Inspection Reports for
Brethren Hillcrest Homes
2705 MOUNTAIN VIEW DRIVE, LA VERNE, CA, 91750
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
1.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Occupancy
Latest occupancy rate
26% occupied
Based on a October 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 151
Capacity: 574
Deficiencies: 0
Date: Oct 16, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-10-09 regarding staff mistreatment and neglect of residents at Brethren Hillcrest Homes.
Complaint Details
The complaint involved multiple allegations including residents being left in the sun causing sunburns, rough handling during oral care, removal of blankets, and failure to address injuries after a fall. All allegations were investigated through resident and staff interviews, record reviews, and observations. The allegations were found to be unsubstantiated due to lack of evidence.
Findings
The investigation found no evidence to substantiate the allegations of residents being left in the sun causing sunburns, rough handling during oral care, removal of residents' blankets, or failure to address injuries after a fall. Resident and staff interviews, document reviews, and observations supported that staff acted appropriately and residents' needs were met.
Report Facts
Capacity: 574
Census: 151
Resident interview counts: 10
Staff interview counts: 7
Hospital visit date: Oct 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Kasin | Director | Facility administrator and interviewee during investigation |
| Luis DeLeon | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
Inspection Report
Annual Inspection
Census: 277
Capacity: 574
Deficiencies: 0
Date: Aug 5, 2025
Visit Reason
The visit was an unannounced annual inspection conducted as a case management continuation to evaluate compliance with licensing requirements.
Findings
No deficiencies were observed during this inspection. The facility demonstrated compliance with infection control, personnel training, staffing, medication management, and resident record maintenance.
Report Facts
Hospice residents: 8
Personnel records reviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Kasin | Administrator | Met with during inspection and noted for Administrator Certificate expiration |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the inspection and observed compliance |
| Gabby Castro | Licensing Program Analyst | Conducted the inspection |
| Fernando Fierros | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 277
Capacity: 574
Deficiencies: 0
Date: Aug 1, 2025
Visit Reason
An unannounced required annual inspection was conducted to assess compliance with licensing requirements and regulatory standards.
Findings
The facility was found to be in compliance with no deficiencies cited at the time of inspection. Observations included safety measures, proper food service practices, resident activities, and residents' rights postings.
Report Facts
Hospice residents: 8
Ambulatory residents capacity: 14
Non-ambulatory residents capacity: 560
Hospice residents capacity: 15
Pinecrest census: 17
Cedar Court census: 10
Maple Court/Birch Court census: 49
Southwood Lodge Memory Care census: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Matthew Neeley | CEO | Met with Licensing Program Analyst during inspection and exit interview |
Inspection Report
Census: 307
Capacity: 574
Deficiencies: 0
Date: Jun 4, 2025
Visit Reason
The visit was an unannounced collateral visit to conduct interviews regarding a recent incident at a different licensed facility.
Findings
The Licensing Program Analyst conducted interviews with one resident about an incident at the resident's previous facility. An exit interview was conducted with the Director of Resident Care and a copy of the report was provided.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Desiree Eudave | Director of Resident Care | Met with Licensing Program Analyst during the visit and exit interview. |
| Mary G Flores | Licensing Program Analyst | Conducted the unannounced collateral visit and interviews. |
| Wei Siew Ho | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 574
Deficiencies: 1
Date: Feb 18, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff do not have adequate staffing to meet residents' needs, particularly during the overnight shift.
Complaint Details
The complaint was substantiated. The allegation that staff do not have adequate staffing to meet residents' needs during the overnight shift was confirmed by interviews with ten staff and six residents. Some residents reported delays up to forty-five minutes for staff response. The report was issued following an unannounced visit on 2025-02-18.
Findings
The allegation was substantiated based on interviews with staff and residents and record review. Several residents and staff confirmed insufficient staffing during the overnight shift, causing delays in resident assistance and potential risks to resident care.
Deficiencies (1)
CCR 87411(a) Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement was not met as staff interviews and resident reports confirmed insufficient staffing during the night shift.
Report Facts
Facility Capacity: 574
Resident Census: 51
Staff interviewed: 10
Residents interviewed: 6
Residents confirming staffing concerns: 4
Staff confirming staffing concerns: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Kasin | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Desiree Eudave | Supervisor | Met with Licensing Program Analyst during investigation and named in findings |
| Alberto Lopez | Licensing Program Analyst | Conducted complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 574
Deficiencies: 1
Date: Feb 18, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff do not have adequate staffing to meet residents' needs, particularly during the overnight shift.
