Inspection Report Summary
Most inspections found no deficiencies, with the facility generally clean, well-maintained, and compliant with regulations. Several complaint investigations were unsubstantiated, including allegations of poor hygiene, staffing, and medication handling. However, some substantiated issues involved medication administration errors, failure to report incidents, and improper admission assessments, with the most serious being a failure to call emergency services promptly after a resident’s fall in October 2023. The facility also faced substantiated complaints related to staff misconduct and residents’ personal rights in 2022. The most recent report from June 6, 2025, was clean with no deficiencies, indicating improvement since earlier findings.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
88% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 97
Capacity: 110
Deficiencies: 0
Date: Jun 6, 2025
Visit Reason
The inspection was conducted as a required annual unannounced visit to evaluate the facility's compliance with regulations.
Findings
The facility was found to be clean, well-maintained, and in substantial compliance with regulations. No deficiencies were cited during this inspection.
Report Facts
Residents present: 97
Total capacity: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Malissa Acuna | Executive Director | Met with Licensing Program Analyst during the inspection |
| Todd Tryon | Licensing Program Analyst | Conducted the inspection visit |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 76
Capacity: 110
Deficiencies: 0
Date: Jun 18, 2024
Visit Reason
The inspection was conducted as a required annual unannounced visit to evaluate the facility's compliance with regulations.
Findings
The facility was found to be clean, well-maintained, and in good condition with no deficiencies cited. Residents appeared active and in good spirits, and all safety and medication storage requirements were met.
Report Facts
Resident files reviewed: 7
Staff files reviewed: 7
Resident apartments toured: 13
Residents spoken with: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Malissa Acuna | Executive Director | Met with Licensing Program Analyst during inspection |
| Todd Tryon | Licensing Program Analyst | Conducted the inspection visit |
| Troy Ordonez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 110
Deficiencies: 0
Date: Oct 11, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-08-21 alleging multiple issues including insufficient staffing, poor hygiene care, medication mishandling, and other concerns.
Complaint Details
The complaint investigation was initiated due to multiple allegations including residents being left soiled, insufficient staffing, unsafe food handling, poor facility maintenance, lack of hygiene products, chemical restraint use, medication mishandling, and staff yelling at residents. After interviews with 5 residents, 4 care staff, 1 housekeeper, 1 medication technician, and the administrator, and review of medications and facility conditions, all allegations were found to be unfounded.
Findings
The Licensing Program Analyst investigated all allegations including insufficient staffing, residents being left soiled, unsafe food handling, poor facility maintenance, lack of hygiene products, chemical restraint use, medication mishandling, and staff yelling at residents. All allegations were found to be unfounded based on interviews with residents, staff, and administrator, as well as facility observations and medication reviews.
Report Facts
Capacity: 110
Census: 73
Number of residents interviewed: 5
Number of care staff interviewed: 4
Number of medication reviews: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Malissa Acuna | Administrator | Facility administrator interviewed during investigation |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 110
Deficiencies: 1
Date: Oct 11, 2023
Visit Reason
The visit was an unannounced case management inspection triggered by a complaint investigation regarding the facility's response to a resident's injury during a walk.
Complaint Details
During the complaint investigation, it was found that resident R1, who was on hospice services, fell during a walk and was in pain. The facility waited 2 to 3 hours for hospice nurse assessment and did not call emergency services immediately. The next day, the resident was sent to the emergency department and diagnosed with a hip fracture. The facility's failure to call emergency services upon injury was cited.
Findings
The facility failed to call emergency services immediately after a resident (R1) fell and was injured, which was not related to the expected course of the resident's terminal illness. This failure posed an immediate health, safety, and personal rights risk to residents in care, resulting in cited deficiencies.
Deficiencies (1)
Facility staff did not call emergency services for resident R1 upon fall at the facility, violating requirements for responding to medical emergencies for terminally ill residents on hospice.
