Inspection Report Summary
Most inspections found no deficiencies, with several complaint investigations determined to be unsubstantiated. However, the facility has had some serious issues over time, including multiple substantiated complaints related to lack of timely medical care, inadequate staffing, and resident neglect resulting in pressure injuries and safety risks. The most recent report from October 28, 2025, substantiated complaints about failure to provide timely medical attention and insufficient staffing, both posing immediate health and safety risks. Earlier investigations also found a medication error and incidents involving resident safety and rights violations, including a staff termination for inappropriate conduct. While some corrective actions were noted, recent findings indicate ongoing challenges in resident care and supervision.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
70% 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: 114
Capacity: 164
Deficiencies: 1
Date: Oct 28, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2025-10-03 alleging that staff did not seek timely medical attention for a resident in care.
Complaint Details
The complaint was substantiated. The allegation that staff failed to seek timely medical attention for a resident was found valid based on photographic evidence, witness statements, and interviews. Six out of nine interviewees confirmed the bruising was identified only in the evening by the resident's daughter, and no timely medical care was provided prior to that.
Findings
The investigation substantiated the complaint, finding that the facility staff failed to ensure timely medical evaluation for Resident 1 despite visible severe bruising. Medical attention was only sought after the resident's daughter discovered the bruising later that evening.
Deficiencies (1)
Facility did not ensure Resident 1 received proper assistance and medical care in a timely manner, posing an immediate health and safety risk to residents in care.
Report Facts
Capacity: 164
Census: 114
Deficiencies cited: 1
Plan of Correction Due Date: Oct 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Goodwin | Executive Director | Assisted with the complaint investigation and was present during exit interview |
| Suzette Paige | Health & Wellness Director | Present during exit interview |
| Michael Tea | Licensing Program Analyst | Conducted the complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 164
Deficiencies: 1
Date: Oct 28, 2025
Visit Reason
The visit was a case management inspection conducted in conjunction with a continued complaint investigation regarding staffing levels at the facility.
Complaint Details
The complaint investigation verified through interviews that seven out of nine interviewees reported inadequate staffing at the time of the incident, negatively affecting quality of care and supervision. The deficiency was substantiated and cited accordingly.
Findings
The investigation found that the facility was inadequately staffed at the time of the incident, with staff responsible for excessive numbers of residents and insufficient supervision, particularly during the nocturnal shift in the Memory Care unit. The facility subsequently increased staffing levels following the incident.
Deficiencies (1)
Facility personnel shall at all times be sufficient in numbers to provide the services necessary to meet resident needs. This requirement was not met as evidenced by lack of proper staffing at the time of the complaint incident, which is an immediate health and safety risk to residents in care.
Report Facts
Census: 114
Total Capacity: 164
Deficiency Count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Goodwin | Executive Director | Met with Licensing Program Analyst during inspection and discussed case management visit |
| Suzette Paige | Health & Wellness Director | Participated in exit interview and received report and appeal rights |
| Michael Tea | Licensing Program Analyst | Conducted the case management visit and complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 164
Deficiencies: 0
Date: Oct 9, 2025
Visit Reason
The inspection was conducted as a case management incident visit to follow up on an incident report regarding elopements of a memory care resident that occurred on October 1 and October 7, 2025.
Complaint Details
The visit was triggered by a complaint related to elopements of a memory care resident diagnosed with Alzheimer's. The complaint was investigated and found to be mitigated by the facility's corrective actions and monitoring.
Findings
The facility was found to have no health and safety issues during the inspection. The facility had addressed the issue of a delayed egress alert by making it more audible and adding an additional siren alert. The resident was safely returned within 20 minutes each time, and the facility followed proper elopement protocols including contacting law enforcement, family, and the resident's primary care physician. No deficiencies were cited at this time.
Report Facts
Elopement incidents: 2
Capacity: 164
Census: 114
Personal caregiver hours: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Goodwin | Executive Director | Met during inspection and involved in discussion of resident care and elopement incidents |
| Suzette Paige | Health and Wellness Director | Submitted the incident report and involved in discussion of resident care and elopement incidents |
| Michael Tea | Licensing Program Analyst | Conducted the case management incident visit |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 164
Deficiencies: 0
Date: Jul 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on July 15, 2025, regarding staff not ensuring resident privacy, inappropriate removal of a resident's door, and use of a resident's room as a passageway to the bathroom.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Michael Tea. Allegations included staff not ensuring resident privacy, inappropriate removal of a resident's door, and use of a resident's room as a passageway to the bathroom. After interviews with residents and staff and review of records, the allegations were determined to be unsubstantiated or unfounded.