Complaint Details
The complaint was substantiated. The allegation that staff do not have adequate staffing to meet residents' needs during the overnight shift was confirmed by interviews with ten staff and six residents. Some residents reported delays up to forty-five minutes for staff response. The investigation included review of staff schedules and resident medical documentation.
Findings
The allegation was substantiated based on interviews with staff and residents and record review. Several residents and staff confirmed insufficient staffing during the night shift, with delays in response times and staff being overworked, posing potential risks to residents.
Deficiencies (1)
CCR 87411(a) Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement was not met as staff interviews and resident reports confirmed insufficient staffing during the night shift.
Report Facts
Capacity: 574
Census: 51
Staff interviewed: 10
Residents interviewed: 6
Staff corroborating allegation: 7
Residents corroborating allegation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Kasin | Administrator | Met with Licensing Program Analyst during investigation and named in report |
| Alberto Lopez | Licensing Program Analyst | Conducted complaint investigation |
| Lisa Hicks | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 574
Deficiencies: 1
Date: Oct 25, 2024
Visit Reason
The visit was conducted as a complaint investigation regarding allegations that staff do not have adequate staffing to meet residents' needs during the overnight shift.
Complaint Details
The complaint alleged inadequate staffing to meet residents' needs during the overnight shift. The allegation was substantiated based on interviews with ten staff and six residents, with most corroborating the claim. Staff schedules from August and October 2024 showed limited overnight staffing. The preponderance of evidence standard was met.
Findings
The investigation found the allegation substantiated based on interviews with staff and residents, and review of staff schedules showing insufficient overnight staffing. Some staff and residents corroborated that assistance during overnight shifts is delayed and that security guards sometimes assist with resident care.
Deficiencies (1)
Staffing levels during the overnight shift are inadequate to meet residents' needs, requiring staff to leave assigned buildings and seek assistance from security guards. This results in delayed assistance to residents and insufficient coverage.
Report Facts
Facility Capacity: 574
Resident Census: 62
Staff interviewed: 10
Residents interviewed: 6
Staff corroborating allegation: 7
Residents corroborating allegation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alberto Lopez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Keith Kasin | Administrator | Facility administrator involved in the investigation |
| Desiree Eudave | Supervisor | Facility supervisor involved in the investigation |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 574
Deficiencies: 1
Date: Oct 15, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 08/08/2024 regarding staffing adequacy, resident supervision, and medication administration at Brethren Hillcrest Homes.
Complaint Details
The complaint investigation was substantiated for inadequate staffing during the overnight shift. Other allegations regarding pressure injuries, supervision, and medication training were unsubstantiated due to insufficient evidence.
Findings
The investigation found insufficient evidence to substantiate allegations of pressure injuries, inadequate supervision leading to residents wandering, and improper medication administration. However, the allegation that staff do not have adequate staffing to meet residents' needs during the overnight shift was substantiated.
Deficiencies (1)
CCR 87411(a) Personnel Requirements – General. Facility personnel are not sufficient in numbers to meet resident needs as overnight staff had to seek security guard assistance.
Report Facts
Capacity: 574
Census: 61
Staff interviewed: 10
Residents interviewed: 6
Plan of Correction due date: Oct 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alberto Lopez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Keith Kasin | Administrator | Facility administrator involved in interviews and exit process |
| Desiree Eudave | Supervisor | Facility supervisor involved in interviews and exit process |
Inspection Report
Annual Inspection
Census: 71
Capacity: 574
Deficiencies: 0
Date: Jul 13, 2024
Visit Reason
The inspection was a subsequent annual inspection conducted as part of case management and annual continuation to assess compliance with licensing requirements.
Findings
No deficiencies were observed during this inspection. The facility was found to be in compliance with operational requirements, infection control, personnel records training, staffing, medication management, and resident records maintenance.
Report Facts
Residents under hospice care: 6
Personnel records reviewed: 9
Personnel records with required annual training observed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the annual inspection and evaluation |
| Keith Kasin | Administrator | Facility administrator with certificate expiring 08/10/2024 |
| Lynn Palin | Director of Social Work | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Census: 71
Capacity: 574
Deficiencies: 0
Date: Jun 22, 2024
Visit Reason
The visit was a required annual unannounced inspection conducted to evaluate compliance with licensing regulations.
