Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, including recent ones in September 2025 and March 2025. The facility’s most recent report from September 17, 2025, had no deficiencies and involved an unsubstantiated investigation of a resident’s self-inflicted injury resulting in death. However, in February 2024, serious deficiencies were cited after an unauthorized male entered through a propped open door and sexually assaulted a resident, posing an immediate safety risk; this was the most severe event in the record. Other issues noted were minor or isolated, such as staff records lacking current First Aid certificates in October 2024 and advisory notes related to medication errors without formal deficiencies. Overall, the facility shows improvement with no deficiencies in the latest reports following the serious safety incident in early 2024.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 128
Capacity: 150
Deficiencies: 0
Sep 17, 2025
Visit Reason
The visit was conducted to deliver the findings of an investigation regarding a self-inflicted injury incident that resulted in the death of a resident.
Findings
The investigation concluded that the incident was unsubstantiated, with no deficiencies cited under California Code of Regulations Title 22.
Complaint Details
The complaint involved a resident (R1) who suffered a self-inflicted injury resulting in death. R1 was an independent living resident without mental health diagnoses or depression medications. The investigation found the complaint unsubstantiated.
Report Facts
Census: 128
Total Capacity: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit and delivered investigation findings |
| Maria Quintero | Met with Licensing Program Analyst during the visit and reviewed the report |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 150
Deficiencies: 0
Mar 19, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-01-04 alleging residents were not provided medications as prescribed, inadequate food service, lack of services to residents, and lack of activities.
Findings
Based on interviews with staff and residents and review of records, although some allegations may have occurred, there was insufficient evidence to substantiate the complaints. No deficiencies were cited under California Code of Regulations Title 22.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included residents not receiving medications as prescribed, inadequate food service, lack of services, and lack of activities. Multiple visits and interviews were conducted, including review of Medication Administration Records, care plans, and interviews with residents and staff. Some medication administration records had empty boxes, but explanations were provided. Residents generally reported receiving services and activities. No violations were substantiated.
Report Facts
Capacity: 150
Census: 128
Number of residents interviewed: 10
Number of food servers scheduled per day: 10
Number of cooks scheduled per day: 4
Number of care givers interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rod Moshiri | Administrator | Facility administrator interviewed during investigation |
| Maria Quintero | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 150
Deficiencies: 0
Dec 20, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-11-02 alleging multiple unexplained injuries to a resident, failure to seek timely medical attention, wrong medication dispensed, and failure to refill medication.
Findings
The investigation included interviews, review of care plans, medication logs, and physician reports. Although the allegations may have happened or be valid, there was insufficient evidence to substantiate the claims. No deficiencies were cited under California Code of Regulations Title 22.
Complaint Details
The complaint was unsubstantiated after investigation. Allegations included unexplained injuries, delayed medical attention, wrong medication dispensed, and failure to refill medication. Interviews with staff and administrators, review of care plans and logs, and examination of incident reports did not provide a preponderance of evidence to prove violations.
Report Facts
Complaint received date: Nov 2, 2022
Facility capacity: 150
Facility census: 121
Investigation visit date: Dec 20, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Maria Quintero | Administrator | Interviewed during investigation regarding care plan and medication issues |
| Mehrad Moshiri | Executive Director | Met during investigation and reviewed report findings |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 117
Capacity: 150
Deficiencies: 1
Oct 10, 2024
Visit Reason
The visit was conducted as the Annual 1-year required inspection to evaluate compliance with licensing regulations.
