Inspection Report Summary
Most inspections found no deficiencies, with many complaint investigations unsubstantiated, indicating generally adequate care and compliance. However, several reports cited deficiencies primarily related to medication management, documentation, resident care plans, and staff clearance or training issues. The most recent report from October 20, 2025, cited a deficiency for lack of a documented care plan for catheter use, which poses a potential health risk. Earlier reports included substantiated medication administration errors, missing incident reports, failure to notify responsible parties, and issues with safeguarding residents' belongings, though these were isolated and addressed over time. Overall, the facility shows some improvement in documentation and compliance, but medication management and resident care planning remain areas needing attention.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
143% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
72% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 122
Capacity: 170
Deficiencies: 1
Date: Oct 20, 2025
Visit Reason
The visit was an unannounced case management inspection to issue a citation observed during a complaint investigation regarding the lack of a documented care plan for the use of a catheter.
Complaint Details
The visit was triggered by a complaint investigation (Control 11-AS-20251015105817) concerning the absence of a documented care plan for catheter use.
Findings
The inspection found that there was no documented care plan for catheter use, which poses a potential health and safety risk to residents. A deficiency was cited under California Code of Regulation Title 22 Division 6 Chapter 8.
Deficiencies (1)
No plan in place for catheter care including documentation by a skilled professional outlining procedures and staff instruction.
Report Facts
Census: 122
Total Capacity: 170
Plan of Correction Due Date: Dec 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joe Niblett | Executive Director | Met during inspection and named in exit interview |
| Lizeth Villegas | Licensing Program Analyst | Conducted the inspection and signed the report |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 170
Deficiencies: 0
Date: Sep 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2025-07-08 regarding staff mistreatment, residents being left soiled, and delayed response to call buttons at Brittany House facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included verbal abuse by staff, residents being left soiled, and delayed response to call buttons. Interviews with staff and residents showed mostly denials of the allegations, with only isolated confirmations that were not supported by evidence. Observations and records review also did not support the allegations.
Findings
The investigation included interviews with staff and residents, records review, and observations. All allegations—staff not treating residents with dignity and respect, leaving residents soiled for extended periods, and not answering call buttons timely—were found to be unsubstantiated due to lack of evidence.
Report Facts
Capacity: 170
Census: 115
Staff interviewed: 7
Residents interviewed: 11
Estimated response time: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joel Niblett | Administrator | Met with during inspection and exit interview |
| Zina Brown | Licensing Program Analyst | Conducted complaint investigation |
| Janae Hammond | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 170
Deficiencies: 2
Date: Aug 27, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff left a resident in soiled clothing for a period of time and that staff were not keeping the resident's room free from odor.
Complaint Details
The complaint was substantiated. Allegations included staff leaving a resident in soiled clothing and not keeping the resident's room free from odor. Interviews with staff and residents, observations, and record reviews supported the findings. The resident had a history of refusing showers and urinating frequently, which staff attempted to manage despite challenges.
Findings
The investigation substantiated both allegations. Staff left the resident in soiled clothing due to the resident's frequent urination and combative behavior, and the resident's room was found to have a strong urine odor and stains on the carpet. Deficiencies were cited related to observation of the resident and maintenance and operation of the facility.
Deficiencies (2)
Observation of the Resident: The licensee failed to ensure residents are regularly observed for changes in functioning and appropriate assistance provided, evidenced by the resident being left in soiled clothing due to frequent urination.
Maintenance and Operation: The facility was not clean, safe, sanitary, and in good repair as evidenced by the resident's bedroom having a strong urine odor and carpet stains.
Report Facts
Capacity: 170
Census: 110
Plan of Correction Due Date: Sep 12, 2025
Fine Amount: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joel Niblett | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 170
Deficiencies: 1
Date: Aug 21, 2025
Visit Reason
The inspection was a case management visit conducted to document deficiencies observed during an investigation related to a complaint (Complaint Control Number: 11-AS-20250812125512).
Complaint Details
The visit was complaint-related, triggered by Complaint Control Number: 11-AS-20250812125512. The deficiency was substantiated as the facility was found non-compliant with criminal clearance requirements.
Findings
The facility was found to be non-compliant with California Code of Regulations Title 22 due to a staff member lacking the required criminal background clearance and not being associated with the facility. A deficiency was cited based on interviews, observations, and record reviews.
Deficiencies (1)
One staff member did not have a Criminal Clearance Background, Clearance Transfer associated with the facility, violating Title 22 Criminal Record Clearance regulations.
Report Facts
Capacity: 170
Census: 107
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Girma Yodit | Staff Member | Named in relation to the deficiency and exit interview |
| Antonine Richard | Licensing Program Analyst | Conducted the inspection and authored the report |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 170
Deficiencies: 0
Date: Aug 20, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations that staff mishandled residents' medications.
Complaint Details
The complaint alleged medication errors and delays on 07/20/2025. After interviews and record reviews on 08/20/2025, no evidence was found to substantiate the allegations. The complaint was unsubstantiated.
