Inspection Report Summary
Most inspections found no deficiencies, including the most recent report on July 29, 2025, which was perfect despite being triggered by a serious complaint involving alleged staff abuse that was investigated and found to have no fractures or regulatory violations. Earlier reports showed isolated issues, notably a substantiated complaint in December 2024 where a resident’s prescribed medication was not administered for nearly two months, posing an immediate health risk. Another significant deficiency occurred in September 2023 when a resident eloped without staff knowledge, resulting in hospitalization and a cited safety risk. Several other complaint investigations were unsubstantiated, and the facility demonstrated compliance with regulations in all other visits. The overall trend suggests improvement, with recent inspections consistently free of deficiencies following earlier isolated problems.
Deficiencies per Year
4
3
2
1
0
High
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Census: 84
Capacity: 110
Deficiencies: 0
Jul 29, 2025
Visit Reason
The visit was an unannounced follow-up on an Unusual Incident Report involving a resident injury reported on July 14, 2025.
Findings
Based on observations, record review, and interviews, the facility was found to be in compliance with applicable regulations on the date of the visit, with no deficiencies cited.
Complaint Details
The visit was triggered by a complaint involving an incident where a staff member allegedly intentionally crushed a resident's finger. Emergency services and law enforcement were involved, and an Elder Abuse Report was filed. The resident was evaluated and returned to the facility with no fractures found.
Report Facts
Incident date: Jul 14, 2025
Inspection start time: 130
Inspection end time: 250
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danny Vera | Executive Director | Met with Licensing Program Analyst during inspection and involved in incident discussion |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the unannounced visit and inspection |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 78
Capacity: 110
Deficiencies: 0
Apr 29, 2025
Visit Reason
Licensing Program Analyst Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation of the facility.
Findings
The facility was inspected for compliance with physical plant safety, food supply, medication storage, staff training, and resident care. No deficiencies were cited and the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations.
Report Facts
Hospice waiver capacity: 20
Hospice residents: 5
Hot water temperature range: 109.4-113.7
Fire extinguisher service date: 2025
Smoke detector last tested: 2024
Fire drill last conducted: 2025
Staff training records reviewed: 4
Resident records reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danny Vera | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
Inspection Report
Follow-Up
Census: 78
Capacity: 110
Deficiencies: 0
Feb 19, 2025
Visit Reason
The visit was an unannounced case management follow-up on an Unusual/Special Incident Report regarding a resident fall that required hospital care.
Findings
Based on interviews, file review, and observations, the facility was found to be in compliance with regulations with no deficiencies cited. Technical assistance was provided to document a family care plan meeting for fall prevention.
Report Facts
Census: 78
Total Capacity: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danny Vera | Executive Director | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Amber Lopez | Health & Wellness Director | Provided information regarding resident care and family communication |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the unannounced case management visit |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 110
Deficiencies: 1
Dec 31, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff mismanaged a resident's medication.
Findings
The investigation substantiated that Resident 1 was prescribed Clopidogrel 75mg (Plavix) on October 22, 2024, but the medication was not administered until December 20, 2024, posing an immediate health and safety risk. The facility delayed verifying the medication order until December 20, 2024, despite hospital discharge paperwork being signed by a doctor and considered an official order.
Complaint Details
The complaint alleging staff mismanaged resident's medication was substantiated based on evidence that the medication was not administered timely, posing an immediate health and safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| To receive or reject medical care or other services. This requirement was not met as evidenced by a record review showing Resident 1 was prescribed Clopidogrel 75mg (Plavix) on October 22, 2024 but it was not administered until December 20, 2024, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 110
Census: 80
Deficiency count: 1
Plan of Correction Due Date: Jan 2, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Danny Vera | Administrator | Facility administrator met with the Licensing Program Analyst during the investigation |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 89
Capacity: 110
Deficiencies: 0
Nov 1, 2024
Visit Reason
An unannounced case management visit was conducted to follow up on an Unusual Incident Report received on October 25, 2024, regarding an incident involving a resident and staff member on October 21, 2024.
Findings
Based on observations during the visit, the facility was found to be in compliance with Title 22 Division 6 of the California Code of Regulations, with no deficiencies cited on this date.