Report Facts
Deficiency Type A: 1
Census: 73
Total Capacity: 110
Plan of Correction Due Date: Oct 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Malissa Acuna | Administrator | Met with Licensing Program Analyst during inspection and named in findings. |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection. |
Inspection Report
Annual Inspection
Census: 76
Capacity: 110
Deficiencies: 0
Date: Jul 11, 2023
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate the health and safety of residents in care at the facility.
Findings
The Licensing Program Analyst toured various areas of the facility and reviewed resident and staff files, medication records, and safety supplies. No immediate health, safety, or personal rights violations were observed, and no deficiencies were cited as a result of the inspection.
Report Facts
Resident files reviewed: 7
Staff files reviewed: 5
Medications reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Malissa Acuna | Administrator | Met with Licensing Program Analyst during inspection |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the annual inspection |
| Troy Ordonez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 110
Deficiencies: 1
Date: May 17, 2023
Visit Reason
Unannounced investigation of a complaint received on 2023-05-10 regarding failure to adhere to the admission agreement.
Complaint Details
The complaint was substantiated. The allegation was that the facility failed to adhere to the admission agreement by charging late fees improperly. The investigation confirmed this finding.
Findings
The investigation found that the facility continued to charge late payments to residents R1 and R2 despite the admission agreement stating late fees apply only if fees are not paid on time. The allegation was substantiated based on evidence gathered.
Deficiencies (1)
The licensee did not comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments, posing a potential risk to residents.
Report Facts
Capacity: 110
Census: 64
Deficiency due date: Jun 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Malissa Acuna | Administrator | Facility administrator met during inspection and involved in investigation |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 110
Deficiencies: 1
Date: May 17, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2023-03-03 regarding medication security, staff training, facility cleanliness, food service, smoking, and resident care.
Complaint Details
The complaint investigation was initiated based on multiple allegations including unlocked medications, incomplete staff training, unclean facility, improper food service, staff smoking, accessible nicotine devices, improper medication assistance, and inadequate incontinence care. The medication assistance allegation was substantiated; others were unsubstantiated or unfounded.
Findings
The investigation found most allegations to be unfounded, including medication security, staff training, cleanliness, food service, incontinence care, hygiene, and smoking. However, the allegation that residents did not receive proper medication assistance was substantiated due to medication not being provided as prescribed, posing an immediate health and safety risk.
Deficiencies (1)
Licensee did not provide medications to residents as prescribed, posing an immediate health and safety risk.
Report Facts
Capacity: 110
Census: 64
Deficiency due date: May 18, 2023
Number of resident medications reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Malissa Acuna | Administrator | Met with Licensing Program Analyst during inspection |
| Morgan Whinery | Administrator | Named as facility administrator in report header |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 110
Deficiencies: 2
Date: May 17, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff were not giving new residents their medications for several days and were not following reporting requirements, as well as allegations that staff leave residents in bed and do not answer call lights promptly.
Complaint Details
The complaint investigation was substantiated regarding failure to administer medications to new residents and failure to follow reporting requirements. Allegations about staff leaving residents in bed and not answering call lights were unfounded.
Findings
The investigation substantiated that new residents did not receive medications as prescribed from April 29th through May 2nd due to medication orders being incorrectly entered as self-administered. The physician was notified late and the incident was not reported to the licensing agency as required. Allegations that staff leave residents in bed and do not answer call lights promptly were found to be unfounded.
Deficiencies (2)
Licensee did not provide medications to residents as prescribed, posing an immediate health and safety risk.
Licensee did not report incident to the licensing agency as required, posing a potential risk to residents.
Report Facts
Capacity: 110
Census: 64
Deficiency Type A POC Due Date: May 18, 2023
Deficiency Type B POC Due Date: May 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Malissa Acuna | Administrator | Facility administrator met during inspection and involved in findings |
| Troy Ordonez | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 110
Deficiencies: 0
Date: Apr 6, 2023
Visit Reason
An unannounced complaint investigation was conducted following allegations including staff not following a licensed physician's orders, non-compliance with infection control practices, failure to notify responsible parties of resident illness, and refusal to clean residents' rooms.