Findings
The inspection found the facility to be in compliance with no deficiencies cited. Observations included safety measures, proper food service practices, resident activities, and accommodations for residents with special needs.
Report Facts
Hospice residents: 6
Ambulatory residents capacity: 14
Non-ambulatory residents capacity: 560
Hospice residents capacity: 15
Rooms inspected: 10
Rooms in Southwoods Lodge Memory Care inspected: 3
Rooms in assisted living wing inspected: 7
Response time to emergency pull cord: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the annual inspection |
| Lynn Palin | Director of Social Work | Met with Licensing Program Analyst during inspection and exit interview |
| Dan Townsend | Director of Facility Operations | Assisted with facility tour during inspection |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 574
Deficiencies: 0
Date: Oct 24, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that a resident's refrigerator was in disrepair and that the facility lacked sufficient maintenance support staff over the weekend.
Complaint Details
The complaint was unsubstantiated. Allegations included a non-working resident refrigerator and insufficient weekend maintenance staff. Interviews with residents and staff, as well as observations, showed appliances were working and maintenance responded promptly. No preponderance of evidence was found to support the allegations.
Findings
The investigation found that the refrigerator was replaced within two hours of the report and was currently working. Staff and residents confirmed timely maintenance responses, including weekends. There was insufficient evidence to prove the alleged violations, so the complaint was unsubstantiated.
Report Facts
Capacity: 574
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Desiree Eudave | Director of Resident Care | Met with Licensing Program Analyst during investigation |
| Keith Kasin | Administrator | Facility administrator named in report header |
| Tony Vasallo | Licensing Program Manager | Named in report signature section |
Inspection Report
Annual Inspection
Capacity: 574
Deficiencies: 0
Date: Jul 21, 2023
Visit Reason
Licensing Program Analyst Tao conducted an unannounced annual inspection visit to evaluate compliance with licensing requirements.
Findings
The facility was found to be in compliance with all applicable regulations. No deficiencies were observed during the visit, and all safety, medication, and facility standards were met.
Report Facts
Hospice residents approved: 6
Ambulatory residents licensed: 14
Non-ambulatory residents licensed: 560
Hot water temperature range: 113.5
Hot water temperature range: 114.4
Facility temperature: 73
Fire extinguisher last service date: Dec 2, 2022
Inspection Report
Complaint Investigation
Census: 377
Capacity: 574
Deficiencies: 0
Date: Mar 6, 2023
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation that facility staff did not adequately supervise a resident, resulting in the resident being found outside with a head injury.
Complaint Details
The complaint alleged inadequate supervision of a resident who was found outside with a head injury. The resident was found within the locked memory care unit patio area after a fall. Staff interviews and record reviews were conducted. The complaint was unsubstantiated as evidence was insufficient to prove violations.
Findings
The investigation found that the resident was found within the memory care unit with a head injury after a fall. Staff confirmed hourly visual checks were conducted, but one auditory device was reported not working. The resident never left the memory care unit. The complaint was unsubstantiated due to lack of preponderance of evidence and no deficiencies were cited.
Report Facts
Capacity: 574
Census: 377
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Kasin | Executive Director | Met with Licensing Program Analyst during investigation |
| Desiree Eudave | Director of Resident Care | Met with Licensing Program Analyst during investigation |
| Valeria Maldonado | Licensing Program Analyst | Conducted the complaint investigation visit |
| Fernando Fierros | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 574
Deficiencies: 1
Date: Jan 13, 2023
Visit Reason
The visit was an unannounced complaint investigation regarding allegations that a resident sustained an unwitnessed fall resulting in a broken bone and that staff did not seek timely medical attention for the resident.
Complaint Details
The complaint investigation was triggered by allegations that a resident sustained an unwitnessed fall resulting in a broken bone and that staff did not seek timely medical attention. The fall allegation was unsubstantiated, but the failure to seek timely medical attention was substantiated.
Findings
The allegation of an unwitnessed fall resulting in a broken bone was unsubstantiated due to lack of preponderance of evidence. The allegation that staff did not seek timely medical attention was substantiated as staff failed to report the resident's fall and pain promptly, posing a potential risk to residents.
Deficiencies (1)
CCR 87466 requires residents to be regularly observed for changes in physical, mental, emotional, and social functioning. Staff failed to report or notify family or management about Resident #1's fall and complaint of pain, posing a potential risk to residents.