Findings
The investigation found that the allegations regarding lack of privacy and inappropriate door removal were unsubstantiated, with residents and staff confirming efforts to accommodate privacy in shared suites. The allegation that a resident's room was used as a passageway to the bathroom was determined to be unfounded. No deficiencies were cited.
Report Facts
Complaint control number: 22-AS-20250715155510
Number of residents interviewed: 9
Number of residents agreeing privacy efforts: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Tea | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| John Goodwin | Executive Director | Facility representative who assisted during the investigation and exit interview |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 111
Capacity: 164
Deficiencies: 0
Date: Jul 15, 2025
Visit Reason
Licensing Program Analyst Michael Tea made an unannounced visit to conduct a continuation of the annual required inspection.
Findings
No deficiencies were noted during the inspection in the areas reviewed, including medication storage and administration, and resident care observations.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Goodwin | Executive Director | Assisted with the continued annual inspection and participated in the exit interview. |
| Michael Tea | Licensing Program Analyst | Conducted the unannounced annual inspection visit. |
Inspection Report
Annual Inspection
Census: 113
Capacity: 164
Deficiencies: 0
Date: Jul 11, 2025
Visit Reason
The visit was an unannounced annual required inspection conducted to evaluate compliance with licensing requirements for the facility.
Findings
The inspection found no deficiencies in the areas inspected during the visit. The facility was generally in compliance with regulations, with all resident and staff files containing required documentation. One emergency pendant in a resident bathroom did not work properly during testing, but staff responded within 15 minutes on a second test.
Report Facts
Residents on hospice: 7
Resident files reviewed: 12
Staff files reviewed: 6
Administrator certificate expiration: Jul 24, 2025
Water temperature range: 110.6-118.4
Inspection start time: 8
Inspection end time: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Goodwin | Executive Director | Met with Licensing Program Analyst during inspection and named in relation to emergency pendant finding |
| Michael Tea | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
| Danielle Chairez | Business Operations Manager | Assisted with the inspection visit |
| Alisa Ortiz | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 164
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on June 2, 2025, alleging that facility staff verbally threatened a resident with eviction and spread lies about a resident.
Complaint Details
The complaint alleged that facility staff verbally threatened a resident with eviction and spread lies about a resident. The investigation determined these allegations to be unsubstantiated based on interviews and observations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews with residents and staff indicated that the alleged verbal threats and spreading of lies did not occur as claimed. No deficiencies were cited.
Report Facts
Capacity: 164
Census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Goodwin | Executive Director | Interviewed regarding resident evictions and assisted with the complaint investigation visit |
| Michael Tea | Licensing Program Analyst | Conducted the complaint investigation visit |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 164
Deficiencies: 1
Date: Jun 10, 2025
Visit Reason
The inspection was a case management incident visit to follow up on an incident report regarding a medication error received by Community Care Licensing on May 21, 2025.
Complaint Details
The visit was triggered by a complaint regarding a medication error involving Resident 1, submitted by Health and Wellness Director Suzette Paige, LVN. The deficiency was substantiated based on interview, document review, and observations.
Findings
The facility did not ensure Resident 1 received assistance with self-administered medications as prescribed, resulting in a medication error. The facility was otherwise observed to be clean and organized with no other health and safety issues.
Deficiencies (1)
Facility did not ensure Resident 1 received assistance with self-administered medications due to medication not given as prescribed, resulting in a medication error.
Report Facts
Deficiency Plan of Correction Due Date: Jun 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Goodwin | Executive Director | Met with Licensing Program Analyst during inspection and named in exit interview |
| Suzette Paige | Health and Wellness Director, LVN | Submitted the incident report regarding medication error |
| Michael Tea | Licensing Program Analyst | Conducted the case management incident visit |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 164
Deficiencies: 1
Date: Feb 20, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-07-09 alleging that a resident sustained multiple pressure injuries due to neglect.
Complaint Details
The complaint was substantiated. Resident 1 was found with multiple pressure injuries after an unwitnessed fall and being left on the floor for one to two days. The resident was admitted to UC Irvine Medical Center with multiple traumas and later passed away. Interviews revealed conflicting staff statements about resident checks.
Findings
The investigation found that Resident 1 sustained multiple pressure injuries as a result of an unwitnessed fall and being left on the floor for approximately one to two days, posing an immediate risk to resident health and safety. The complaint was substantiated.
Deficiencies (1)
Basic services shall at a minimum include care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by Resident 1 sustaining pressure injuries due to neglect.
