Inspection Report Summary
Most inspections found no deficiencies, with several complaint investigations unsubstantiated. However, the facility has had multiple substantiated issues primarily related to medication management, timely staff response to call systems, and staffing adequacy, some of which posed immediate risks to resident health and safety. Civil penalties were assessed on several occasions, including for repeated failures to respond to call buttons and for lacking a qualified administrator. The most recent report from October 2, 2025, was clean with no deficiencies, indicating improvement after earlier issues were addressed. Older deficiencies involving medication errors and staffing were resolved or followed up on, showing a trend toward compliance in recent months.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Census: 101
Capacity: 140
Deficiencies: 0
Oct 2, 2025
Visit Reason
The visit was an unannounced case management visit to follow up on a suspected adult/elder financial abuse report submitted on 2025-09-24.
Findings
The suspected abuser was determined to be an outside party not involving the facility or its staff, and no deficiencies were observed or cited during the visit. Relevant parties including law enforcement and Ombudsman were cross reported.
Complaint Details
The visit was complaint-related to suspected adult/elder financial abuse, but the complaint was not substantiated as it involved an outside party beyond the facility's jurisdiction.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Gustin | Administrator | Met with Licensing Program Analyst during the case management visit. |
| Marissa Vargas | BOM | Met with Licensing Program Analyst during the case management visit. |
| Marisol Cuadra | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 102
Capacity: 140
Deficiencies: 0
Sep 9, 2025
Visit Reason
Unannounced case management visit to follow up on five self-incident reports and one death report related to falls in the assisted living unit.
Findings
The visit reviewed multiple incidents involving resident falls and hospitalizations, including one resident death. Updated care plans and increased monitoring were noted, but no citations were issued during the visit.
Report Facts
Incident reports followed up: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Gustin | Administrator | Met with Licensing Program Analyst during the inspection and involved in incident discussions. |
| Marisol Cuadra | Licensing Program Analyst | Conducted the unannounced case management visit and reviewed incident reports. |
| Bethany Moellers | Licensing Program Manager | Named in report header and signature sections. |
Inspection Report
Follow-Up
Census: 99
Capacity: 140
Deficiencies: 3
Aug 13, 2025
Visit Reason
The inspection was an unannounced case management visit to follow up on uncleared deficiencies cited during a complaint investigation on 2025-07-17.
Findings
The Administrator provided proof of correction for previously cited deficiencies related to resident needs follow-up and staffing schedules. Deficiencies cited on 2025-07-17 were cleared as of this visit.
Complaint Details
Visit was a follow-up to complaint investigation #21-AS-20250602090022 dated 2025-07-17. Outstanding citations from that investigation were addressed during this visit.
Deficiencies (3)
| Description |
|---|
| §1569.269 (a)(6) - written plan ensuring that the facility is following up on resident's needs timely. |
| 87411(a) - staffing schedule for July and August 2025 ensuring adequate staffing to meet residents' medication management needs. |
| 87625(b)(3) - staffing schedule reflecting additional hired staffing to assist residents with incontinent care needs timely. |
Report Facts
Facility capacity: 140
Census: 99
Dates of outstanding citations: 3
Inspection start time: 848
Inspection end time: 1147
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Gustin | Executive Director/Administrator | Met with Licensing Program Analyst during inspection and provided proof of correction for deficiencies |
| Marisol Cuadra | Licensing Program Analyst | Conducted the unannounced case management inspection |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 140
Deficiencies: 0
Jul 17, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff were not keeping an accurate record of residents' payments.
Findings
The investigation found that a system glitch caused rejection of in-person check payments and automatic late fees, but the facility notified the resident to ignore these fees and provided consistent account records. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged staff were not keeping accurate records of resident payments, specifically citing late fees and billing discrepancies for resident R1. The allegation was found unsubstantiated after review and interviews.
Report Facts
Late fee amount: 250
Resident bill amount: 6784
Resident bill amount: 13985.52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marisol Cuadra | Licensing Program Analyst | Conducted the complaint investigation |
| Patricia Gustin | Executive Director/Administrator | Met with investigator during complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 140
Deficiencies: 1
Apr 21, 2025
Visit Reason
The visit was an unannounced case management follow-up on a self-incident report regarding a medication error involving resident R1.
Findings
The facility failed to properly assist resident R1 with prescribed medication Namenda 5mg and 10mg, resulting in medication overdosing. The resident was monitored with no reported discomfort, and corrective actions including care plan updates and staff retraining were planned. A civil penalty was assessed for a repeat violation within 12 months.