Report Facts
Total Capacity: 574
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Wong | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Matthew Neeley | Administrator | Facility administrator interviewed during investigation |
| Lynn Palin | MSW | Met with Licensing Program Analyst during investigation and exit interview |
| David Sicairos | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Census: 277
Capacity: 574
Deficiencies: 0
Date: Oct 10, 2022
Visit Reason
Licensing Program Analyst Mary Flores conducted a case management visit to follow up on an incident report submitted on 8/31/22 regarding an altercation between a resident and staff.
Findings
No deficiencies were noted during this visit. The investigation found no further action was needed after reviewing incident reports, interviews, and documentation.
Report Facts
Incident report date: Aug 31, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Flores | Licensing Program Analyst | Conducted the case management visit and investigation |
| Desiree Eudave | LVN | Met with Licensing Program Analyst during visit |
Inspection Report
Census: 309
Capacity: 574
Deficiencies: 0
Date: Sep 7, 2022
Visit Reason
The visit was a case management follow-up on an incident report regarding an altercation between a resident and staff.
Findings
No deficiencies were cited during the visit. Further investigation is needed, and the licensing analyst will return at a later time.
Inspection Report
Annual Inspection
Census: 58
Capacity: 574
Deficiencies: 0
Date: Jul 25, 2022
Visit Reason
Licensing Program Analyst Vasallo conducted an annual unannounced visit to evaluate the facility's compliance with regulations, including infection control and physical plant conditions.
Findings
The facility was found to be in compliance with all applicable regulations with no deficiencies observed. The physical plant, infection control procedures, resident medications, food supply, and staff records were all satisfactory.
Report Facts
Hospice residents: 4
Resident records reviewed: 6
Staff records reviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tony Vasallo | Licensing Program Analyst | Conducted the annual inspection visit |
| Dan Townsend | Facility Operations Director | Assisted with the tour of the facility during the inspection |
| Matthew Neeley | Administrator | Met with Licensing Program Analyst during the inspection |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 574
Deficiencies: 1
Date: Jun 14, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2021-03-25 regarding resident hygiene, staff communication with families, staffing sufficiency, and medication management.
Complaint Details
The complaint investigation addressed allegations that residents' hygiene needs were unmet, staff failed to communicate effectively with families, the facility lacked sufficient staff, and staff did not properly manage residents' medications. The first three allegations were unsubstantiated, while the medication management allegation was substantiated.
Findings
The investigation found the allegations about resident hygiene, staff communication, and staffing sufficiency to be unsubstantiated based on interviews and observations. However, the allegation regarding improper medication management was substantiated due to a resident not receiving prescribed medication for several days without documentation or explanation.
Deficiencies (1)
CCR 87465(j) requires designated staff to ensure residents receive needed medication and emergency services. Resident medication Quetiapine 25mg was not administered from June 5 to June 11, 2022, with no documented reason, posing a potential risk to residents.
Report Facts
Capacity: 574
Census: 68
Deficiencies cited: 1
POC Due Date: Jun 15, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Neeley | CEO | Facility CEO involved in investigation and exit interview |
| Christine Wong | Licensing Program Analyst | Investigator conducting complaint visit |
| Bennette Pena | Licensing Program Analyst | Investigator conducting complaint visit |
| Lynn Palin | Director of Social Work | Interviewed during investigation |
Inspection Report
Annual Inspection
Census: 62
Capacity: 574
Deficiencies: 3
Date: Jul 20, 2021
Visit Reason
Licensing Program Analysts conducted an annual required visit to evaluate the facility, including infection control, medication management, and safety compliance.
Findings
The inspection found issues with water temperatures in five bathrooms, medication administration errors involving three residents, and inoperable smoke alarms in the Birch Court side of the building.
Deficiencies (3)
CCR 87303(e)(2): Water temperatures in five bathrooms exceeded the required range, posing an immediate health and safety risk.
CCR 87465(c)(2): Medication administration errors were observed for three residents, including missed doses and incorrect documentation.
CCR 87303(a): Smoke alarms in the Birch Court side were not operable, posing a potential health and safety risk.
Report Facts
Bathrooms with water temperature issues: 5
Residents with medication errors: 3
Capacity: 574
Census: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Neeley | Administrator | Met with Licensing Program Analysts during the inspection and involved in findings. |
| Sue Fairley | Administrator | Met with Licensing Program Analysts during the inspection. |
| Dan Townsend | Director of Facility Operations | Met with Licensing Program Analysts during the inspection and involved in smoke alarm testing. |
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