Report Facts
Capacity: 164
Census: 114
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| John Goodwin | Executive Director | Facility administrator met during the investigation |
| Suzette Paige | Health and Wellness Director | Reported activation of 9-1-1 and involved in resident care |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 164
Deficiencies: 1
Date: Dec 24, 2024
Visit Reason
An unannounced visit was conducted to deliver findings related to allegations of sexual abuse involving a resident and staff member, following a self-reported incident and subsequent investigation.
Complaint Details
The visit was complaint-related due to allegations of sexual abuse by Staff 1 towards Resident 1. The complaint was substantiated based on interviews, police investigation, and facility records. Staff 1 admitted to inappropriate comments and showing explicit photos but denied any physical sexual acts. Staff 1 was terminated.
Findings
The investigation confirmed that Staff 1 engaged in inappropriate sexually explicit conversations and showed explicit images to Resident 1, repeatedly entered the resident's room without knocking, and violated the resident's personal rights. Staff 1 was terminated for violating facility harassment policies.
Deficiencies (1)
Based on interviews with residents, staff and documents reviewed, S1 engaged in inappropriate conversations and showed sexually explicit photographs to R1 and repeatedly entered their room without knocking which poses an immediate safety and personal rights risk to persons in care.
Report Facts
Capacity: 164
Census: 116
Plan of Correction Due Date: Dec 27, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Goodwin | Executive Director | Met during inspection and involved in exit interview |
| Michael Tea | Licensing Program Analyst | Conducted the unannounced visit and investigation |
| Alisa Ortiz | Licensing Program Manager | Supervisor overseeing the investigation and report |
| Danielle Chairez | Business Office Manager | Met during inspection visit |
Inspection Report
Census: 113
Capacity: 164
Deficiencies: 0
Date: Aug 13, 2024
Visit Reason
The visit was an unannounced case management inspection conducted by Licensing Program Analyst Michael Tea.
Findings
The Licensing Program Analyst amended reports LIC809 and LIC809C dated 08/12/2024 and reviewed the amended report with the Executive Director. An exit interview was conducted and copies of the reports were provided to the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Tea | Licensing Program Analyst | Conducted the unannounced case management visit and amended reports. |
| John Goodwin | Executive Director | Greeted the Licensing Program Analyst and participated in the exit interview. |
Inspection Report
Census: 113
Capacity: 164
Deficiencies: 0
Date: Aug 12, 2024
Visit Reason
The inspection was a case management incident visit to follow up on an incident report received by Community Care Licensing on August 9, 2024, submitted by the Health and Wellness Director.
Findings
During the inspection, no health and safety concerns were observed. The facility was clean and organized, food supplies were adequately stocked, utilities were functioning, and medications and toxins were properly stored. No deficiencies were cited at this time.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Goodwin | Executive Director | Met with Licensing Program Analyst during inspection and involved in the exit interview. |
| Suzette Paige | Health and Wellness Director | Submitted the incident report that triggered the inspection. |
| Michael Tea | Licensing Program Analyst | Conducted the case management incident visit. |
Inspection Report
Annual Inspection
Census: 110
Capacity: 164
Deficiencies: 1
Date: Jul 19, 2024
Visit Reason
The visit was an unannounced annual required inspection conducted to evaluate compliance with licensing regulations at the facility.
Findings
The facility was generally found to be in compliance with regulations, including operational safety systems, adequate resident accommodations, and proper medication administration. However, a deficiency was cited for accessible cleaning supplies and disinfectants in the memory care unit, posing a health and safety risk.
Deficiencies (1)
Cleaning supplies and disinfectants were found accessible to residents in the memory care unit dining room area and one resident's room, posing an immediate health and safety risk.
Report Facts
Licensed capacity: 164
Current census: 110
Plan of Correction due date: Jul 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Tea | Licensing Program Analyst | Conducted the inspection and authored the report |
| John Goodwin | Executive Director | Facility Executive Director who assisted during the visit and participated in the exit interview |
| Danielle Chairez | Business Operations Manager | Greeted the Licensing Program Analyst and explained the reason for the visit |
| Alisa Ortiz | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 164
Deficiencies: 1
Date: Jul 11, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that lack of staff supervision resulted in a resident being left on the floor for an extended period of time.
Complaint Details
The complaint was substantiated regarding lack of staff supervision resulting in a resident being left on the floor for an extended period, leading to injury. The allegation of lack of care and supervision resulting in injury was unsubstantiated due to insufficient evidence.