Findings
The investigation found no evidence to support the allegations of medication mishandling. Interviews with the administrator, residents, and staff, as well as a review of medication records, showed no discrepancies or delays in medication administration. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 170
Census: 107
Number of residents interviewed: 7
Number of staff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joel Niblett | Administrator | Named in relation to the complaint investigation and interviews |
| Antonine Richard | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 170
Deficiencies: 0
Date: Aug 20, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that the facility unlawfully evicted a resident.
Complaint Details
Allegation: Facility unlawfully evicted resident. The allegation was found to be unsubstantiated after interviews with staff, witnesses, and the resident, and review of records.
Findings
The investigation found that the resident voluntarily left the facility with a friend and was not evicted. Staff and witnesses confirmed the resident requested relocation due to care concerns and declined a scheduled transfer. The allegation was determined to be unsubstantiated due to lack of evidence.
Report Facts
Capacity: 170
Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Joel Niblett | Administrator | Facility administrator met during the investigation and received the report |
Inspection Report
Census: 56
Capacity: 170
Deficiencies: 1
Date: Aug 13, 2025
Visit Reason
An announced Case Management - Other visit was conducted to provide Technical Assistance to Brittany House facility, including review of staff and resident records and an interview with the Administrator.
Findings
A Type B deficiency was cited for failure to maintain a separate, complete, and current resident record for each resident, as evidenced by the inability to locate resident R1's file, posing a safety risk to clients in care.
Deficiencies (1)
Failure to ensure that a separate, complete, and current record is maintained for each resident; specifically, resident R1's file could not be located.
Report Facts
Deficiency count: 1
Plan of Correction Due Date: Aug 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joel Niblett | Administrator | Interviewed during inspection and involved in exit interview |
| Jose Calderon | Licensing Program Analyst | Conducted the inspection and authored the report |
| Ulysses Coronel | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 170
Deficiencies: 0
Date: Aug 1, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2024-12-16 regarding dietary needs, dental hygiene, outdoor activities, accommodations, refunds, and sanitation at Brittany House facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to meet residents' dietary needs, dental hygiene needs, provision of outdoor activities, comfortable accommodations, refunds to responsible parties, and maintaining sanitary conditions. After interviews with residents and staff, review of records including physicians' reports and admission agreements, and facility tours, no evidence was found to support the allegations.
Findings
The investigation found no evidence to support any of the allegations. Interviews with residents and staff, review of records, and facility observations indicated that residents' dietary and dental hygiene needs were met, outdoor activities were provided, accommodations were comfortable, refunds were handled according to policy, and the facility was maintained in a sanitary condition. All allegations were unsubstantiated.
Report Facts
Facility capacity: 170
Census: 94
Number of residents interviewed: 5
Number of staff interviewed: 4
Notice period for refunds: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Troy Watson | Licensing Program Analyst | Conducted complaint investigation and interviews |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw complaint investigation |
| Joel Niblett | Administrator | Facility administrator interviewed during investigation and exit interview |
| Marcus Fulanai | Resident Care Coordinator | Facility staff member who assisted during investigation and facility tour |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 170
Deficiencies: 0
Date: Jul 24, 2025
Visit Reason
An unannounced subsequent visit was made to deliver findings regarding a complaint allegation. Due to insufficient time and need for more documentation, the investigation will continue at a later date.
Complaint Details
The visit was related to complaint #11-AS-20241216112039. The investigation is ongoing and requires further documentation and time.
Findings
The visit was a follow-up to a complaint investigation, but the investigation was not completed due to lack of sufficient time and documentation. An exit interview was conducted with the Administrator and a copy of the report was provided.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joel Niblett | Administrator | Met with during the inspection and exit interview. |
| Troy Watson | Licensing Program Analyst | Conducted the unannounced subsequent visit to deliver findings. |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 170
Deficiencies: 0
Date: Jul 17, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate multiple allegations regarding staff handling of residents, medication management, resident care, and facility environment.
Complaint Details
The complaint included nine allegations: rough handling of residents causing injuries, inappropriate restraint, unsafe environment, lack of privacy, medication mismanagement, residents left unattended, inadequate food service, improper medication storage, and residents not being changed timely. The investigation found no substantiation for these allegations.
Findings
The investigation found no evidence to support the allegations after interviews with staff and residents, observations, and records review. The allegations were determined to be unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 170
Census: 96
Number of allegations: 9
Number of staff interviewed: 10
Number of residents interviewed: 10
Resident statements supporting no rough handling: 3
Residents unable to engage in clear conversation: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw the complaint investigation |
| Joel Niblett | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 170
Deficiencies: 0
Date: Jul 17, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-09-09 regarding resident care issues including pressure injuries, medication administration, daily activities, and adequate feeding.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included unstageable pressure injury due to lack of care, failure to provide medication as prescribed, lack of daily activities, and inadequate feeding. Evidence was insufficient to confirm these allegations.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Interviews, record reviews, and observations indicated that the facility provided appropriate care, medication, activities, and meals to residents. The allegations were determined unsubstantiated.
Report Facts
Facility capacity: 170
Resident census: 96
Staff interviewed: 10
Residents interviewed: 8
Hospice care frequency: 2
Wound care frequency: 1
Meals observed: 2
Food supply days: 5
Food supply days: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw the complaint investigation |
| Joel Niblett | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 170
Deficiencies: 0
Date: Jul 17, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2024-12-17 regarding resident falls, untrained staff administering medication, and rough handling of residents.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was insufficient evidence to prove the alleged violations occurred. Allegations included failure to prevent resident falls, untrained staff administering medication, and rough handling of residents.