Findings
The facility was found to be generally compliant with safety and operational standards, including clear exits, functional fire extinguishers, and proper food storage. However, a deficiency was cited due to 2 out of 5 reviewed staff records lacking current First Aid certificates, posing a potential safety risk.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 2 out of 5 reviewed staff records did not contain a current First Aid certificate, posing a potential safety risk to persons in care. | Type B |
Report Facts
Residents' rooms inspected: 12
Bathrooms inspected: 12
Resident records reviewed: 5
Personnel records reviewed: 5
Staff without current First Aid certificate: 2
Food storage days required: 7
Food storage days required: 2
Hot water temperature range (°F): Measured between 106.7°F and 118.9°F
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mehrad Moshiri | Executive Director | Met with Licensing Program Analysts during inspection |
| Maria Quintero | Assistant Executive Director | Met with Licensing Program Analysts during inspection |
| Kiran Jain | Licensing Program Analyst | Conducted the inspection and signed the report |
| David Marrufo | Licensing Program Analyst | Conducted the inspection |
| April Cowan | Licensing Program Manager | Supervisor and named in report |
| Rod Moshiri | Executive Director | Reviewed the report with Licensing Program Analysts |
Inspection Report
Monitoring
Capacity: 150
Deficiencies: 0
Mar 28, 2024
Visit Reason
The visit was a case management visit regarding an incident report involving a resident.
Findings
The Licensing Program Analyst conducted a file review and requested copies of the resident's file including admission agreement, medication list, and physician's report. No deficiencies were cited during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Partoza | Licensing Program Analyst | Conducted the case management visit and file review. |
| Mehrad Moshiri | Administrator | Met with Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 150
Deficiencies: 2
Feb 13, 2024
Visit Reason
The visit was conducted to address an incident reported by the facility involving an unauthorized male who entered the facility through a propped open side exit door and sexually assaulted a resident on 01/07/2023.
Findings
The investigation found that staff did not supervise the side exit door which was propped open, allowing unauthorized access that led to the sexual assault of a resident. Residents were reported to open the exit doors to prevent them from locking, and staff ignored warnings from another resident about the unauthorized male's presence.
Complaint Details
The visit was complaint-related, triggered by a self-reported incident of suspected adult/elder abuse involving sexual assault of a resident by an unauthorized male who entered through a propped open side exit door. The Department investigated starting 01/11/2023, including interviews and record reviews.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff did not supervise the side door exit that had been left propped open, allowing an unauthorized male to enter the facility, posing an immediate safety risk to residents. | Type A |
| An unauthorized male entered the facility and sexually abused resident R1, posing an immediate safety risk to residents. | Type A |
Report Facts
Deficiencies cited: 2
Plan of Correction Due Date: Feb 14, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rod Moshiri | Administrator | Met during the visit and reviewed the report |
| David Marrufo | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
| Sarah Yip | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 150
Deficiencies: 0
Feb 13, 2024
Visit Reason
The visit was conducted to address incident reports filed by the facility concerning medication errors, including an unusual incident involving a medication technician giving another resident's morning medications to resident R1.
Findings
No deficiencies were cited at this time as per California Code of Regulations Title 22. An Advisory Note was issued regarding the medication errors.
Complaint Details
The visit was complaint-related, triggered by incident reports about medication errors. The incident involved a medication technician administering another resident's medications to resident R1. The facility was requested to submit a Plan of Action by 02/20/2024 to address staff training and prevention of medication errors.
Report Facts
Facility capacity: 150
Census: 113
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rod Moshiri | Administrator | Met with Licensing Program Analyst during the visit and discussed the report |
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit and authored the report |
Inspection Report
Census: 120
Capacity: 150
Deficiencies: 0
Jan 12, 2023
Visit Reason
The visit was an unannounced Case Management visit to obtain documents regarding an incident that occurred on 2023-01-07 and was self-reported by the facility.
Findings
No deficiencies were cited at this time as per California Code of Regulations Title 22. Copies of relevant medical documents were obtained and the report was reviewed with the facility administrator.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rod Moshiri | Administrator | Met with Licensing Program Analyst during the visit and reviewed the report. |
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit and obtained documents. |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 121
Capacity: 150
Deficiencies: 0
Dec 1, 2022
Visit Reason
The inspection was an unannounced Required - 1 Year visit to evaluate the facility's compliance with regulations.