Complaint Details
The complaint investigation was triggered by multiple allegations: staff not following physician's orders, infection control non-compliance, failure to notify responsible parties of resident illness, and refusal to clean residents' rooms. The findings were unsubstantiated due to conflicting evidence and lack of proof.
Findings
The investigation found conflicting information for all allegations, including issues related to COVID-19 positive residents and staff actions. Due to lack of preponderance of evidence, all allegations were determined to be unsubstantiated.
Report Facts
Capacity: 110
Census: 63
COVID positive clients: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Malissa Acuna | Administrator | Met with Licensing Program Analyst during inspection |
| Morgan Whinery | Administrator | Facility administrator at time of report |
| Troy Ordonez | Licensing Program Manager | Named in report as Licensing Program Manager |
| Maintenance Director Assistant | Interviewed regarding housekeeping refusal allegation |
Inspection Report
Complaint Investigation
Capacity: 110
Deficiencies: 0
Date: Mar 1, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 08/15/2022 regarding COVID-19 spread prevention, resident clothing changes, medication ordering and dispensing, and refund issues at the facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to stop COVID-19 spread, failure to routinely change resident's clothes, failure to order and dispense prescribed medication, and failure to provide a refund. Each allegation was investigated and found to be unsubstantiated or unfounded based on evidence and interviews.
Findings
The investigation found that the facility was routinely screening for COVID-19 and following isolation protocols, but it was not possible to determine if COVID was contracted at the facility; staff addressed resident clothing issues appropriately once aware; medication ordering and dispensing delays were due to issues between the doctor's office and pharmacy, not facility fault; and refund allegations were unfounded based on the facility's admission agreement. All allegations were unsubstantiated or unfounded.
Report Facts
Facility capacity: 110
Refund amount offered: 2000
Customer service credit: 895.35
Refund amount not required: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Todd Tryon | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Troy Ordonez | Licensing Program Manager | Oversaw the complaint investigation |
| Morgan Whinery | Administrator | Facility administrator mentioned in the report |
| Malissa Acuna | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 110
Deficiencies: 1
Date: Dec 7, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2022-11-09 regarding the facility staff not releasing past resident's records.
Complaint Details
The allegation that facility staff are not releasing past resident's records was substantiated based on the preponderance of evidence.
Findings
The investigation found that the facility provided some documentation as requested but failed to furnish several required documents to the POA/Representative, substantiating the allegation of not releasing past resident's records. A deficiency was cited under Title 22, Section 87648.2(a)(19).
Deficiencies (1)
Facility failed to provide requested resident records to POA/Representative within two business days, causing a potential violation of resident rights.
Report Facts
Deficiency Type: Type B deficiency cited under CCR 87468.2(a)(19)
Plan of Correction Due Date: 12/14/2022
Capacity: 110
Census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Todd Tryon | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Troy Ordonez | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Ronica Rao | Business Office Coordinator | Met with the Licensing Program Analyst during the investigation |
| Morgan Whinery | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Capacity: 110
Deficiencies: 1
Date: Nov 9, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff forced a resident to take medication not prescribed to them, staff did not safeguard residents' personal belongings, and staff did not ensure a resident had a shower curtain.
Complaint Details
The complaint investigation was substantiated for the allegation that staff forced a resident to take medication not intended for them. The other allegations about safeguarding personal belongings and providing a shower curtain were unfounded.
Findings
The allegation that staff forced a resident to take medication not intended for them was substantiated due to a medication being given to the wrong resident. Allegations regarding failure to safeguard personal belongings and failure to provide a shower curtain were found to be unfounded.
Deficiencies (1)
The licensee did not assist residents properly with self-administered medications, resulting in a resident receiving medication intended for another resident.