Findings
The investigation found all allegations to be unsubstantiated. Staff were observed to closely monitor residents to prevent falls, medication technicians were certified except for some staff who did not dispense medications, and no evidence was found that residents were handled roughly.
Report Facts
Facility capacity: 170
Resident census: 96
Staff interviewed: 10
Residents interviewed: 10
In-service training dates: Training conducted on 01/10/2025, 02/25/2025, and 04/07/2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw the complaint investigation |
| Joel Niblett | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 170
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff did not assist a resident with care needs in a timely manner, specifically that a resident was neglected and left sitting in urine.
Complaint Details
The complaint alleged neglect of a resident who was unable to use the bathroom and was left sitting in urine. Interviews with six staff members, five residents, and the Assistant Director of Staff Development denied the allegations. Records showed the resident refused assistance at times. Staff response to alarm cord pull was within two minutes. The allegation was unsubstantiated due to insufficient evidence.
Findings
The investigation included interviews with staff, residents, and review of records. No evidence was found to support the allegations, and the complaint was determined to be unsubstantiated. No deficiencies were cited.
Report Facts
Capacity: 170
Census: 94
Staff interviewed: 6
Residents interviewed: 5
Alarm response time (minutes): 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joel Niblett | Executive Director | Met with Licensing Program Analyst during investigation and named in exit interview |
| Antonine Richard | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 170
Deficiencies: 0
Date: Jun 18, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation of lack of supervision resulting in a resident being assaulted by another resident while in care.
Complaint Details
The complaint alleged lack of supervision resulting in a resident being assaulted by another resident. The allegation was found unsubstantiated after interviews and record reviews. There was no preponderance of evidence to prove the alleged violation did or did not occur.
Findings
The investigation included interviews with staff, residents, and review of records. Three out of ten staff confirmed an incident occurred between two residents, but seven staff had no knowledge of it. Residents interviewed were unaware of the incident. Records showed no history of similar incidents or injury reports. Based on the evidence, the allegation was unsubstantiated due to insufficient proof that the incident occurred as alleged.
Report Facts
Staff interviewed: 10
Residents interviewed: 5
Staff on duty during incident: 7
Census at time of incident: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zina Brown | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Joel Niblett | Administrator Designee | Met with Licensing Program Analyst during visits and exit interview |
| Shane Winkelbauer | Administrator | Named as facility administrator during investigation |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 170
Deficiencies: 0
Date: Jun 4, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-07-19 alleging multiple issues including rough handling of residents, inappropriate restraint, unsafe environment, lack of privacy, medication mismanagement, residents left unattended, inadequate food service, improper medication storage, and untimely changing of residents.
Complaint Details
The complaint investigation was unsubstantiated. Despite multiple allegations regarding resident care and safety, the Department found insufficient evidence to support the claims after interviews, observations, and record reviews.
Findings
The investigation included interviews with staff and residents, record reviews, and facility observations. No evidence was found to substantiate any of the allegations. Staff and residents interviewed generally denied the allegations, and observations showed the facility provided a safe, comfortable environment with proper medication management, adequate food service, and appropriate resident care.
Report Facts
Complaint Control Number: 11
Number of allegations: 9
Number of staff interviewed: 10
Number of residents interviewed: 10
Food supply duration: 5
Food supply duration: 7
Meals per day: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw the complaint investigation |
| Joel Niblett | Administrator | Facility Administrator present during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 170
Deficiencies: 0
Date: May 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-12-17 regarding staff not preventing resident falls, untrained staff administering medication, and rough handling of residents.
Complaint Details
The complaint investigation addressed three allegations: 1) staff failing to prevent residents from multiple falls, 2) untrained staff administering medication, and 3) staff handling residents roughly. The investigation included interviews with staff and residents, review of records, and facility observations. All allegations were found unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found all allegations to be unsubstantiated based on staff and resident interviews, review of resident files and incident reports, and direct observation. Staff were found to closely monitor residents, medication technicians were certified, and no evidence of rough handling was observed.
Report Facts
Capacity: 170
Census: 80
Staff interviewed: 10
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Joel Niblett | Administrator | Facility Administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 170
Deficiencies: 2
Date: May 29, 2025
Visit Reason
The visit was an unannounced complaint investigation to deliver findings related to alleged allegations under complaint Control Number 11-AS-20241217143234.
Complaint Details
Complaint Control Number 11-AS-20241217143234 was investigated, with findings substantiated related to medication administration and staff certification deficiencies.
Findings
The inspection found deficiencies related to medication administration records where medications for some residents were not properly documented as dispensed, and staff certifications for medication administration were not current or available. These deficiencies posed potential health, safety, and personal rights risks to residents.
Deficiencies (2)
Medications for Residents 1 and 2 were not properly documented as dispensed; medications were still in original packaging despite being recorded as dispensed.
Personnel records lacked current medtech certifications and annual trainings for staff members S1 through S7.