Complaint Details
The visit was triggered by a self-incident report dated 2025-04-07 regarding a medication error. The complaint was substantiated as the facility did not comply with medication assistance requirements, posing an immediate health and safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly assist resident R1 with prescribed medication Namenda 5mg and 10mg, resulting in overdosing. | Type A |
Report Facts
Capacity: 140
Census: 74
Plan of Correction Due Date: Apr 22, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marisol Cuadra | Licensing Program Analyst | Conducted the inspection and signed the report |
| Bethany Moellers | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Daniela Oseguera | Business Office Manager | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Capacity: 140
Deficiencies: 0
Mar 5, 2025
Visit Reason
The inspection visit was conducted as a continuation of the Annual inspection originally conducted on 2025-02-19, to complete the annual compliance evaluation of the facility.
Findings
The annual inspection was completed with deficiencies cited from the California Code of Regulations and the Health and Safety Code. Appeal rights were given and discussed with the Administrator. Failure to correct deficiencies or repeat deficiencies within 12 months may result in civil penalties.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Alvarado | Administrator | Met with during inspection and discussed appeal rights |
| Christi Coppo | Licensing Program Analyst | Conducted the inspection visit |
| Victoria Bertozzi | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Capacity: 140
Deficiencies: 2
Mar 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-01-27 regarding staff response times to pendant call system and care related to incontinence briefs.
Findings
The investigation substantiated that staff did not respond timely to pendant call system alerts, with 42 of 192 calls receiving no response and some residents waiting over 15 minutes. It was also substantiated that two residents requiring assistance with incontinence briefs experienced long wait times, sometimes over an hour. Another allegation of rough treatment was found unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not respond timely to pendant call system alerts and left residents in soiled incontinence briefs for extended periods. The allegation of rough treatment was unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure pendant call button system is operational and staff respond timely to calls, with 42 of 192 calls unanswered between 2/9/25 and 2/13/25. | Type B |
| Failure to ensure incontinent residents are kept clean and dry, with two residents waiting over an hour for staff assistance to change briefs. | Type B |
Report Facts
Pendant call button presses: 192
Unanswered pendant calls: 42
Residents interviewed: 8
Residents requiring incontinence assistance: 2
Capacity: 140
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Alvarado | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Christi Coppo | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager overseeing investigation |
Inspection Report
Annual Inspection
Capacity: 140
Deficiencies: 7
Feb 19, 2025
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations and facility operations.
Findings
The inspection found multiple deficiencies including expired administrator certification, failure of the automatic sprinkler system inspection, uncovered food items, inadequate staff fingerprint clearances, incomplete staff training hours, unsanitary conditions in the Memory Care kitchen, and a notable urine odor in the Memory Care unit. Some deficiencies posed immediate health, safety, or personal rights risks to residents.
Severity Breakdown
Type A: 5
Type B: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Administrator does not have an actively current Administrator certificate. | Type A |
| Automatic Sprinkler System failed inspection; riser pressure gauges over 5 years old and need replacement; water flow switch for sprinklers did not activate alarm. | Type A |
| Emergency exit door propped open with a brick. | Type A |
| Seven staff did not have fingerprint clearance. | Type A |
| Trash, food scraps, discarded food items, and used paper towels piled underneath sink in Memory Care kitchen. | Type B |
| Four staff did not have required training hours completed. | Type B |
| Notable urine smell coming from room next to Sauna room in Memory Care. | Type B |
Report Facts
Capacity: 140
Water temperature: 148
Water temperature: 109
Water temperature: 110.4
Deficiency counts: 7
Staff records reviewed: 7
Resident records reviewed: 7
Fire extinguisher inspection dates: 2
Disaster drill date: Jan 29, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Alvarado | Administrator | Named in deficiency for expired administrator certificate. |
| Danielle Oseguera | Business Operations Manager | Discussed staff fingerprint clearance issues during inspection. |
| Christi Coppo | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Ali Deniz | Licensing Program Analyst | Conducted the inspection. |
| Victoria Bertozzi | Licensing Program Manager | Supervisor of the inspection. |
Inspection Report
Complaint Investigation
Capacity: 140
Deficiencies: 1
Jan 9, 2025
Visit Reason
The visit was an unannounced case management inspection to amend a previous citation (9009D) issued on 12/27/2024 related to complaint 21-AS-20241217154914. The purpose was to address deficiencies regarding failure to submit an Incident Report related to a substantiated complaint allegation.
Findings
The inspection found that the facility failed to submit an Incident Report for a medication error involving resident R1, which posed a potential health, safety, or personal rights risk. A citation was issued for this deficiency, amending the previous citation to be cited under case management deficiencies (809D).
Complaint Details
The visit was triggered by complaint 21-AS-20241217154914. The allegation was substantiated, but the facility failed to submit the required Incident Report to the licensing agency.
Deficiencies (1)
| Description |
|---|
| Failure to submit an Incident Report for R1's medication error within the required timeframe, posing a potential health, safety, or personal rights risk. |
Report Facts
Plan of Correction Due Date: Jan 10, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Alvarado | Administrator | Met with Licensing Program Analyst during inspection and discussed appeal rights |
| Christi Coppo | Licensing Program Analyst | Conducted the inspection and issued the citation |
| Victoria Bertozzi | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Capacity: 140
Deficiencies: 1
Jan 9, 2025
Visit Reason
The visit was an unannounced Case Management - Incident inspection triggered by reported incidents including missing resident cash and a medication error involving administration of another resident's medications.
