirements and infection control practices at Belmont Village Westwood.

Findings
The facility was found to have appropriate infection control measures, proper medication storage and administration, and adequate resident and staff files, although some staff records were missing specific documentation. Deficiencies issued were technical assistance in nature.

Deficiencies (1)
Several staff records were missing required documentation including LIC508, LIC503, LIC501, and LIC9052.
Report Facts
Residents on hospice: 7 Facility units: 176 Two-bedroom units: 31

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorMet during inspection and informed about staff record deficiencies
David EspañaLicensing Program AnalystConducted the inspection
Ulysses CoronelSupervisorSupervisor overseeing the inspection

Inspection Report

Annual Inspection
Census: 181 Capacity: 240 Deficiencies: 0 Date: Jun 13, 2023

Visit Reason
The visit was an unannounced required annual inspection of Belmont Village Westwood to assess compliance with licensing regulations.

Findings
The Licensing Program Analyst conducted a facility tour observing infection control practices, physical plant conditions, and resident accommodations. The facility was found to have appropriate infection control measures, adequate resident room furnishings, and safe common areas. The visit was not completed due to time constraints and will be resumed.

Report Facts
Residents on hospice: 7 Units in facility: 176 Two-bedroom units: 31

Employees mentioned
NameTitleContext
Chris SchroederAdministrator / Executive DirectorMet with Licensing Program Analyst during inspection and received report copy
David EspañaLicensing Program AnalystConducted the unannounced annual inspection visit
Ulysses CoronelLicensing Program ManagerNamed in report header

Inspection Report

Annual Inspection
Census: 181 Capacity: 240 Deficiencies: 0 Date: Jun 13, 2023

Visit Reason
The visit was an unannounced required annual inspection of Belmont Village Westwood to assess compliance with licensing requirements.

Findings
The inspection included a risk assessment, verification of infection control practices, review of facility physical plant and medication, and observation of resident living areas. The facility was found to have appropriate infection control measures, adequate resident accommodations, and no immediate hazards noted. The visit was not completed due to time constraints and will be resumed.

Report Facts
Residents on hospice: 7 Facility units: 176 Two-bedroom units: 31

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorMet with Licensing Program Analyst during the inspection and received the report copy
David EspañaLicensing Program AnalystConducted the unannounced annual inspection visit

Inspection Report

Complaint Investigation
Census: 171 Capacity: 240 Deficiencies: 0 Date: Mar 9, 2023

Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility's physical plant is unsafe, specifically concerning heavy or sharp objects on surfaces without anchoring.

Complaint Details
The complaint alleged that life-threatening heavy or sharp objects on surfaces were not anchored, specifically bookcases and accent tables with ceramic pots and sharp-edge decorative materials. The Bureau of Fire Prevention inspected and recommended anchoring bookshelves to prevent falling hazards. The Executive Director confirmed a request was made to anchor all bookshelves. No health or safety violations were found, and the allegation was unsubstantiated.
Findings
The investigation found no sufficient evidence to support the allegation that the facility physical plant is unsafe. The Bureau of Fire Prevention did not find any fire safety violations, and the facility was found to be in compliance with Title 22 Regulations. The allegation was determined to be unsubstantiated.

Report Facts
Facility capacity: 240 Census: 171

Employees mentioned
NameTitleContext
Ernand DabuetLicensing Program AnalystConducted the complaint investigation visit
Chris SchroederExecutive Director met during the investigation and exit interview

Inspection Report

Complaint Investigation
Census: 171 Capacity: 240 Deficiencies: 0 Date: Mar 9, 2023

Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility's physical plant is unsafe, specifically concerning heavy or sharp objects on surfaces without anchoring.

Complaint Details
The complaint alleged that life-threatening heavy or sharp objects on surfaces were not anchored, posing a safety risk. The Bureau of Fire Prevention inspected and recommended anchoring bookshelves to prevent falling items. The allegation was unsubstantiated due to lack of evidence.
Findings
The investigation found no sufficient evidence to support the allegation. The facility was cleared of COVID-19 infection, and the Bureau of Fire Prevention did not find any fire or safety code violations. The Executive Director stated that management would anchor all bookshelves to the wall as a precaution.

Report Facts
Facility capacity: 240 Census: 171

Employees mentioned
NameTitleContext
Ernand DabuetLicensing Program AnalystConducted the complaint investigation
Chris SchroederExecutive DirectorMet with the Licensing Program Analyst and provided information during the investigation
James ArpAdministratorFacility administrator named in the report

Inspection Report

Annual Inspection
Census: 176 Capacity: 240 Deficiencies: 0 Date: Nov 30, 2022

Visit Reason
The visit was an unannounced required annual inspection with a primary focus on Infection Control measures using the new CARE Inspection Tools.