Report Facts
Facility Capacity: 170
Census: 80
Deficiency Count: 2
Plan of Correction Due Date: Jun 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joel Niblett | Administrator | Met during inspection and informed of findings; verified staff training registration |
| Bernadette Allen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Marcus Falanai | Resident Care Coordinator | Unable to confirm whether Resident 2's medications had been dispensed |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 170
Deficiencies: 0
Date: May 28, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2024-09-09 regarding allegations of inadequate care, medication administration, daily activities, and feeding at Brittany House facility.
Complaint Details
The complaint included allegations that a resident sustained an unstageable pressure injury due to lack of care, staff did not provide medications as prescribed, did not provide daily activities, and did not ensure adequate feeding. The investigation determined all allegations to be unsubstantiated due to insufficient evidence.
Findings
The investigation found no sufficient evidence to substantiate the allegations of unstageable pressure injury due to lack of care, failure to provide medications as prescribed, lack of daily activities, or inadequate feeding. Observations, interviews, and record reviews indicated that care and services were provided appropriately.
Report Facts
Facility capacity: 170
Census: 80
Staff interviewed: 10
Residents interviewed: 7
Hospice care frequency: 2
Wound care frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw the complaint investigation |
| Joel Niblett | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 170
Deficiencies: 0
Date: May 22, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 07/19/2024 regarding staff handling residents roughly, inappropriate restraint, unsafe environment, lack of privacy, medication mismanagement, residents being left unattended, inadequate food service, improper medication storage, and untimely resident care.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included rough handling of residents, inappropriate restraint, unsafe environment, lack of privacy, medication mismanagement, residents left unattended, inadequate food service, improper medication storage, and untimely resident care. Interviews and observations found no evidence to support these allegations.
Findings
The investigation included interviews with staff and residents, review of records, and facility observations. No evidence was found to substantiate any of the allegations. Staff and residents interviewed denied the allegations, and observations confirmed a safe, comfortable environment with proper medication management, adequate food service, and timely resident care.
Report Facts
Facility capacity: 170
Census: 80
Staff interviewed: 10
Residents interviewed: 10
Food supply days: 5
Food supply days: 7
Meals per day: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joel Niblette | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 170
Deficiencies: 0
Date: May 8, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation of lack of supervision resulting in a resident being assaulted by another resident while in care.
Complaint Details
The allegation was lack of supervision resulting in a resident being assaulted by another resident. Interviews revealed mixed awareness of the incident among staff and residents. Records showed no history of aggravation or unusual incident reports. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation included interviews with staff, residents, and review of records. There was insufficient evidence to substantiate the allegation, and the complaint was determined to be unsubstantiated.
Report Facts
Capacity: 170
Census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zina Brown | Licensing Program Analyst | Conducted the complaint investigation and visit |
| Marcus Falanai | Resident Care Coordinator | Met with during the exit interview and visit |
| Shane Winkelbauer | Administrator | Interviewed regarding the allegation |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 170
Deficiencies: 0
Date: Apr 30, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-12-16 regarding multiple allegations about staff not meeting residents' needs and facility conditions.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not meeting residents' dietary needs, dental hygiene needs, providing outdoor activities, comfortable accommodations, refunds to responsible parties, and maintaining sanitary conditions. Interviews with 5 residents and 4 staff members all denied the allegations, and no evidence was found to support them.
Findings
The investigation included interviews with residents and staff and a review of records. All allegations, including failure to meet dietary, dental hygiene, outdoor activity, accommodation, refund, and sanitary condition needs, were found to be unsubstantiated due to lack of evidence.
Report Facts
Residents interviewed: 5
Staff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marcus Fulanai | Resident Care Coordinator | Met with during the investigation and exit interview |
| Troy Watson | Licensing Program Analyst | Conducted the complaint investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 170
Deficiencies: 0
Date: Apr 28, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations including unexplained injuries to a resident, unmet grooming needs, and untimely medical condition response.
Complaint Details
The complaint included allegations that a resident sustained unexplained injuries, staff did not meet a resident's grooming needs, and staff did not timely address a resident's change in medical condition. All allegations were found unsubstantiated after investigation.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Interviews, record reviews, and observations did not prove the alleged violations occurred, resulting in all allegations being unsubstantiated.
Report Facts
Capacity: 170
Census: 71
Staff interviewed: 9
Residents interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Marcus Falanai | Resident Service Coordinator | Met with Licensing Program Analyst during the investigation and received the exit interview |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 170
Deficiencies: 1
Date: Apr 3, 2025
Visit Reason
The visit was an unannounced case management inspection to issue a citation observed during a complaint investigation related to an incident that occurred around December 2024 - January 2025, which the facility failed to report as required.
Complaint Details
The visit was triggered by a complaint investigation. The complaint involved an incident occurring around December 2024 - January 2025 that the facility failed to report as required. The deficiency was substantiated and cited.
Findings
The facility was cited for failing to submit a serious incident report to the licensing agency within the required timeframe, violating California Code of Regulation Title 22 Division 6 Chapter 8.
Deficiencies (1)
Failure to submit serious incident reports to the licensing agency within 7 days of occurrence as required.