Report Facts
Facility capacity: 110
Resident census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danny Vera | Administrator | Met with Licensing Program Analyst during the visit and participated in exit interview |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Annual Inspection
Census: 85
Capacity: 110
Deficiencies: 0
Jul 19, 2024
Visit Reason
An unannounced required annual inspection was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be in compliance with all inspected areas including food storage, resident room conditions, medication security, fire safety systems, and staff certifications. No issues or concerns were observed during the visit.
Report Facts
Hospice residents: 7
Fire clearance capacity: 104
Perishable food supply: 2
Non-perishable food supply: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janette Romero | Licensing Program Analyst | Conducted the inspection visit |
| Danny Vera | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 110
Deficiencies: 0
May 30, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2024-04-19 alleging that facility staff did not provide itemized statements of charges to a resident.
Findings
The investigation found conflicting information regarding the allegation. Some residents confirmed receiving itemized statements, while one resident corroborated the complaint. The Licensing Program Analyst determined that itemized statements are mailed to the facility and placed in residents' mailboxes, and the facility maintains copies to provide upon request. There was insufficient evidence to substantiate the allegation, which was therefore deemed unsubstantiated.
Complaint Details
The complaint alleged that facility staff did not provide itemized statements of charges to a resident. The allegation was unsubstantiated due to insufficient evidence after interviews and record review.
Report Facts
Complaint Control Number: 22-AS-20240419101753
Facility Capacity: 110
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dwayne L Mason | Licensing Program Analyst | Conducted the complaint investigation |
| Tierny Wilburn | Interim Executive Director | Met with Licensing Program Analyst during inspection |
| Lisabelle Paranda | Business Office Manager | Met with Licensing Program Analyst during inspection |
Inspection Report
Follow-Up
Census: 82
Capacity: 110
Deficiencies: 1
Sep 8, 2023
Visit Reason
An unannounced case management visit was conducted to follow up on an incident report received regarding a resident who eloped from the facility and was hospitalized for dehydration.
Findings
The inspection found that the resident was able to elope from the facility without staff knowledge, resulting in hospitalization, which poses an immediate safety risk. One deficiency was cited related to care and supervision responsibilities.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| "Care and supervision" means the facility assumes responsibility for ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidence by; Based on interviews and record review, LPA determined R1 was able to elope from the facility without staff knowledge, resulting in hospitalization, which poses an immediately safety risk to persons in care. | Type A |
Report Facts
Census: 82
Total Capacity: 110
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Gutierrez | Licensing Program Analyst | Conducted the inspection and cited the deficiency |
| Armando J Lucero | Licensing Program Manager | Supervisor of the inspection |
| Samantha Lole | Resident Care Coordinator | Met with Licensing Program Analyst during the visit |
Inspection Report
Annual Inspection
Census: 67
Capacity: 110
Deficiencies: 0
May 24, 2022
Visit Reason
Licensing Program Analyst Lydia Martinez conducted an unannounced Required - 1 Year Annual inspection with an emphasis on Infection Control due to the COVID-19 pandemic.
Findings
The facility appeared clean, sanitary, and well maintained with residents happy and well cared for. No deficiencies were noted during the visit, and all required Department posters were observed.
Report Facts
Residents receiving Hospice care: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Devore | Executive Director | Met with Licensing Program Analyst during inspection and named in report |
| Lydia Martinez | Licensing Program Analyst | Conducted the inspection visit |
| Armando J Lucero | Licensing Program Manager | Named in report |
Inspection Report
Annual Inspection
Census: 68
Capacity: 110
Deficiencies: 0
Jul 15, 2021
Visit Reason
Licensing Program Analyst Jim August conducted an unannounced visit for the purpose of conducting a required annual visit.
Findings
The facility was found to be clean and well maintained with no active COVID-19 cases. All required postings, sanitation supplies, emergency plans, and COVID-19 mitigation measures were observed and approved. No citations were noted during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah DeVore | Administrator | Greeted Licensing Program Analyst and explained reason for visit. |
| James August | Licensing Program Analyst | Conducted the unannounced annual inspection visit. |
| Sheila Santos | Licensing Program Manager | Named in report header. |
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