Findings
The facility was found to have 9 active Covid-19 cases with an approved mitigation plan. Infection control practices, physical plant conditions, safety measures, and sanitation were observed and found compliant. No deficiencies were cited during the visit.

Report Facts
Active Covid-19 cases: 9 Residents on hospice: 6 Facility units: 176 Two-bedroom units: 31

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorMet with Licensing Program Analyst during inspection and received report copy
Troy AgardLicensing Program AnalystConducted the inspection visit
Ulysses CoronelLicensing Program ManagerNamed in report header and signature section

Inspection Report

Annual Inspection
Census: 176 Capacity: 240 Deficiencies: 0 Date: Nov 30, 2022

Visit Reason
The visit was an unannounced required annual inspection with a primary focus on Infection Control measures using the new CARE Inspection Tools.

Findings
The facility was found to be in compliance with no deficiencies cited. Infection control practices, physical plant conditions, safety measures, and regulatory requirements were all observed to be satisfactory.

Report Facts
Active Covid-19 cases: 9 Residents on hospice: 6 Facility units: 176 Two-bedroom units: 31

Employees mentioned
NameTitleContext
Chris SchroederExecutive DirectorMet with Licensing Program Analyst during the inspection and received the exit interview
Troy AgardLicensing Program AnalystConducted the inspection and evaluation
Ulysses CoronelSupervisorSupervisor overseeing the inspection

Inspection Report

Complaint Investigation
Capacity: 240 Deficiencies: 0 Date: Apr 7, 2022

Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff stole a resident's belongings.

Complaint Details
The allegation was that staff stole a resident's ring. The investigation revealed no reports of stolen property to facility staff, and interviews with five staff members and five residents found no evidence of theft. The allegation was found to be unsubstantiated.
Findings
The investigation found no preponderance of evidence to substantiate the allegation of staff stealing resident's belongings. Interviews with staff and residents, review of records, and observations supported an unsubstantiated finding.

Report Facts
Facility capacity: 240

Employees mentioned
NameTitleContext
Ann Margaret ZavelaDirector of Resident Care ServicesMet during the investigation and named in the exit interview
James ArpAdministrator / Executive DirectorUnavailable during visit but spoke via landline and confirmed no reports of theft
Elizabeth CenicerosLicensing Program Analyst / Retired AnnuitantConducted the complaint investigation visit
Troy AgardLicensing Program AnalystConducted initial 10-day visit related to the complaint

Inspection Report

Complaint Investigation
Capacity: 240 Deficiencies: 0 Date: Apr 7, 2022

Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that the facility changed a resident's medication without consent.

Complaint Details
Allegation: Facility changed resident's medication without consent. The allegation was unsubstantiated after investigation.
Findings
The investigation found that the facility administered medication (Xanax) to Resident #1 based on a physician's order, but the resident's responsible person was not fully informed about the medication change. After review of evidence and interviews, the allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

Report Facts
Facility capacity: 240

Employees mentioned
NameTitleContext
Elizabeth CenicerosLicensing Program Analyst/Retired AnnuitantConducted the complaint investigation visit and authored the report
James ArpAdministrator/Executive DirectorFacility administrator involved in communication during investigation
Ann Margaret ZavelaDirector of Resident Care ServicesMet with Licensing Program Analyst during the visit
Yul RapoportNeurologistFacility attending group physician who prescribed the medication (Xanax) to Resident #1
Elizabeth WhitmanPrimary Care PhysicianDiscontinued the medication (Xanax) for Resident #1

Inspection Report

Complaint Investigation
Capacity: 240 Deficiencies: 0 Date: Apr 7, 2022

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff stole a resident's belongings.

Complaint Details
The allegation was that staff stole a resident's ring. The investigation revealed no reports of stolen property to the facility, and the allegation was based on hearsay. Interviews with five staff members and five residents found no reports or evidence of stolen property. The facility has a posted 'Theft and Loss' Program. The allegation was found to be unsubstantiated.
Findings
The investigation found no substantiated evidence that staff stole resident belongings. Interviews with staff and residents, review of records, and observations did not support the allegation, which was therefore found to be unsubstantiated.

Report Facts
Facility capacity: 240 Number of staff interviewed: 5 Number of residents interviewed: 5

Employees mentioned
NameTitleContext
Elizabeth CenicerosLicensing Program Analyst/Retired AnnuitantConducted the complaint investigation visit and authored the report
Ann Margaret ZavelaDirector of Resident Care ServicesMet with evaluator during visit and received complaint report copy
James ArpExecutive Director/AdministratorFacility administrator unavailable during visit; provided information via phone

Inspection Report

Complaint Investigation
Capacity: 240 Deficiencies: 0 Date: Apr 7, 2022

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility changed a resident's medication without consent.