Report Facts
Capacity: 170
Census: 68
Plan of Correction Due Date: Apr 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zina Brown | Licensing Program Analyst | Conducted the inspection and signed the report |
| Marcus Falanai | Resident Coordinator | Met with during inspection and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 170
Deficiencies: 1
Date: Feb 19, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations including staff mismanaging a resident's medication, failure to safeguard resident's personal items, inadequate dental hygiene, and inadequate feeding of a resident.
Complaint Details
The complaint alleged staff mismanaged Resident #1's medication, including unauthorized medication administration, failure to monitor blood glucose levels, and medication refill errors. The complaint also included allegations of failure to safeguard personal items, inadequate dental hygiene, and inadequate feeding. The medication mismanagement allegation was substantiated, while the others were unsubstantiated due to insufficient evidence.
Findings
The investigation substantiated the allegation of neglect and lack of care related to medication management, including failure to administer necessary diabetic medications and lack of blood glucose monitoring. Other allegations regarding safeguarding personal items, dental hygiene, and adequate feeding were found unsubstantiated due to insufficient evidence. Significant deficiencies in record-keeping, including missing Medication Administration Records from 2020 through 2024, were identified.
Deficiencies (1)
Failure to comply with CCR 87465(a)(4) regarding incidental medical and dental care, including inconsistent and incomplete medication administration records posing risk to residents.
Report Facts
Facility capacity: 170
Census: 55
Deficiency due date: Mar 11, 2025
Number of medications prescribed: 18
Number of medications with appetite loss side effects: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marcus Falanai | Resident Service Coordinator | Met with during inspection and exit interview |
| Shane Winkelbauer | Administrator | Facility administrator named in report header |
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 170
Deficiencies: 2
Date: Dec 31, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 07/25/2024 regarding staff not reporting incidents to residents' responsible parties, not administering medications as prescribed, and staff training deficiencies.
Complaint Details
The complaint alleged that staff do not report incidents to residents' responsible parties. The investigation included interviews with residents, staff, and responsible parties, as well as document reviews. The allegation was found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found the allegation that staff do not report incidents to residents' responsible parties to be unsubstantiated. However, the allegations that staff do not administer medications as prescribed and that staff are not properly trained were substantiated based on interviews, record reviews, and medication administration record (MAR) reviews.
Deficiencies (2)
Medications passes were not properly documented, posing a potential health and safety risk for residents.
Lack of documentation confirming that certain staff have obtained and passed required training(s).
Report Facts
Capacity: 170
Census: 57
Deficiencies cited: 2
Plan of Correction Due Date: Jan 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marcus Falanai | Resident care coordinator | Met with during the investigation and mentioned in findings |
| Shane Winkelbauer | Administrator | Named in relation to deficiencies and plan of correction |
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Janae Hammond | Licensing Program Manager | Oversaw the investigation and signed the report |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 170
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
The visit was conducted as a complaint investigation following allegations received on 07/25/2024 regarding residents being forced to use the facility's medical care provider, insufficient staffing to meet residents' needs, and staff falsifying records.
Complaint Details
The complaint investigation addressed three main allegations: 1) Residents being forced to use the facility's medical care provider, with mixed resident responses but staff denying the allegation; 2) Facility not providing enough staff, with some residents reporting short staffing at times but staff denying this; 3) Staff falsifying records to remove a dementia diagnosis, which residents denied. The overall conclusion was that the allegations were unsubstantiated.
Findings
The investigation included interviews with residents and staff, review of documents, and a facility tour. No immediate health or safety concerns were found. The allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Caregivers scheduled per shift: 7
Caregivers scheduled between 6:30am-5pm: 11
Med techs scheduled between 6:30am-2:30pm: 2
Caregivers scheduled between 2:30pm-10:30pm: 6
LVN scheduled between 2:30pm-10:30pm: 1
Caregivers scheduled between 10:30pm-6:30am: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marcuc Falanai | Resident Care Coordinator | Met with during the investigation visit |
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
| David España | Licensing Program Analyst | Conducted initial complaint visit on 07/31/2024 |
| Shane Winkelbauer | Administrator | Facility administrator |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 170
Deficiencies: 1
Date: Dec 16, 2024
Visit Reason
An unannounced complaint investigation was conducted based on a complaint received on 2024-12-09 alleging that staff did not dispense residents' medication as prescribed and other related allegations.
Complaint Details
The complaint alleged that staff did not dispense residents' medication as prescribed. The allegation was substantiated based on interviews, record reviews, and evidence gathered. Other allegations including inappropriate staff communication, denial of private phone calls, failure to safeguard personal belongings, failure to provide prescribed medical garments, and unclean facility floors were investigated and found to be unsubstantiated.
Findings
The investigation substantiated the allegation that staff did not dispense residents' medication as prescribed, with discrepancies found in medication administration records for five residents. Other allegations regarding inappropriate staff behavior, privacy, safeguarding personal belongings, provision of prescribed medical garments, and cleanliness of the facility were found to be unsubstantiated.
Deficiencies (1)
Licensee did not comply with medication administration record requirements, with discrepancies observed in all 5 residents' medication administration records posing potential health, safety, or personal rights risks.