Report Facts
Capacity: 110
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Executive Director | Met with Licensing Program Analyst during complaint investigation and interviewed regarding allegations |
| Todd Tryon | Licensing Program Analyst | Conducted the complaint investigation |
| Troy Ordonez | Licensing Program Manager | Oversaw complaint investigation and signed report |
Inspection Report
Census: 61
Capacity: 110
Deficiencies: 0
Date: Aug 18, 2022
Visit Reason
The visit was an unannounced case management inspection related to legal/non-compliance to deliver an immediate exclusion for staff member S1.
Findings
An immediate exclusion was delivered to staff S1, prohibiting them from being present in or working with residents of any facility licensed by the Department of Social Services. The exclusion was delivered to the facility Executive Director and read to S1, who then left the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Executive Director | Received the immediate exclusion for staff S1. |
| Todd Tryon | Licensing Program Analyst | Visited the facility to deliver the immediate exclusion. |
| Troy Ordonez | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Capacity: 110
Deficiencies: 1
Date: Aug 15, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that a staff member inappropriately touches female residents in care.
Complaint Details
The complaint was substantiated based on interviews with witnesses, residents, staff, and the accused staff member. The preponderance of evidence standard was met confirming inappropriate touching by staff member S1.
Findings
The investigation substantiated the allegation that male staff member S1 inappropriately touched female residents by reaching into their undergarments and smelling the crotch area to check if they were wet. The facility was cited for violating residents' personal rights and required to submit a plan of correction.
Deficiencies (1)
Residents in all residential care facilities for the elderly shall have personal rights to be free from punishment, humiliation, intimidation, abuse, or other punitive actions. The facility failed to meet this requirement as staff member S1 put his hand into the back of the pants of a female resident to check if she was dry or wet.
Report Facts
Capacity: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Executive Director | Met with Licensing Program Analyst during complaint investigation and mentioned in findings |
| Todd Tryon | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Troy Ordonez | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 110
Deficiencies: 1
Date: Aug 15, 2022
Visit Reason
The visit was conducted to complete a complaint investigation regarding staff behavior and care practices at the facility.
Complaint Details
The complaint investigation found substantiated allegations of inappropriate staff conduct and failure to report these incidents to the Department of Social Services or other agencies.
Findings
During the investigation, staff reported that an employee acted inappropriately by sniffing residents' undergarments, not wearing gloves during incontinence care, and sitting close to a resident on the toilet. The facility failed to report these incidents to appropriate agencies, resulting in a deficiency for failure to report.
Deficiencies (1)
Failure to report incidents of inappropriate staff behavior and resident care to appropriate agencies.
Report Facts
Capacity: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Todd Tryon | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Troy Ordonez | Licensing Program Manager | Supervisor overseeing the investigation |
Inspection Report
Annual Inspection
Census: 69
Capacity: 110
Deficiencies: 0
Date: Jul 20, 2022
Visit Reason
The visit was an unannounced annual inspection conducted to evaluate the facility's infection control practices using the Infection Control Domain of the CARES Tool.
Findings
The facility was found to be in overall compliance with no deficiencies cited. The facility was clean, well-furnished, well-stocked with PPE and COVID tests, and residents participated in various activities.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Executive Director | Met with during inspection and mentioned in the report narrative. |
| Yuriy Kutsenko | Health and Wellness Director | Met with during inspection and mentioned in the report narrative. |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 110
Deficiencies: 1
Date: Jul 11, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2022-07-07 regarding refund issuance and proper resident assessment.
Complaint Details
Two allegations were investigated: 1) Facility has not issued a refund - found unfounded. 2) Facility accepted a client without a proper assessment - substantiated.
Findings
The allegation that the facility had not issued a refund was found to be unfounded as the refund was in process. The allegation that the facility accepted a client without a proper assessment was substantiated, citing that the initial assessment missed prohibited and restricted health conditions requiring extra care.