Findings
The facility reported two incidents: a resident missing $500-$600 in cash and a medication error where a resident was given another resident's medications, resulting in hospitalization. A deficiency was cited related to the medication error, requiring a plan of correction.
Complaint Details
The visit was complaint-related due to incidents reported by the facility: missing resident cash and a medication error. The medication error was substantiated with a deficiency cited. The missing cash incident had no deficiencies cited.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assist residents with self-administered medications as needed, resulting in another resident's medication being administered to R2, posing an immediate health, safety, or personal rights risk. | Type A |
Report Facts
Capacity: 140
Incident dates: 2
Plan of Correction Due Date: Jan 17, 2025
Alert charting duration: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Alvarado | Administrator | Met with Licensing Program Analyst during inspection and involved in incident reporting |
| Christi Coppo | Licensing Program Analyst | Conducted the unannounced inspection and authored the report |
| Victoria Bertozzi | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Capacity: 140
Deficiencies: 1
Jan 9, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to complaints alleging the facility did not provide the correct refund to a resident's authorized representative, billed after resident's departure for incontinence items, and did not return a rented wheelchair.
Findings
Two allegations were substantiated: the facility did not provide the correct refund to the resident's authorized representative and billed incontinence items after the resident's departure. One allegation regarding failure to return a rented wheelchair was unsubstantiated due to lack of evidence.
Complaint Details
The complaint investigation was substantiated for two allegations: incorrect refund to resident's authorized representative and erroneous billing for incontinence items after resident's departure. The allegation that the facility did not return a rented wheelchair was unsubstantiated due to insufficient evidence.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not provide resident's authorized representative with the correct refund and billed resident's authorized representative after resident's departure for incontinence items, posing a potential health, safety or personal rights risk to persons in care. | Type B |
Report Facts
Capacity: 140
Charges billed in error: 3
Refund amount: 307.5
Plan of Correction Due Date: Jan 16, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christi Coppo | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Victoria Bertozzi | Licensing Program Manager | Oversaw the complaint investigation |
| Robert Alvardo | Acting Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 140
Deficiencies: 1
Dec 27, 2024
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that the licensee failed to administer medications as prescribed by a physician.
Findings
The investigation substantiated that resident R1 received an incorrect dose of Sevelamer Carbonate from 11/27/24 through 12/16/24, which posed an immediate health and safety risk. The facility failed to report the medication error to Community Care Licensing and did not submit an incident report.
Complaint Details
Complaint was substantiated. The allegation was that the licensee failed to administer medications as prescribed by the physician. The preponderance of evidence standard was met based on record review.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assist residents with self-administered medications as needed, resulting in incorrect dosing of Sevelamer for resident R1 from 11/27/24 through 12/16/24. | Type A |
Report Facts
Capacity: 140
Census: 140
Deficiency Type A: 1
Plan of Correction Due Date: Dec 30, 2024
Proof of training submission date: Jan 3, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christi Coppo | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Victoria Bertozzi | Licensing Program Manager | Oversaw the complaint investigation |
| Robert Alvarado | Administrator | Facility administrator met during investigation and involved in exit interview |
Inspection Report
Complaint Investigation
Capacity: 140
Deficiencies: 2
Nov 15, 2024
Visit Reason
Licensing Program Analyst Christi Coppo arrived unannounced to open a complaint investigation at the facility due to concerns about the absence of a qualified and certified Administrator.
Findings
The facility did not have a qualified and currently certified Administrator present. The Interim Administrator lacked fingerprint clearance and an active Administrator certificate, posing an immediate health, safety, or personal rights risk to residents. Deficiencies were cited and a civil penalty was assessed.
Complaint Details
Complaint investigation opened due to absence of a qualified Administrator. Interim Administrator lacks fingerprint clearance and active certification. Civil penalty assessed.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Interim Administrator does not have fingerprint clearance as required for criminal record clearance. | Type A |
| Interim Administrator does not have an actively current Administrator certificate as required. | Type A |
Report Facts
Capacity: 140
Deficiency Type A count: 2
Plan of Correction Due Date: Nov 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christi Coppo | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kelly Ording | Administrator | Administrator of record no longer employed at the facility |
| Jannluy Trevino | Interim Administrator | Interim Administrator lacking fingerprint clearance and active certification |
| Karin Berry | Sales Manager | Met with Licensing Program Analyst during inspection and discussed appeal rights |
| Victoria Bertozzi | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Capacity: 140
Deficiencies: 1
Aug 13, 2024
Visit Reason
The visit was an unannounced case management inspection regarding an incident report received on 2024-08-09 about a resident elopement.