Report Facts
Residents with medication discrepancies: 5
Facility capacity: 170
Census: 56
Plan of Correction due date: Dec 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Mandy Taylor | Executive Director | Facility representative met during investigation and exit interview |
| Shane Winkelbauer | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Capacity: 170
Deficiencies: 1
Date: Dec 16, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-10-22 regarding staff not posting notice for residents council meetings.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The allegation was that staff did not post notice for residents council meetings, which was confirmed by interviews and record reviews.
Findings
The investigation found that the facility did not have a Resident Council in place and staff did not post notices for Resident Council meetings. Six out of seven staff interviewed confirmed notices were not posted, and six residents interviewed were unaware of any Resident Council. The allegation was substantiated.
Deficiencies (1)
Facility staff did not assist residents in the formation of a resident council, did not provide space or post notice for meetings, violating residents' personal rights.
Report Facts
Capacity: 170
Staff interviewed: 7
Residents interviewed: 6
Deficiency Plan of Correction due date: Dec 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Mandy Taylor | Administrator | Facility Administrator interviewed during investigation |
| Stephanie Rubio | Receptionist | Met with Licensing Program Analyst during inspection and received report copy |
Inspection Report
Annual Inspection
Census: 57
Capacity: 170
Deficiencies: 6
Date: Dec 10, 2024
Visit Reason
The inspection was an unannounced one-year inspection conducted to assess compliance with licensing requirements and regulations, as the annual inspection was due in February 2025.
Findings
The facility was found to have multiple deficiencies including staff lacking CPR/First Aid certification, incomplete health screenings with TB test results, medication administration record discrepancies, and missing Needs and Services Plans for residents. The physical plant and safety equipment were generally compliant, but several regulatory requirements were not met.
Deficiencies (6)
4 out of 10 staff had no CPR/First Aid Certification.
8 out of 10 staff did not have a LIC 503 Health Screening with TB Test results.
10 out of 10 residents' medications were not listed on the MAR, with missing or unchecked documentation on consecutive days.
5 out of 10 residents' files lacked a Needs and Services Plan within 30 days after admission.
4 out of 10 staff had expired or no First Aid/CPR Certification.
7 out of 10 staff did not have proof of good physical health verified by health screening including chest x-ray or intradermal test.
Report Facts
Residents diagnosed with dementia: 50
Residents receiving home health: 9
Residents receiving hospice care: 10
Residents receiving palliative care: 1
Resident bedrooms: 142
Full bathrooms: 43
Dining areas: 4
Outdoor shaded patio areas: 10
Facility annual fee: 2311
Staff without CPR/First Aid Certification: 4
Staff without LIC 503 Health Screening with TB Test: 8
Residents with medication documentation issues: 10
Residents without Needs and Services Plan within 30 days: 5
Staff with expired or no First Aid/CPR Certification: 4
Staff without proof of good physical health: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marcus Falani | Resident Care Coordinator | Met with Licensing Program Analyst during inspection. |
| Zina Brown | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Janae Hammond | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection. |
| Shane Winkelbauer | Administrator | Facility Administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 170
Deficiencies: 0
Date: Nov 6, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff were not properly reporting incidents involving residents, including failure to send incident reports when residents were injured or passed away.
Complaint Details
The complaint alleged that staff were not properly reporting incidents involving residents, specifically not sending incident reports for injuries or deaths. The allegation was found to be unsubstantiated due to insufficient evidence.
Findings
The investigation included interviews with staff and review of incident reports. All interviewed staff denied the allegation and stated that incident reports are sent timely. The department found no discrepancies in the incident reports reviewed and concluded there was insufficient evidence to substantiate the allegation. No citations were issued.
Report Facts
Incident reports reviewed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation visit and interviews. |
| Mandy Taylor | Executive Director | Met with the Licensing Program Analyst during the investigation. |
| Marcus Falanai | Service Coordinator | Participated in the exit interview and was provided a copy of the report. |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 170
Deficiencies: 0
Date: Oct 31, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that staff did not post notice for residents council meetings.
Complaint Details
The complaint alleged that staff did not post notice for residents council meetings. The allegation was found to be unsubstantiated after investigation.
Findings
The investigation found that the facility does not have a Resident Council and notices for Resident Council meetings were not posted. Interviews with staff and residents revealed lack of knowledge about Resident Council meetings. Based on gathered information, the allegation was unsubstantiated.
Report Facts
Capacity: 170
Census: 64
Staff interviewed: 7
Staff answered no: 6
Residents interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Mandy Taylor | Administrator | Facility administrator interviewed during the investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 170
Deficiencies: 0
Date: Oct 2, 2024
Visit Reason
An unannounced case management visit was conducted to follow up on an incident that occurred on September 20, 2024, involving inappropriate sexual activity between two residents.
Complaint Details
The visit was triggered by a complaint regarding inappropriate sexual activity between Resident #1 and Resident #2. The investigation is ongoing due to insufficient information at this time.
Findings
During the visit, the Licensing Program Analyst toured the facility, reviewed resident files, and interviewed staff and residents. Due to insufficient information, further investigation is required and will be conducted at a later date.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mandy Taylor | Administrator | Met with during the visit and participated in interviews. |
| Zina Brown | Licensing Program Analyst | Conducted the inspection and interviews. |
| Janae Hammond | Licensing Program Manager | Oversaw the inspection visit. |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 170
Deficiencies: 1
Date: Oct 2, 2024
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that staff do not report incidents to Community Care Licensing, specifically regarding the failure to submit incident reports for the death of a resident (R1).