Deficiencies (1)
Initial assessment did not note prohibited health condition and two restricted health conditions that required extra care that the resident could not perform for self.
Report Facts
Capacity: 110
Census: 69
Deficiencies cited: 1
Plan of Correction Due Date: Aug 11, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with Licensing Program Analyst and provided information regarding complaint and refund process |
| Todd Tryon | Licensing Program Analyst | Conducted the complaint investigation visit |
| Troy Ordonez | Licensing Program Manager | Oversaw complaint investigation and signed report |
Inspection Report
Follow-Up
Census: 64
Capacity: 110
Deficiencies: 0
Date: Jun 20, 2022
Visit Reason
The visit was conducted to follow up on an incident report sent in on 2022-06-14 regarding an allegation that a staff member grabbed a resident's arm roughly, causing bruising.
Complaint Details
The visit was complaint-related due to an incident report alleging staff misconduct. The staff member admitted to grabbing the resident's arm, was terminated by the staffing agency, and the facility filed reports with the Community Care Licensing, Ombudsman, Placer County Sheriff, and notified the resident's POA.
Findings
The facility had thoroughly investigated the incident, took immediate and appropriate action including terminating the staff involved, and reported the incident to relevant authorities. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Executive Director | Spoke with LPA regarding the incident and investigation. |
| Todd Tryon | Licensing Program Analyst | Conducted the visit and investigation. |
| Troy Ordonez | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 110
Deficiencies: 0
Date: Apr 15, 2022
Visit Reason
Unannounced visit/investigation of a complaint received on 03/16/2022 regarding staff speaking rudely to residents.
Complaint Details
Complaint was unsubstantiated. Although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation occurred.
Findings
The investigation found no evidence that the staff member was rude to residents, although the staff may have spoken gruffly with other staff. The complaint was determined to be unsubstantiated due to lack of evidence.
Report Facts
Capacity: 110
Census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Facility administrator met during investigation |
| Todd Tryon | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Troy Ordonez | Licensing Program Manager | Manager overseeing the licensing program |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 110
Deficiencies: 1
Date: Apr 15, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including untrained individuals administering medications, failure to report incidents, staff causing injury to a resident, residents not receiving medications as needed, and inadequate staffing.
Complaint Details
The complaint investigation was substantiated for the allegation that untrained individuals were administering medications to residents due to lack of documentation of medication training for agency staff. Other allegations including failure to report incidents, staff causing injury, residents not receiving medications, and inadequate staffing were found unsubstantiated or unfounded.
Findings
The investigation substantiated the allegation that untrained agency staff were administering medications without documented training, posing a potential immediate danger. Other allegations regarding failure to report incidents, staff causing injury, residents not receiving medications, and inadequate staffing were found to be unsubstantiated or unfounded.
Deficiencies (1)
All personnel shall be given on the job training or have related experience in the job assigned to them. The facility asked agency staff to assist with medications without documentation that the staff had received appropriate training, posing a potential immediate danger.
Report Facts
Capacity: 110
Census: 66
Deficiencies cited: 1
Plan of Correction Due Date: Apr 18, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Todd Tryon | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Morgan Whinery | Executive Director | Met with during investigation |
| Antoinette Edwards | Administrator | Facility administrator named in the report |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 110
Deficiencies: 0
Date: Apr 15, 2022
Visit Reason
Unannounced visit/investigation of a complaint received on 01/19/2022 regarding the allegation that the facility over charged a resident.
Complaint Details
The complaint alleged that the facility over charged a resident. The allegation was investigated and found to be unfounded.
Findings
The investigation found that the facility had repaid the responsible party appropriately as per the admission agreement/contract. Therefore, the allegation that the facility over charged the resident was determined to be unfounded.