Findings
The investigation found that a resident with dementia eloped due to a north egress door not latching properly, causing the alarm not to sound. The resident was found safe and returned without injury. Staff training and an elopement drill were conducted following the incident.
Complaint Details
The visit was complaint-related due to an incident report of resident elopement. The report details the investigation and corrective actions taken.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Incident of resident elopement, which poses a potential health, safety or personal rights risk to residents in care. | Type B |
Report Facts
Capacity: 140
Plan of Correction Due Date: Aug 20, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christi Coppo | Licensing Program Analyst | Conducted the case management visit and signed the report |
| Victoria Bertozzi | Licensing Program Manager | Supervisor and named in the report |
| Kelly Ording | Administrator | Met with during inspection and involved in exit interview |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 140
Deficiencies: 0
Jul 11, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility did not notify the responsible party of a resident's change of condition and did not seek timely medical care for the resident.
Findings
The investigation included interviews and document reviews and found that the resident had been declining for about a year with low appetite and medication refusal due to pill size. On the day of passing, the resident became unresponsive and died at the facility. The complaint was determined to be unsubstantiated due to insufficient evidence to prove violations.
Complaint Details
The complaint alleged failure to notify the responsible party of the resident's change of condition and failure to seek timely medical care. The complaint was found to be unsubstantiated based on record review and inconsistent statements during interviews.
Report Facts
Capacity: 140
Census: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Gallagher | Director of Health and Wellness | Met with Licensing Program Analyst during investigation |
| Alex Baiasu | Temporary Administrator | Contacted by phone and gave permission for Director of Health and Wellness to sign |
| Christi Coppo | Licensing Program Analyst | Conducted the complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 140
Deficiencies: 0
Jun 11, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not following a resident's needs and services plan, specifically regarding the care and rotation frequency of Resident 1.
Findings
The investigation included document reviews, interviews, and observations which revealed inconsistent statements about care provision. The Licensing Program Analyst was unable to determine if violations occurred due to conflicting information and evidence showing improvement in the resident's condition. The allegation was found to be unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint alleged that staff did not follow Resident 1's care plan by failing to change or rotate the resident every two hours as required. The investigation found inconsistent statements from staff and family, with some family members stating care was refused and others stating it was not. Hospice provider observations indicated care was provided and pressure injuries were improving. Ultimately, the complaint was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Complaint Control Number: 21-AS-20240118085437
Facility Capacity: 140
Census: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caitlynn Felias | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager on report |
| Heidi Gallagher | Health and Wellness Director | Met with Licensing Program Analyst during investigation |
| Alex Baiasu | Interim Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 140
Deficiencies: 0
Mar 19, 2024
Visit Reason
The unannounced visit was conducted as a case management inspection pertaining to Incident Reports received by Community Care Licensing on 2/15/2024 and 2/20/2024.
Findings
The inspection found that the facility lacked a current certified Administrator, with a corporate representative temporarily filling the role but with an expired certificate in renewal status. Staff encountered combative and profane behavior from a resident's family member who was denying staff access to administer pain management medications, which were ultimately administered by hospice staff. Another incident involved a resident with suspected osteomyelitis whose care plan did not reflect the need for foot care, prompting a recommendation to update the care plan. No deficiencies were cited.
Complaint Details
The visit was complaint-related based on incident reports involving resident care issues on 2/15/2024 and 2/20/2024. The complaint regarding denial of staff access to a resident for medication administration was investigated and addressed. The complaint about foot care needs for another resident was reviewed with recommendations for care plan updates. No substantiation status was explicitly stated.
Report Facts
Incident Reports: 2
Staff care attempts: 10
Plan submission deadline: Apr 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katelyn Ledesma | Administrator | Former Administrator, position currently vacant |
| Dimple Kamdar | Operations Specialist | Interim corporate representative during Administrator vacancy |
| Heidi Gallagher | Health and Wellness Director | Informed about resident care incidents and involved in care coordination |
| Christi Coppo | Licensing Program Analyst | Conducted the inspection visit |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 82
Capacity: 140
Deficiencies: 2
Feb 15, 2024
Visit Reason
The inspection was an unannounced annual continuation visit to evaluate compliance with regulations for an assisted living and memory care facility.
Findings
The facility was found to have well-organized staff files but had deficiencies including two staff members lacking current first aid certificates and one resident's routine medications not being properly documented or centrally stored as required.
Severity Breakdown
Technical Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Two staff members did not have current first aid certificates (Technical Violation, LIC9102, H&S Code 1569.618(c)(3)). | Technical Violation |
| One resident had three routine medications that were not documented or centrally stored as required (LIC809D, 87465(h)(6)). | — |
Report Facts
Direct care staff on-site: 7
Staff files reviewed: 5
Resident medications reviewed: 4
Hospice waiver capacity: 15
Fire clearance capacity: 140
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marissa Vargas | Resident Care Coordinator | Met with Licensing Program Analyst during inspection |
| Heidi Gallagher | Health and Wellness Director | Met with Licensing Program Analyst during inspection |
| Danielle Oseguera | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Katelyn Ledesma | Administrator | Facility Administrator named in report header |
Inspection Report
Routine
Census: 80
Capacity: 140
Deficiencies: 0
Jan 26, 2024
Visit Reason
Unannounced Required 1 Year visit to evaluate compliance with regulations for an assisted living and memory care facility.