Complaint Details
The complaint was substantiated. The allegation was that staff did not report incidents to Community Care Licensing, specifically the failure to submit incident reports for the death of R1. Interviews confirmed that a previously employed staff member responsible for submitting reports did not complete the required report. The current staff member responsible for submitting incident reports confirmed this failure.
Findings
The investigation substantiated the allegation that the facility failed to submit the required incident report related to the death of R1. The facility did not have proof that the certified confirmation form was faxed to Community Care Licensing, posing a potential health, safety, or personal rights risk to residents.
Deficiencies (1)
Failure to comply with CCR 87211 Reporting Requirements; the facility failed to submit written report associated with the death of R1 and did not have proof of certified confirmations faxed to CCL.
Report Facts
Capacity: 170
Census: 67
Deficiencies cited: 1
Plan of Correction Due Date: Oct 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Mandy Taylor | Executive Director | Interviewed during investigation and confirmed the allegation |
| Shane Winkelbauer | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 170
Deficiencies: 2
Date: Aug 31, 2024
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 08/16/2024 regarding allegations of neglect and lack of care at Brittany House facility.
Complaint Details
Complaint involved allegations that staff did not notify authorized representative of incident, resident sustained injury while in care, staff did not provide a safe environment, staff left resident in soiled clothing/bedding, and staff did not ensure resident's hygiene needs were met. Only the failure to notify authorized representative was substantiated.
Findings
The investigation substantiated the allegation that staff did not notify the authorized representative of an incident involving resident #1. Other allegations including resident injury, unsafe environment, and neglect of hygiene needs were found to be unsubstantiated due to insufficient evidence.
Deficiencies (2)
Facility failed to notify the responsible person/conservator for resident #1 when hospitalized on 08/05/24.
Facility failed to submit required reports for serious injury and incidents threatening resident welfare.
Report Facts
Capacity: 170
Census: 74
Deficiency count: 2
POC Due Date: Sep 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Laurie Riffel | Med-Ted (Staff) | Facility staff member who greeted the investigator and participated in interviews |
| Shane Winkelbauer | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 170
Deficiencies: 0
Date: Jul 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the licensee was not isolating COVID-19 positive residents.
Complaint Details
The complaint alleged that the licensee was not isolating COVID-19 positive residents. The investigation included interviews with staff and residents, observation of isolation practices, and review of relevant records. The allegation was found unsubstantiated as there was not a preponderance of evidence to prove the violation occurred.
Findings
The investigation found that exposed residents were isolated in their rooms, masked, and kept apart, with staff following protocols including notifying families and following physician orders. Interviews with staff and residents showed mixed responses about isolation practices. The allegation was determined to be unsubstantiated due to insufficient evidence.
Report Facts
Staff interviewed: 8
Residents interviewed: 7
Residents answering No: 2
Residents answering Yes: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation visit |
| Neil Chandra | Resident Service Director | Met with Licensing Program Analyst during investigation and provided information on isolation protocols |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 170
Deficiencies: 1
Date: Jul 9, 2024
Visit Reason
An unannounced complaint investigation was conducted following an allegation that staff did not safeguard a resident's personal belongings during a unit transfer.
Complaint Details
The complaint was substantiated based on interviews with staff and residents, document review, and observation of missing personal belongings and equipment. The allegation involved failure to safeguard a resident's personal belongings during a unit transfer.
Findings
The investigation substantiated the allegation that facility staff failed to safeguard a resident's personal belongings, including medical equipment and personal items, posing a potential personal rights risk. Deficiencies were cited and a plan of correction was developed with the facility administrator.
Deficiencies (1)
Facility staff did not take appropriate measures to safeguard residents' cash, personal property, and valuables, and failed to provide receipts for such articles.
Report Facts
Facility capacity: 170
Resident census: 70
Plan of Correction due date: Jul 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw the complaint investigation |
| Shane Winkelbauer | Administrator | Facility administrator during the investigation |
| Yessica Martinez | Office Manager | Facility staff member who met with the investigator and received the report |
| Susie Fuentes | Administrator | Administrator involved in plan of correction development |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 170
Deficiencies: 0
Date: Jul 1, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-06-24 regarding staffing adequacy, food quality, facility odor, and resident relocation notification at Brittany House.
Complaint Details
The complaint included four allegations: inadequate staffing, poor food quality, facility odor, and moving residents without notifying responsible parties. All allegations were denied by staff and residents and deemed unsubstantiated due to insufficient evidence.
Findings
The investigation found no substantiated evidence supporting the allegations. Staff and residents confirmed adequate staffing, quality food provision, absence of facility odor, and proper notification to responsible parties before resident relocation. The facility was observed to be well-maintained with ample food supplies and a comfortable living environment.
Report Facts
Capacity: 170
Census: 62
Meals per day: 3
Snacks per day: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation visit |
| Mandy Taylor | Executive Director | Facility representative met during the investigation |
| Shane Winkelbauer | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 170
Deficiencies: 2
Date: Jun 20, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-06-07 regarding allegations that staff violated residents' personal rights and did not provide a safe and comfortable environment.
