Most inspections found no deficiencies, with several complaint investigations determined to be unsubstantiated. The facility generally maintained safe conditions, proper staffing, and adequate infection control measures over time. The most recent report from October 28, 2025, cited two serious deficiencies related to personnel records, specifically missing health screenings and lack of current CPR/First Aid certification for staff, which posed immediate health and safety risks. Prior annual inspections were clean, indicating a recent decline in compliance with staff documentation requirements. Other issues raised in complaints were either unsubstantiated or minor, showing no clear pattern of ongoing problems.
The visit was an unannounced required comprehensive annual inspection conducted by Licensing Program Analysts to evaluate compliance with licensing requirements.
Findings
The facility was found to be operating within approved capacity and in generally good condition with adequate staffing and supplies. However, two Type A deficiencies were cited related to personnel records: missing health screenings and lack of current CPR/First Aid certification for staff, posing immediate health and safety risks.
Severity Breakdown
Type A: 2
Deficiencies (2)
Description
Severity
Personnel records did not include required health screenings for staff, posing an immediate health, safety, or personal rights risk to persons in care.
Type A
Staff on each shift did not have current CPR/First Aid certification, posing an immediate health, safety, or personal rights risk to persons in care.
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff improperly transferred a resident resulting in the resident's death.
Findings
The investigation included interviews and records review. The allegation was unsubstantiated due to lack of sufficient evidence, as records and medical documentation were unavailable and staff did not recall the incident. The allegation may have happened but there was no preponderance of evidence to prove it.
Complaint Details
The complaint alleged that staff improperly transferred a resident causing a fall, back fractures, and subsequent death about four months later. Interviews revealed a similar incident in 2018 involving Resident #1 who fell from an unlocked wheelchair, sustained fractures, was given medication, and later died. No medical or death records were obtained. Staff did not recall the incident due to its occurrence seven years prior. The allegation was unsubstantiated.
Report Facts
Complaint received date: Feb 16, 2021Number of staff interviews conducted: 2Number of fractures sustained by Resident #1: 3Resident #1 death date: Oct 10, 2018
Employees Mentioned
Name
Title
Context
Janira Arreola
Licensing Program Analyst
Conducted the complaint investigation visit and authored the report
Cristina Miller
Director
Facility Director met with Licensing Program Analyst during investigation
The visit was an unannounced required comprehensive annual inspection conducted by the Licensing Program Analyst to evaluate the facility's compliance with regulations.
Findings
The facility was found to be operating within approved capacity and in safe, clean conditions with no deficiencies cited. All physical plant, food service, and care and supervision standards were met, and client and staff files were reviewed and found current.
Report Facts
Client files reviewed: 4Staff files reviewed: 4
Employees Mentioned
Name
Title
Context
Bernadette Allen
Licensing Program Analyst
Conducted the inspection and signed the report
Christina Miller
Administrator
Facility representative met during inspection and received the report
The visit was an unannounced complaint investigation regarding an allegation that unqualified staff were administering insulin to residents.
Findings
The investigation found that insulin was administered only by medically qualified staff as documented in Medication Administration Records and staff records. Therefore, the allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged unqualified staff administering insulin to residents. The allegation was investigated and found unsubstantiated based on staff interviews and documentation review.
Report Facts
Capacity: 66Census: 54
Employees Mentioned
Name
Title
Context
Javier Prieto
Licensing Program Analyst
Conducted the complaint investigation
Brittany Butts
Resident Care Coordinator
Met with investigator and involved in investigation
Licensing Program Analyst Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection.
Findings
The facility was inspected inside and out, including client bedrooms, bathrooms, kitchen, and safety features. The facility was found to be well maintained, with safe food storage, proper medication administration, and all client and staff records in order.
Report Facts
Client bedrooms inspected: 5Client bathrooms inspected: 5Hot water temperature range: 105Hot water temperature range: 110
Employees Mentioned
Name
Title
Context
Susiani Halim
Executive Director
Met with Licensing Program Analyst during the inspection and received the report
An unannounced complaint investigation was conducted in response to an allegation that the facility did not correctly refund a resident.
Findings
After interviews, record review, and gathering evidence, it was determined that the resident's funds were refunded, and the allegation was deemed unfounded.
Complaint Details
The complaint allegation that the facility did not correctly refund the resident was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
Employees Mentioned
Name
Title
Context
Bernadette Allen
Evaluator / Licensing Program Analyst
Conducted the complaint investigation and delivered findings.
Susiani Halium
Administrator
Met with the Licensing Program Analyst during the investigation.
The visit was an unannounced required annual inspection with an emphasis on infection control due to the COVID-19 pandemic.
Findings
The inspection found no health or safety concerns and no deficiencies were cited. The facility demonstrated adequate infection control measures, including COVID-19 postings, hand hygiene supplies, symptom monitoring, and proper cleaning protocols.
Employees Mentioned
Name
Title
Context
Susiani Halium
Administrator
Met during inspection and confirmed no COVID-19 cases/exposures.
Bernadette Allen
Licensing Program Analyst
Conducted the unannounced annual inspection visit.
The visit was an unannounced required annual inspection with an emphasis on infection control due to the COVID-19 pandemic.
Findings
No health and safety concerns were observed during the inspection, and no deficiencies were cited. The facility demonstrated adequate infection control measures, sufficient PPE supplies, and proper staff training.
Report Facts
PPE supply duration: 30
Employees Mentioned
Name
Title
Context
Susiani Halium
Administrator
Facility Administrator who confirmed no COVID-19 cases and was present during the inspection
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff neglect contributed to a resident's death.
Findings
The investigation found that the resident was hospitalized from June 11, 2019 until their death on July 31, 2019, and a review of medical records did not indicate that the cause of death was related to neglect by the facility. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff neglect contributed to a resident's death. The investigation included interviews and medical record reviews. The allegation was found to be unsubstantiated due to lack of evidence linking neglect to the resident's death.
Report Facts
Facility capacity: 66Census: 49
Employees Mentioned
Name
Title
Context
Deborah Mullen
Licensing Program Analyst
Conducted the complaint investigation and unannounced visit
Susiani Halim
Executive Director
Met with the Licensing Program Analyst during the investigation
The Licensing Program Analyst conducted an unannounced health and safety tele-inspection to address concerns relating to complaint #18-AS-20200731095043.
Findings
No reports of concerns were received during resident interviews, and no health and safety concerns were observed at the time of the visit.
Complaint Details
Complaint #18-AS-20200731095043 was investigated; no substantiated concerns were found.
Employees Mentioned
Name
Title
Context
Stephanie Torres
Licensing Program Analyst
Conducted the tele-inspection and discussed the purpose of the call.
Yndira Lepe
Health Service Director
Facility representative who spoke with the Licensing Program Analyst during the inspection.
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