Findings
The facility was found to be clean, well-maintained, and compliant with regulations including infection control, food supply, safety features, and documentation. No deficiencies were cited during the visit.
Report Facts
Direct care staff on-site: 6
Sample size of sinks tested for hot water temperature: 10
Sample size of resident files reviewed: 8
Fire extinguisher last inspection date: 2023
Approved hospice waiver capacity: 15
Fire clearance capacity: 140
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marissa Vargas | Resident Care Coordinator | Met with Licensing Program Analyst during inspection. |
| Heidi Gallagher | Health and Wellness Director | Met with Licensing Program Analyst during inspection and received report. |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection visit. |
| Kimberley Mota | Licensing Program Manager | Named in report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 140
Deficiencies: 2
Jan 8, 2024
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff did not repair a resident's pull cord device and did not respond timely to resident alerts.
Findings
Investigation substantiated that some resident pull cords were inoperable and call system occasionally failed, resulting in residents waiting 30 minutes or longer for assistance or not receiving assistance at all. Immediate civil penalty of $500 was assessed for repeat violations.
Complaint Details
Complaint was substantiated based on record review and staff interviews confirming that residents' pull cords were not repaired and call system failures caused delayed or absent responses to resident calls.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility personnel were insufficient and incompetent to meet resident needs, evidenced by residents waiting 30 minutes or longer for assistance or not receiving assistance. | Type A |
| Facility signal systems were not properly maintained; call cords needed replacement and pagers did not always indicate resident calls. | Type A |
Report Facts
Civil penalty amount: 500
Resident wait time: 30
Deficiency count: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caitlynn Felias | Licensing Program Analyst | Conducted the complaint investigation and signed the report. |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Danielle Oseguera | Business Office Manager | Met with Licensing Program Analyst during investigation and involved in plan of correction discussions. |
Inspection Report
Complaint Investigation
Capacity: 140
Deficiencies: 0
Nov 30, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-10-23 regarding allegations that facility staff did not ensure that a resident's call button was accessible and that the facility was not meeting the needs of a resident in care.
Findings
The investigation found that the pull cord call button was accessible and laying on the resident's bed, and that the resident did not require one-to-one supervision as confirmed by the resident's doctor. The allegations were unsubstantiated and no deficiencies were cited during the inspection.
Complaint Details
The complaint alleged that the resident's call button was not accessible because the pull cord was tucked behind the bed, and that the facility was not meeting the resident's needs by failing to provide constant supervision. The investigation found no evidence to substantiate these allegations.
Report Facts
Facility capacity: 140
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Bertozzi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Hope DeBenedetti | Licensing Program Manager | Named in report as Licensing Program Manager |
| Robert Alvarado | Met with Licensing Program Analyst during investigation | |
| Katelyn Ledesma | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Capacity: 140
Deficiencies: 1
Nov 30, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that the facility failed to respond to a resident's pendant/call button/phone calls.
Findings
The investigation substantiated the allegation that staff failed to respond to residents' call pendants on multiple occasions, posing an immediate risk to resident health and safety. A civil penalty of $250 was assessed for repeated violations within a 12-month period.
Complaint Details
The complaint was substantiated based on document review and evidence that staff failed to respond to residents' pendants/call buttons multiple times. A civil penalty was assessed for repeating regulation 87411(a) more than once in a 12 month period.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel did not respond to residents' call bells, failing to meet personnel requirements to provide necessary services. | Type A |
Report Facts
Civil Penalty Amount: 250
Facility Capacity: 140
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Bertozzi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Robert Alvarado | Facility representative met with during the investigation. | |
| Katelyn Ledesma | Administrator | Facility administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 140
Deficiencies: 1
Nov 20, 2023
Visit Reason
The inspection was an unannounced Case Management visit to follow up on two medication errors reported by the facility.
Findings
Two medication errors were identified: one resident was given a discontinued medication but did not suffer adverse effects, and another resident did not receive medication for approximately one week due to missing information in the medication database. Deficiencies were cited related to failure to assist residents with self-administered medications, posing an immediate risk to health and safety.
Complaint Details
The visit was complaint-related, following up on two medication errors reported by the facility. No adverse effects were reported for either incident.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assist residents with self-administered medications as needed, evidenced by two residents not receiving medications as prescribed. | Type A |
Report Facts
Deficiencies cited: 1
Capacity: 140
Census: 98
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katelyn Ledesma | Administrator | Named as facility administrator; unavailable during the visit. |
| Robert Alvarado | Met with Licensing Program Analyst during the inspection. | |
| Victoria Bertozzi | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Hope DeBenedetti | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 140
Deficiencies: 2
Nov 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/27/2023 regarding insufficient staffing and lack of incontinence supplies for residents.