Complaint Details
The complaint alleged that staff violated residents' personal rights by moving residents between units without notifying residents or their families, causing confusion and upset. It also alleged that staff did not provide a safe and comfortable environment due to construction-related overcrowding, loud noises, chemical smells, and lack of caregiver availability. Both allegations were substantiated based on interviews with staff, witnesses, and residents, and review of records.
Findings
The investigation substantiated that staff violated residents' personal rights by relocating residents without notifying them or their families, causing confusion and distress. Additionally, staff failed to provide a safe and comfortable environment during construction and relocation, resulting in overcrowding, exposure to loud noises, chemical smells, and emotional distress among residents.
Deficiencies (2)
Failure to accord residents safe, healthful and comfortable accommodations, furnishings and equipment as evidenced by relocation without notification causing confusion and potential health risk.
Failure to regularly inform residents' representatives of activities related to care or services, including ongoing evaluations, specifically failure to inform about construction and resident movement posing potential health risk.
Report Facts
Capacity: 170
Census: 68
Fine amount: 100
Plan of Correction Due Date: Jun 28, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
| Yessica Martinez | Office Manager | Facility representative met during investigation and exit interview |
| Shane Winkelbauer | Administrator | Named in findings for failure to ensure residents' personal rights and failure to inform responsible parties about construction and resident movement |
Inspection Report
Complaint Investigation
Capacity: 170
Deficiencies: 2
Date: May 22, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff were not administering residents' medications as prescribed and were mismanaging residents' medications.
Complaint Details
The complaint investigation was substantiated. Allegations included staff not administering medications as prescribed and mismanaging medications, including a resident missing Memantine medication for a week due to delayed refills. Interviews, record reviews, and audits confirmed these issues.
Findings
The investigation substantiated that staff failed to administer medications as prescribed, leading to residents missing vital medications and experiencing adverse effects. Staff admitted to delays in medication refills causing residents to go days without medication. Deficiencies were cited related to medication administration and medical care plans.
Deficiencies (2)
Med tech failed to give medication to resident which poses a potential health, safety risk to persons in care.
Med tech admitted to notifying nurse last minute about refilling medications causing delays and residents going days without medication.
Report Facts
Days with 'Not Applicable' medication notes: 18
Days with 'Not Applicable' medication notes: 11
Staff interviewed: 8
Residents interviewed: 6
Plan of Correction due date: Jun 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvira Gonzalez | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Neio Chandra | Resident Services Director | Met with Licensing Program Analyst during investigation and exit interview |
| Shane Winkelbauer | Administrator | Facility Administrator named in report header |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 170
Deficiencies: 2
Date: Mar 21, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the facility admitted a resident with a prohibited health condition and that the facility operates beyond conditions and limitations specified on the license.
Complaint Details
The complaint was substantiated based on interviews with staff and residents, file reviews, and observations. The resident R1 was admitted on March 12, 2024, with a prohibited health condition. The facility also allowed a non-resident client to use the facility as a daycare and participate in meals and activities, which is beyond the licensed conditions.
Findings
The investigation substantiated both allegations: a resident (R1) was admitted with a prohibited communicable health condition, and the facility allowed a non-resident client (C1) to participate in activities and meals, effectively operating beyond licensed conditions. Two deficiencies were cited related to these findings.
Deficiencies (2)
Failure to ensure resident R1 did not have a prohibited health condition (Staphylococcus aureus infection or other serious infection).
Facility operated beyond licensed conditions by allowing a non-resident client (C1) to participate in activities and meals and be charged for these services.
Report Facts
Deficiencies cited: 2
Capacity: 170
Census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Mandy Taylor | Administrator | Interviewed during the investigation; provided information about resident R1 and facility operations. |
| Juan Talavera | Maintenance Director | Participated in exit interview and received a copy of the report. |
Inspection Report
Original Licensing
Census: 68
Capacity: 170
Deficiencies: 0
Date: Jan 19, 2024
Visit Reason
The visit was a pre-licensing evaluation conducted to assess the facility's readiness for licensing as an RCFE (Residential Care Facility for the Elderly) to serve 170 elderly residents aged 60 and older.
Findings
The facility was found to be clean, sanitary, and in good repair with proper protective devices and safety measures in place. All required areas including resident rooms, medication storage, kitchen, and common areas were inspected and found compliant. No corrections were needed during this pre-licensing inspection.
Report Facts
Fire clearance capacity: 146
Fire clearance capacity: 24
Hot water temperature: 113
Freezer temperature: 0
Refrigerator maximum temperature: 45
Non-perishable food supply: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Tistoj | Administrator | Authorized administrator present during pre-licensing evaluation and exit interview |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the pre-licensing evaluation |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 69
Capacity: 170
Deficiencies: 0
Date: Nov 16, 2023
Visit Reason
The visit was an office evaluation involving a telephone interview with the applicant/administrator to verify identification and confirm understanding of community care facility licensing laws and regulations.
Findings
The applicant and administrator demonstrated understanding of facility operation, admission policies, staffing requirements, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness.
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