Findings
The investigation substantiated that a resident (R1) was left on the floor for at least 24 hours after a fall resulting in a broken hip due to lack of staff supervision and failure to monitor the resident's whereabouts. Facility staff failed to use the Resident Meal Check Record properly, and the resident's pendant was out of reach. Immediate civil penalties were assessed. Another allegation regarding lack of care and supervision resulting in injury was unsubstantiated due to insufficient evidence.
Deficiencies (1)
Failure to ensure resident received care and supervision when left on the floor for an extended period after a fall, posing immediate safety risk.
Report Facts
Capacity: 164
Census: 93
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Goodwin | Administrator | Met with Licensing Program Analyst during investigation and provided information related to findings |
| Sean Haddad | Licensing Program Analyst | Conducted the complaint investigation |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 164
Deficiencies: 0
Date: Apr 24, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2024-04-16 alleging financial abuse at the facility.
Complaint Details
The complaint alleged financial abuse. After investigation including interviews with three staff members and one resident, and review of records, the allegation was deemed unfounded.
Findings
The investigation determined that the alleged individual involved in the financial abuse was not employed by the facility. Based on interviews and record reviews, the complaint was found to be unfounded and was dismissed.
Report Facts
Capacity: 164
Census: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Goodwin | Executive Director II | Named in the investigation and authorized the exit interview |
| Jessica Cho | Licensing Program Analyst | Conducted the complaint investigation |
| Danielle Chairez | Business Office Manager | Met with the Licensing Program Analyst and participated in the investigation |
Inspection Report
Complaint Investigation
Capacity: 164
Deficiencies: 0
Date: Apr 16, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that a lack of care and supervision resulted in a resident falling several times.
Complaint Details
The complaint alleged that a lack of care and supervision resulted in a resident falling several times. The resident was newly diagnosed with Parkinson's disease and had episodes of dizziness and anxiety causing falls. Staff implemented safety checks and encouraged use of assistive devices. The allegation was found unsubstantiated.
Findings
The investigation included interviews, a tour of the facility, and review of pertinent documents. The Department was unable to ascertain if the allegation occurred as reported and deemed the allegation unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 164
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Goodwin | Executive Director | Met with Licensing Program Analyst during investigation |
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Armando J Lucero | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 164
Deficiencies: 0
Date: Apr 1, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation of lack of care and supervision resulting in an unstageable wound on a resident.
Complaint Details
The complaint was unsubstantiated after investigation, which included interviews, document review, and observations. The allegation was that lack of care and supervision caused an unstageable wound, but evidence was insufficient to confirm this.
Findings
The investigation involved interviews and record reviews and found insufficient evidence to substantiate the allegation. The resident was discharged from the hospital without documented skin breakdown, wounds were first observed by facility staff on January 14, 2024, and the family expressed satisfaction with the care provided.
Report Facts
Facility capacity: 164
Census: 106
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and made the unannounced visit |
| Danielle Chairez | Business Office Manager | Met with the Licensing Program Analyst during the visit and participated in the exit interview |
| John Goodwin | Administrator | Named as facility administrator |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 164
Deficiencies: 0
Date: Feb 9, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that a resident sustained multiple falls due to lack of care and supervision.
Complaint Details
The complaint alleged that a resident sustained multiple falls due to lack of care and supervision. The allegation was unsubstantiated after investigation, interviews, and documentation review.
Findings
The investigation found that staff responded appropriately to the resident's fall and that the resident was taken to the hospital for evaluation. Documentation and interviews did not corroborate the allegation, and there was insufficient evidence to prove or refute the claim, resulting in the allegation being deemed unsubstantiated.
Report Facts
Complaint Control Number: 22
Complaint Control Number: 20240201085538
Staff response time: 9
Facility capacity: 164
Resident census: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Suzette Paige | Health and Wellness Director | Met with the investigator and participated in interviews |
| John Goodwin | Administrator | Facility administrator named in the report |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 164
Deficiencies: 0
Date: Oct 4, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff do not respond to resident calls on the signal system and that the facility's signal system is not functioning properly.
Complaint Details
The complaint was unsubstantiated due to conflicting information and insufficient evidence to prove or refute the allegations.
Findings
The investigation included file reviews, interviews with residents and staff, and testing of the signal system pendants. Conflicting information was found regarding staff response times and signal system functionality. Due to lack of preponderance of evidence, the allegations were deemed unsubstantiated.
Report Facts
Staff response time range: 40
Staff response time range: 790
Capacity: 164
Census: 97
Staff response time reported by residents: 15
Staff response time reported by residents: 30
Staff response time reported by Executive Director: 20
Smartcare pendant call log response time range: 1
Smartcare pendant call log response time range: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alvaro Ramirez Jr. | Licensing Program Analyst | Conducted the complaint investigation |
| John Goodwin | Executive Director | Met with Licensing Program Analyst during investigation and provided statements regarding staff response times |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 164
Deficiencies: 0
Date: May 25, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-04-21 regarding staff response times, presence of insects, and availability of toiletries in public bathrooms.