Findings
The investigation substantiated that the facility did not always have two caregivers available for residents requiring two-person transfers, and that incontinence supplies were not consistently available, leading to staff using supplies from other residents. Facility policies on supply procurement were not fully known by all staff.
Complaint Details
The complaint was substantiated based on interviews and document reviews. Allegations included insufficient staffing for two-person resident transfers and inadequate provision of incontinence supplies. The facility was cited under California Code of Regulations sections 87411(a) and 87464(d).
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility personnel were not sufficient in numbers and competent to meet resident needs, with caregivers working alone despite residents requiring two-person assists, posing an immediate risk. | Type A |
| Facility failed to ensure residents had sufficient incontinence supplies, resulting in staff using supplies from other residents. | Type B |
Report Facts
Capacity: 140
Census: 98
Plan of Correction Due Date: Nov 21, 2023
Plan of Correction Due Date: Nov 30, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Bertozzi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Katelyn Ledesma | Administrator | Facility administrator unavailable during visit |
| Robert Alvarado | Met with Licensing Program Analyst during investigation | |
| Hope DeBenedetti | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 140
Deficiencies: 1
Nov 6, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that the facility did not provide a written incident report to the responsible party.
Findings
The investigation substantiated that the facility failed to provide the resident's death report to the responsible party because the facility was unable to determine if the responsible party had authority to receive the report. The death report was not provided to the individual who signed the Admission Agreement, violating reporting requirements.
Complaint Details
Complaint was substantiated. The allegation that the facility did not provide the resident's death report to the responsible party was confirmed based on interviews and record review.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit a written death report to the responsible party within 7 days as required by CCR 87211(a)(1)(A). | Type B |
Report Facts
Capacity: 140
Census: 103
Plan of Correction Due Date: Nov 10, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Bertozzi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Katelyn Ledesma | Administrator | Met with Licensing Program Analyst during investigation |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 140
Deficiencies: 2
Oct 23, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-09-14 regarding non-functioning resident pendants and untimely staff assistance.
Findings
The investigation substantiated that the call bell system, including resident pendants, was inoperable for multiple weeks, resulting in staff not always meeting the required timelines to assist residents, which posed an immediate risk to resident health and safety.
Complaint Details
The complaint was substantiated based on interviews and record reviews. Allegations included residents' pendants not working and staff not helping residents in a timely manner due to the call button system failure.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility personnel were not sufficient in numbers and competent to meet resident needs timely due to the signal system being down and staff unable to supervise per protocol. | Type A |
| Signal system was inoperable for multiple weeks, failing to meet maintenance and operation requirements. | Type B |
Report Facts
Capacity: 140
Census: 103
Deficiencies cited: 2
Plan of Correction Due Date: Oct 24, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Bertozzi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Hope DeBenedetti | Licensing Program Manager | Oversaw the complaint investigation process |
| Heidi Gallagher | Health and Wellness Director | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 140
Deficiencies: 0
Oct 3, 2023
Visit Reason
Unannounced complaint investigation conducted due to allegations that the facility did not meet resident's needs, did not follow resident's care plan, did not respond to call buttons, staff did not ensure resident received warm food, and did not properly respond to resident's injuries.
Findings
The investigation found conflicting information regarding the allegations, including issues with catheter bag emptying, meal delivery, call button response, and injury response. Despite the allegations, there was insufficient evidence to substantiate the claims, and no deficiencies were cited.
Complaint Details
Complaint investigation was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred. Allegations included failure to meet resident needs, failure to follow care plan, failure to respond to call buttons, failure to ensure warm food, and improper response to injuries.
Report Facts
Facility capacity: 140
Census: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katelyn Ledesma | Administrator | Met with during complaint investigation |
| Victoria Bertozzi | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Hope DeBenedetti | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 103
Capacity: 140
Deficiencies: 0
Jul 20, 2023
Visit Reason
The inspection was an unannounced Case Management visit following up on a recent incident where a resident was found on the floor and subsequently hospitalized, with notification of the resident's passing the next day.
Findings
No deficiencies were cited during this inspection. The Licensing Program Analyst reviewed documents and requested the facility obtain and provide a copy of the resident's death certificate to the Community Care Licensing division.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katelyn Ledesma | Administrator | Met with Licensing Program Analyst during the inspection and involved in the incident follow-up. |
| Victoria Bertozzi | Licensing Program Analyst | Conducted the unannounced Case Management inspection. |
| Hope DeBenedetti | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Capacity: 140
Deficiencies: 0
Apr 27, 2023
Visit Reason
The inspection was an unannounced Case Management visit following up on a self-reported incident where a resident fell and was sent to the hospital, later passing away.