Findings
No deficiencies were cited during the inspection. Observations included visitor screening, adequate PPE and cleaning supplies, perishable food supply, and contracted meal preparation during kitchen construction.
Report Facts
PPE supply duration: 30
Perishable food supply duration: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the inspection and made observations |
| Donna Daniel-Herr | Interim Executive Director | Met with Licensing Program Analyst during inspection and reviewed report |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 150
Deficiencies: 0
Dec 1, 2022
Visit Reason
The visit was conducted to investigate a medication error reported by the facility via an Unusual Incident Report related to a missing narcotic medication for resident R1.
Findings
The investigation found that the missing medication was logged but never administered, and the facility staff did not know what happened to it. No deficiencies were cited, but an Advisory Note was issued regarding medication count procedures.
Complaint Details
The visit was triggered by a complaint regarding a medication error involving a missing narcotic medication for resident R1. The complaint was investigated through interviews and record reviews. No deficiencies were cited, and the complaint was not substantiated with violations.
Report Facts
Capacity: 150
Census: 121
Date of incident: Nov 10, 2022
Date reported: Nov 16, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Daniel-Herr | Interim Executive Director | Met with Licensing Program Analyst during visit and involved in medication error investigation |
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit and investigation |
Inspection Report
Annual Inspection
Census: 109
Capacity: 150
Deficiencies: 0
Dec 3, 2021
Visit Reason
The inspection was an unannounced Required 1 Year visit to evaluate the facility's compliance with regulations.
Findings
The Licensing Program Analyst observed proper visitor screening, hand hygiene signage, adequate PPE and food supplies, and COVID-19 safety measures. No deficiencies were cited as per California Code of Regulations Title 22.
Report Facts
Capacity: 150
Census: 109
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the inspection and observations |
| Maria Quintero | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 150
Deficiencies: 0
Aug 20, 2021
Visit Reason
The Department conducted an unannounced Case Management visit following a death report regarding resident R1's self-inflicted gunshot wound and investigated allegations of neglect and lack of supervision.
Findings
The investigation found no deficiencies or substantiated neglect; staff interviews and record reviews indicated the resident did not show suicidal behavior and did not require safety checks. The allegation was determined to be unfounded.
Complaint Details
Investigation was conducted due to a death report alleging neglect and lack of supervision resulting in resident R1's death by self-inflicted gunshot wound. The investigation was found to be unfounded.
Report Facts
Staff interviewed: 6
Resident interviewed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit and investigation |
| Jayden Bettencourt | Wellness Director | Met with Licensing Program Analyst during visit and reviewed report |
| Maria Quintero | Administrator | Facility Administrator named in report header |
Inspection Report
Census: 98
Capacity: 150
Deficiencies: 0
Jun 1, 2021
Visit Reason
The visit was an unannounced Case Management visit to inquire about a death that occurred at the facility, following submission of a death report on 05/28/2021.
Findings
During the visit, Licensing Program Analysts interviewed the Administrator and reviewed relevant documents related to the deceased resident. No deficiencies were cited as per California Code of Regulations Title 22.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Quintero | Administrator | Interviewed during the visit regarding the death incident. |
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Ryker Heberle | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
Inspection Report
Census: 99
Capacity: 150
Deficiencies: 0
Jan 6, 2021
Visit Reason
The visit was a tele-visit conducted to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility.
Findings
No deficiencies were cited during the visit. Recommendations were made regarding proper use of masks and gowns to prevent COVID-19 spread.
Report Facts
COVID-19 positive residents: 3
COVID-19 positive staff: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Quintero | Administrator | Met with Licensing Program Analyst and HFEN Nurse during the tele-visit. |
| David Marrufo | Licensing Program Analyst | Conducted the tele-visit and provided technical assistance. |
| Emma Erickson | HFEN Nurse | Conducted the tele-visit and provided technical assistance. |
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