Complaint Details
The complaint included allegations that staff were not responding timely to resident pendants, the facility had insects, and lacked toiletries in public bathrooms. The investigation included interviews, tours, and record reviews. The allegations were found to be unsubstantiated or unfounded based on observations and interviews.
Findings
The investigation found that staff response times to resident pendants varied between 10-45 minutes with mixed interview reports; no evidence of water contamination or malodor was found; insect presence was minimal and not substantiated by pest control records; toiletries were generally available though some interviews noted occasional shortages. Overall, allegations were deemed unsubstantiated or unfounded with no citations issued.
Report Facts
Interviews conducted: 11
Facility capacity: 164
Facility census: 69
Staff response time range (minutes): 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| John Goodwin | Executive Director | Facility representative met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 164
Deficiencies: 2
Date: Feb 10, 2023
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that the facility did not have hot water.
Complaint Details
The complaint was substantiated based on evidence gathered through record reviews and interviews. The allegation was that the facility did not have hot water in parts of the facility, which was confirmed during the investigation.
Findings
The investigation substantiated the complaint that from 01/28/2023 to 02/04/2023, at least five resident rooms lacked hot water, posing a potential health and safety risk. Repairs were completed on 02/04/2023, and the facility notified residents and responsible parties while providing alternate rooms with hot water.
Deficiencies (2)
Maintenance and Operation - Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degrees F.
This requirement was not met as evidenced by: From 1/28/23 until 2/4/23; hot water was not available in resident rooms, 335, 230, 109 and 210. This poses a potential health and safety risk to residents in care.
Report Facts
Resident rooms without hot water: 5
Hot water temperature: 113
Hot water temperature: 115
Plan of Correction due date: Feb 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Luz Adams | Licensing Program Manager | Named in relation to the licensing program management and report |
| Danielle Chairez | Business Office Manager | Met with Licensing Program Analyst during investigation |
| Carole Presley | Clinical Specialist | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 86
Capacity: 164
Deficiencies: 0
Date: Jul 14, 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 mitigation plans were observed and approved. No citations were noted during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim August | Licensing Program Analyst | Conducted the unannounced annual visit and approved the LIC808 Mitigation Plan. |
| Kimia Ataeian | Administrator | Greeted the Licensing Program Analyst and explained the reason for the visit. |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 164
Deficiencies: 0
Date: Jun 9, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that a resident sustained an injury while in care and that staff did not seek medical attention in a timely manner.
Complaint Details
The complaint involved a resident (R1) who allegedly sustained a burn injury from a coffee spill on October 16, 2021, and claims that staff did not seek timely medical attention. Interviews with staff and the resident revealed conflicting accounts, but ultimately the resident refused hospital care initially and the facility treated the injury. The resident was later hospitalized due to difficulty moving. The investigation concluded the allegations were unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. No deficiencies were observed, no citations were issued, and the allegations were determined to be unsubstantiated.
Report Facts
Facility capacity: 164
Census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James August | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Kimia Ataeian | Administrator | Interviewed regarding the incident and facility response |
| Danielle Chairez | Business Office Director | Met with during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 164
Deficiencies: 1
Date: Jun 9, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted to address multiple allegations including questionable death, residents left in soiled diapers for prolonged time, understaffing, inadequate care and supervision, presence of mold, and facility disrepair.
Complaint Details
The complaint investigation was triggered by allegations including questionable death, residents left in soiled diapers for prolonged time, understaffing, inadequate care and supervision, mold, and disrepair. The allegation that staff did not seek timely medical care for resident 1 was substantiated. The other allegations were unsubstantiated.
Findings
The investigation found insufficient evidence to substantiate most allegations such as mold, understaffing, and residents left in soiled diapers. However, the allegation that staff did not seek timely medical care for a resident was substantiated, resulting in a deficiency citation. No other deficiencies or citations were issued.
Deficiencies (1)
Failure to immediately telephone 9-1-1 when an injury or other circumstance resulted in an imminent threat to a resident's health.
Report Facts
Capacity: 164
Census: 77
Deficiencies cited: 1
Plan of Correction Due Date: Jun 10, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimia Ataeian | Administrator | Interviewed regarding resident death and facility practices |
| Danielle Chairez | Business Office Director | Met with during inspection and exit interview |
| James August | Licensing Program Analyst | Conducted the complaint investigation |
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