Findings
No deficiencies were cited during this inspection. The resident did not require 1:1 supervision, and the cause of death was not provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Cortes | Administrator | Met with Licensing Program Analyst during inspection and discussed the incident. |
Inspection Report
Annual Inspection
Census: 81
Capacity: 140
Deficiencies: 0
Mar 17, 2023
Visit Reason
The inspection was an unannounced annual required inspection conducted by the Licensing Program Analyst to evaluate compliance with regulations.
Findings
The facility was found to be in compliance with no deficiencies cited. Observations included proper infection control measures, safe water temperatures, secured medications, up-to-date fire safety equipment, and staff certifications. The Administrator's certificate had expired but renewal paperwork was submitted and will be monitored.
Report Facts
Water temperature readings: 105
Water temperature readings: 109
Water temperature readings: 111
Fire extinguisher last serviced: 2023
Smoke/Carbon Monoxide detector last serviced: 2022
Most recent fire/disaster drill: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Cortes | Administrator | Met with Licensing Program Analyst during inspection; Administrator certificate expired but renewal paperwork submitted |
| Victoria Bertozzi | Licensing Program Analyst | Conducted the annual inspection |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 140
Deficiencies: 0
Feb 16, 2023
Visit Reason
The inspection was an unannounced Case Management visit to follow up on the passing of a resident who was not on hospice and to review a recent self-reported incident involving another resident and a family member.
Findings
No deficiencies were cited during this inspection. The Licensing Program Analyst reviewed medical documentation and incident reports as part of the follow-up.
Complaint Details
The visit was complaint-related, following up on the passing of resident R1 and a self-reported incident involving resident R2 and a family member. Facility reported per Mandatory Reporting requirements.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Cortes | Administrator | Met with Licensing Program Analyst during the inspection. |
| Victoria Bertozzi | Licensing Program Analyst | Conducted the Case Management inspection. |
| Hope DeBenedetti | Licensing Program Manager | Named in the report header. |
Inspection Report
Census: 76
Capacity: 140
Deficiencies: 0
Dec 9, 2022
Visit Reason
The inspection was an unannounced Case Management visit to follow up on three residents who passed away but were not on hospice.
Findings
The inspection found no deficiencies. The report detailed the circumstances of three resident deaths, including hospital admissions and emergency response.
Report Facts
Residents passed away: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Cortes | Administrator | Met with Licensing Program Analyst during the inspection |
| Victoria Bertozzi | Licensing Program Analyst | Conducted the Case Management inspection |
| Hope DeBenedetti | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 140
Deficiencies: 1
Oct 19, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-07-26 alleging staff were not responding to call buttons, residents left soiled causing rash and UTI, failure to maintain hygiene, medication not administered as prescribed, and missing laundry.
Findings
The allegation that staff were not responding to call buttons was substantiated based on call log reviews showing delayed or no responses. The other allegations regarding resident hygiene, medication administration, and missing laundry were unsubstantiated due to insufficient evidence. No deficiencies were cited except for the call button response issue, which was cited as a Type A deficiency.
Complaint Details
The complaint investigation was substantiated for the allegation that staff were not responding to call buttons timely, posing an immediate risk to resident health and safety. Other allegations including residents left soiled causing rash and UTI, failure to maintain hygiene, medication not administered as prescribed, and missing laundry were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit. Requirement has not been met based on review of call logs for resident over a 15 day period showing that out of 125 calls, 42 of them were responded to 15 minutes or later and 6 were not responded to. This is an immediate risk to health and safety. | Type A |
Report Facts
Call logs reviewed: 125
Calls responded to 15 minutes or later: 42
Calls not responded to: 6
Facility capacity: 140
Facility census: 78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Bertozzi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Maria Cortes | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 140
Deficiencies: 1
Oct 19, 2022
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 08/30/2022 alleging that staff did not treat a resident with dignity and respect.
Findings
The investigation substantiated the allegation that staff raised their voice at a resident, which was described as sharp, firm, and loud. The involved resident denied being fearful but confirmed staff yelled at them. The deficiency was cited under California Code of Regulations Title 22, Section 87468.1(a)(1) for failure to accord dignity to residents.
Complaint Details
The complaint was substantiated based on evidence that staff communicated in a loud and demanding manner to a resident, violating the resident's dignity and respect.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to accord dignity to residents as staff raised their voice at a resident, violating personal rights. | Type A |
Report Facts
Capacity: 140
Census: 78
Deficiencies cited: 1
Plan of Correction Due Date: Oct 20, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Cortes | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Victoria Bertozzi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Hope DeBenedetti | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 140
Deficiencies: 0
Oct 6, 2022
Visit Reason
The inspection was conducted as a Case Management - Incident visit following an incident report indicating that a staff member observed another staff treating a resident with a lack of dignity and respect.