Complaint Details
The complaint alleged that the facility changed a resident's medication without consent. The investigation was unsubstantiated as evidence did not prove the alleged violation occurred.
Findings
The investigation found that the facility administered medication (Xanax) prescribed by a neurologist to Resident #1 without the responsible person's prior knowledge, but based on physician's orders on file. After review of evidence and interviews, the allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

Report Facts
Facility capacity: 240

Employees mentioned
NameTitleContext
Elizabeth CenicerosLicensing Program Analyst/Retired AnnuitantConducted the complaint investigation visit and authored the report
James ArpExecutive Director/AdministratorFacility administrator involved in the investigation
Ann Margaret ZavelaDirector of Resident Care ServicesFacility staff member met during the investigation and recipient of the complaint report

Inspection Report

Complaint Investigation
Census: 176 Capacity: 240 Deficiencies: 0 Date: Jan 11, 2022

Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that the facility was not following quarantine/isolation guidelines, staff were not trained to care for residents with COVID-19, and the administrator was not demonstrating good character.

Complaint Details
The complaint investigation addressed three allegations: 1) Facility not following quarantine/isolation guidelines; 2) Staff not trained to care for residents with COVID-19; 3) Administrator not demonstrating good character. All allegations were found unsubstantiated after interviews and record reviews.
Findings
The investigation found that all allegations were unsubstantiated based on interviews with staff and residents, review of training and PPE protocols, and observation of infection control measures. Staff and residents denied the allegations, and the facility demonstrated appropriate COVID-19 precautions and training.

Report Facts
Capacity: 240 Census: 176 Complaint control number: 11-AS-20220105120439

Employees mentioned
NameTitleContext
James ArpAdministrator / Executive DirectorMet with Licensing Program Analyst during investigation and was subject of character allegation
Troy AgardLicensing Program AnalystConducted the complaint investigation
Angela J KendrickLicensing Program ManagerOversaw the complaint investigation

Inspection Report

Complaint Investigation
Census: 176 Capacity: 240 Deficiencies: 0 Date: Jan 11, 2022

Visit Reason
The visit was an unannounced complaint investigation initiated due to allegations that the facility was not following quarantine/isolation guidelines, staff were not trained to care for residents with COVID-19, and the administrator was not demonstrating good character.

Complaint Details
The complaint investigation was initiated based on allegations that the facility was not following quarantine/isolation guidelines, staff were not trained to care for residents with COVID-19, and the administrator was not demonstrating good character. The investigation found all allegations unsubstantiated after interviews and record reviews.
Findings
The investigation included interviews with staff and residents, review of training and PPE protocols, and observation of infection control measures. All allegations were denied by staff and residents, and no preponderance of evidence was found to substantiate the complaints. The report concluded the allegations were unsubstantiated.

Report Facts
Capacity: 240 Census: 176 Number of allegations: 3 Number of staff interviewed: 7 Number of residents interviewed: 5

Employees mentioned
NameTitleContext
James ArpExecutive Director / AdministratorMet with Licensing Program Analyst during complaint investigation and named in allegations
Troy AgardLicensing Program AnalystConducted the complaint investigation
Angela J KendrickSupervisorSupervisor overseeing the complaint investigation

Inspection Report

Annual Inspection
Census: 170 Capacity: 240 Deficiencies: 0 Date: Jun 8, 2021

Visit Reason
The visit was an unannounced required annual inspection with a primary focus on Infection Control measures using the new CARE Inspection Tools.

Findings
The facility was found to be clear of Covid-19 infection with an approved mitigation plan. Infection control practices were observed to be adequate, PPE supplies were available, and the physical plant was in good condition. No deficiencies were cited during the visit.

Report Facts
Residents on hospice: 14 Facility units: 176 Two-bedroom units: 31

Employees mentioned
NameTitleContext
James ArpExecutive DirectorMet with Licensing Program Analyst during inspection and received exit interview
Ann ZavelaDirector of Resident CareJoined the Licensing Program Analyst during the facility tour
Troy AgardLicensing Program AnalystConducted the inspection visit
Angela J KendrickLicensing Program ManagerNamed in the report

Inspection Report

Annual Inspection
Census: 170 Capacity: 240 Deficiencies: 0 Date: Jun 8, 2021

Visit Reason
The visit was an unannounced required annual inspection with a primary focus on Infection Control measures using the new CARE Inspection Tools.

Findings
The facility was found to be clear of Covid-19 infection with approved mitigation plans in place. Infection control practices, physical plant, medication storage, and safety equipment were all observed to be in compliance. No deficiencies were cited during the visit.

Report Facts
Residents on hospice: 14 Facility units: 176 Two-bedroom units: 31

Employees mentioned
NameTitleContext
James ArpExecutive DirectorMet with Licensing Program Analyst during inspection and received exit interview
Ann ZavelaDirector of Resident CareJoined the Licensing Program Analyst during the facility tour

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