Report Facts
Capacity: 110
Census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Todd Tryon | Evaluator | Conducted the complaint investigation |
| Antonette Edwards | Administrator | Facility administrator mentioned in the report |
| Morgan Whinery | Person met with during the investigation | |
| Troy Ordonez | Licensing Program Manager | Named in the report |
Inspection Report
Annual Inspection
Census: 68
Capacity: 110
Deficiencies: 0
Date: Jun 29, 2021
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted to assess infection control and overall compliance at the facility.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Report Facts
Resident rooms toured: 10
Dining rooms toured: 2
Kitchens toured: 2
Public restrooms toured: 4
Activity rooms toured: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antoinette Edwards | Administrator | Met with Licensing Program Analyst during inspection |
| Konnor Leitzell | Licensing Program Analyst | Conducted the inspection |
| Kylie Whitaker | Health and Wellness Director | Met with Licensing Program Analyst during inspection |
| Troy Ordonez | Licensing Program Manager | Named in report header |
Inspection Report
Census: 70
Capacity: 110
Deficiencies: 0
Date: May 18, 2021
Visit Reason
The visit was an unannounced virtual case management incident review conducted to discuss an incident report submitted regarding a resident sustaining a fracture from an un-witnessed fall on 2021-05-14.
Findings
The facility staff conducted rounds as scheduled and responded promptly to the resident's call for help, immediately dialing 911 and notifying the responsible party and primary physician. No deficiencies were cited during the visit.
Report Facts
Incident date: May 14, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Whitaker | Health and Wellness Director | Interviewed regarding the incident and facility rounds |
| Konnor Leitzell | Licensing Program Analyst | Conducted the unannounced virtual case management visit |
| Christine Salee | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 110
Deficiencies: 1
Date: May 6, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility failed to follow the admission agreement, failed to answer promptly to communications from resident’s representatives, and did not follow reappraisal procedures.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility failed to follow the admission agreement, specifically regarding failure to communicate cost changes to the DPOA. The other allegations regarding communication delays and reappraisal procedures were unsubstantiated.
Findings
The complaint that the facility failed to follow the admission agreement was substantiated due to the facility increasing a resident's monthly fee without properly discussing the cost changes with the Durable Power of Attorney (DPOA). The allegations that the facility failed to answer promptly to communications and did not follow reappraisal procedures were found to be unfounded after investigation.
Deficiencies (1)
Facility did not ensure the cost of providing additional personal services (the ‘Personal Service Rate’) was shared with the Durable Power of Attorney (DPOA) of Resident-1, violating Admission Agreements regulation 87507(f).
Report Facts
Capacity: 110
Census: 72
Days of communication lapse: 8
Plan of Correction Due Date: May 10, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Konnor Leitzell | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Christine Salee | Administrator | Facility administrator involved in investigation and findings |
| Troy Ordonez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 110
Deficiencies: 1
Date: Feb 18, 2021
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by a complaint received on 07/20/2020 regarding staff failing to follow licensed physician's orders for a resident while in care.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The allegation was that staff failed to follow licensed physician's orders for a resident while in care.
Findings
The investigation found that while the facility was following the physician's medication orders, they were not following the PRN authorization form which required physician authorization prior to each PRN medication dose. The complaint was substantiated and a deficiency was cited.
Deficiencies (1)
Facility staff did not follow the PRN authorization form requiring physician authorization prior to each PRN prescription medication dose given.
Report Facts
Capacity: 110
Census: 69
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Lusby | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
| Christine Salee | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 110
Deficiencies: 0
Date: Feb 18, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff failed to ensure a resident was properly transported to the hospital.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis.
Findings
Based on interviews and documentation review, the allegation was found to be unfounded as the preponderance of evidence standard was not met. The complaint was determined to be false or without reasonable basis.
Report Facts
Capacity: 110
Census: 69
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Lusby | Licensing Program Analyst | Conducted the complaint investigation and exit interview |
| Christine Salee | Administrator | Facility administrator involved in the investigation |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
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