Findings
During the unannounced visit, interviews were conducted with involved staff who denied recalling the events as described. The staff member involved no longer works at the facility. No deficiencies were cited during this inspection.
Complaint Details
The visit was complaint-related based on an incident report alleging staff mistreatment of a resident. The involved staff denied the allegations and is no longer employed at the facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Cortes | Administrator | Available by phone during the inspection |
| Danielle Oseguera | Business Office Manager | Met with Licensing Program Analyst during the inspection |
| Victoria Bertozzi | Licensing Program Analyst | Conducted the Case Management inspection |
| Hope DeBenedetti | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 140
Deficiencies: 1
Jul 27, 2022
Visit Reason
An unannounced complaint investigation was conducted due to an allegation of lack of supervision resulting in a resident eloping from the facility.
Findings
The investigation found that a resident who was unable to be in the community unassisted eloped the facility through a malfunctioning delayed egress door in the Memory Care unit. The resident was missing for approximately three hours before being found by local law enforcement and was diagnosed with a stress fracture. An immediate civil penalty of $500 was issued for the violation resulting in bodily injury.
Complaint Details
The complaint was substantiated. The allegation was lack of supervision resulting in a resident eloping from the facility. The resident eloped through a malfunctioning delayed egress door and was found approximately 2.5 miles away with a stress fracture.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement has not been met as evidenced by interview and document review showing that resident eloped the facility despite not being able to be in the community by themselves. | Type A |
Report Facts
Civil penalty amount: 500
Census: 87
Total capacity: 140
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Willis | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Maria Cortes | Administrator | Facility administrator met during investigation and named in findings. |
| Hope DeBenedetti | Licensing Program Manager | Named in report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 140
Deficiencies: 3
May 26, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-03-01 regarding resident care needs not being met, facility cleanliness, safeguarding of resident property, and insufficient staffing.
Findings
The complaint investigation substantiated that resident care needs were not being met, the facility was not clean, and staff were not safeguarding resident property. The allegation of insufficient staffing was unsubstantiated. Deficiencies were cited related to managed incontinence, observation of residents, and personal rights violations.
Complaint Details
The complaint investigation was substantiated for allegations that resident care needs were not met, the facility was not clean, and staff were not safeguarding resident property. The allegation of insufficient staffing was unsubstantiated.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Resident was left in a soiled brief until after eating and resident's room smelled of urine, violating managed incontinence requirements. | Type A |
| Facility failed to notify resident's doctor of significant weight loss, violating observation of resident requirements. | Type A |
| Resident in memory care was observed going into other residents' rooms and going through their personal belongings, violating personal rights of residents. | Type B |
Report Facts
Resident weight loss: 28
Facility capacity: 140
Census: 80
Deficiency count: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Willis | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Maria Cortes | Administrator | Facility administrator met with Licensing Program Analyst during investigation. |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Annual Inspection
Census: 72
Capacity: 140
Deficiencies: 0
Feb 23, 2022
Visit Reason
An unannounced annual required inspection was conducted focusing on the Infection Control procedures and practices of the facility.
Findings
The facility had appropriate infection control signage, staff were observed wearing masks, and common areas were disinfected multiple times daily. Staff COVID-19 screenings were not documented for the day of inspection. Fire extinguishers were serviced but tags were not updated. No deficiencies were cited during this inspection.
Report Facts
Incident reports followed up: 3
Facility capacity: 140
Resident census: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Cortes | Executive Director/Administrator | Met with Licensing Program Analysts during the inspection and discussed infection control and visitation. |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection and signed the report. |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 140
Deficiencies: 0
Sep 3, 2021
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that a staff member inappropriately handled a resident, left the resident on the floor after pulling her out of bed, and verbally threatened the resident.
Findings
The investigation found inconsistent information regarding the alleged incident, and based on police and physical exam reports showing no bruising or swelling, the complaint allegations were unsubstantiated and dismissed.
Complaint Details
Complaint allegations included inappropriate handling of a resident, leaving the resident on the floor after pulling her out of bed, and verbal threats by staff. The complaint was found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Complaint Control Number: 21
Capacity: 140
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Willis | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Maria Cortes | Administrator | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 140
Deficiencies: 0
Jul 8, 2021
Visit Reason
The inspection was conducted due to a report received from the facility where a resident accused a staff member of abuse. The facility reported the alleged abuse as required of mandated reporters.
Findings
The Licensing Program Analyst conducted interviews and reviewed documents related to the alleged abuse and found no deficiencies during this inspection.
Complaint Details
The visit was complaint-related due to an allegation of staff abuse reported by a resident. The complaint was investigated and no deficiencies were cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Nunez | Administrator | Met with Licensing Program Analyst during the inspection |
| Victoria Willis | Licensing Program Analyst | Conducted the case management inspection |
| Hope DeBenedetti | Licensing Program Manager | Named in the report as Licensing Program Manager |
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