Inspection Report Summary
Most inspections found deficiencies, with the most recent report on October 21, 2025, citing a deficiency for failing to provide requested corrective action documents, which was noted as a potential personal rights violation. Earlier investigations revealed substantiated issues including inadequate staffing, locked resident rooms without keys, failure to safeguard personal property, medication management errors, and delayed notifications to physicians, along with some unsubstantiated complaints. The facility experienced a serious event in October 2025 involving staff abuse allegations that led to the termination of the Executive Director, and ongoing concerns about staffing and environment safety were noted in multiple reports. While some annual inspections found no deficiencies, others identified problems such as incomplete employee files, missing training, and safety documentation lapses. Recent reports show continued challenges, with no clear pattern of improvement over time.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 22
Capacity: 42
Deficiencies: 1
Oct 21, 2025
Visit Reason
The inspection was conducted as a case management visit related to complaint 15-AS-20250612143154 to follow up on requested documents and investigate compliance.
Findings
The facility failed to provide requested corrective action documents (write-ups) to the licensing agency as required, which was cited as a deficiency posing a potential personal rights violation to residents in care.
Complaint Details
The visit was complaint-related for complaint 15-AS-20250612143154. The facility refused to provide corrective actions/write-ups issued to staff, which was identified as a potential personal rights violation to residents in care.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility not providing requested documents as allowed; Inspection Authority of the Licensing Agency | Type B |
Report Facts
Plan of Correction (POC) due date: Oct 24, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dimple Kamdar | Operations Specialist | Interviewed regarding refusal to provide corrective action documents |
| Alona Gomez | Licensing Program Analyst | Conducted the case management visit and inspection |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 23
Capacity: 42
Deficiencies: 0
Oct 3, 2025
Visit Reason
The visit was an unannounced case management inspection conducted in response to a self-reported incident alleging abuse and inadequate care by staff members, as well as failure of the Executive Director to escalate the incidents.
Findings
The inspection found allegations of staff abuse and inadequate care, termination of the Executive Director for failure to escalate incidents, dirty resident rooms and bathrooms, insufficient caregiver staffing for residents requiring two-person assist, and damaged furniture in common areas. The facility is actively seeking new maintenance and housekeeping staff and plans to hire more caregivers.
Complaint Details
The complaint involved allegations that staff members S1 and S2 were abusing residents, and that S2 and S3 were not providing adequate care. The Executive Director was suspended and then terminated for failure to escalate the alleged abuse incidents.
Report Facts
Caregivers on shift: 3
Residents requiring two-person assist: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hong Phuc Truong | Executive Director | Terminated for failure to escalate alleged incidents of abuse |
| Dimple Kamdar | Operations Specialist | Met with Licensing Program Analyst during inspection |
| Alona Gomez | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Annual Inspection
Census: 21
Capacity: 42
Deficiencies: 0
Apr 4, 2025
Visit Reason
The visit was an unannounced 1-Year Annual Required inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The inspection found no deficiencies. The facility was toured, records reviewed, and safety measures such as fire clearance, emergency plans, and medication storage were verified to be in compliance.
Report Facts
Residents records reviewed: 6
Staff records reviewed: 5
Fire extinguisher last serviced: Jan 9, 2025
Emergency disaster drill date: Mar 25, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Hong Phuc Truong | Executive Director | Met with Licensing Program Analyst during inspection and involved in facility tour |
| Alona Gomez | Licensing Program Analyst | Conducted the inspection visit |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 21
Capacity: 42
Deficiencies: 0
Apr 4, 2025
Visit Reason
The visit was conducted as a case management inspection resulting from an unusual incident report received on 2025-03-27 involving a resident found on the floor with a possible abuse allegation.
Findings
The investigation found no visible injuries to the resident and no deficiencies were cited. The incident was reported by staff who may have misinterpreted the event, and the resident was unable to recall the incident.
Complaint Details
The visit was triggered by a complaint regarding a resident (R1) found on the floor with a staff member allegedly stepping on them. The allegation was unsubstantiated as no injuries were found and the reporting staff indicated they may have seen the incident from a wrong angle.
Report Facts
Capacity: 42
Census: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Hong Phuc Truong | Executive Director | Met with during inspection and involved in incident discussion |
| Alona Gomez | Licensing Program Analyst | Conducted the case management inspection |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 42
Deficiencies: 0
Jun 14, 2024
Visit Reason
The inspection was conducted as a case management visit resulting from an unusual incident report received on 2024-05-24 involving resident altercations.
Findings
The investigation found that resident R1 attempted to hit residents R2 and R3, resulting in R2 and R3 being hospitalized. R1 was provided 1:1 supervision and later discharged from the facility. No deficiencies were cited during the visit, and staff received additional training on dementia and aggressive behavior care.
Complaint Details
The visit was triggered by a complaint related to an incident on 2024-05-23 where R1 attempted to hit R2 and R3. The complaint was investigated, and no deficiencies were cited. R2 and R3 returned to baseline after hospitalization. R1 no longer resides at the facility.
Report Facts
Incident date: May 23, 2024
Incident report received date: May 24, 2024
Visit start time: 1400
Visit end time: 1526
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Hong Phuc Truong | Executive Director | Met with during inspection and discussed incident and care plans |
| Alona Gomez | Licensing Program Analyst | Conducted the case management visit |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 42
Deficiencies: 0
Apr 25, 2024
Visit Reason
The visit was an unannounced Case Management inspection conducted in response to an unusual incident report received regarding a medication error involving resident R1 on 3/17/2024.
Findings
The inspection found that a medication error occurred where resident R1 was given the wrong dose of Ativan due to a change in milligrams per tablet that was not noticed by the Medtech. The Executive Director acknowledged the oversight, staff were retrained, and the Medtech was disciplined. No ill side effects were sustained by the resident and no deficiencies were cited during the visit.
Complaint Details
The complaint involved a medication error where resident R1 was given 8 mg of Ativan instead of the prescribed 2 mg dose on 3/17/2024. The error was identified on 3/18/2024 and reported. The complaint was investigated and substantiated with corrective actions taken.
Report Facts
Medication dosage error: 8
Facility capacity: 42
Resident census: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Hong Phuc Truong | Executive Director | Met with Licensing Program Analyst and acknowledged medication error oversight |
| Alona Gomez | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Annual Inspection
Census: 21
Capacity: 42
Deficiencies: 2
Apr 10, 2024
Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing regulations and facility safety standards.
Findings
The inspection found that the facility generally maintained adequate safety and comfort conditions, including adequate lighting, temperature control, and locked medication storage. However, two deficiencies were noted: hot water temperature in one resident room exceeded the allowed maximum, and the facility lacked updated documentation of emergency disaster drills.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Hot water temperature in room 12 measured at 121.6 degrees F, exceeding the maximum allowed temperature. | Type A |
| No records of emergency disaster drills were found, indicating failure to maintain required documentation. | Type B |
Report Facts
Hot water temperature: 121.6
Census: 21
Total capacity: 42
Plan of Correction Due Date: Apr 12, 2024
Plan of Correction Due Date: Apr 19, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Hong Phuc Truong | Executive Director | Met with Licensing Program Analyst during inspection and agreed to plans of correction |
| Alona Gomez | Licensing Program Analyst | Conducted the inspection and signed the report |
| Yvonne Flores-Larios | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 21
Capacity: 42
Deficiencies: 4
Apr 10, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 2024-01-31 regarding resident hygiene, safeguarding of personal items, locked resident bedrooms, reporting requirements, and staffing adequacy.
Findings
The investigation substantiated that there was insufficient staffing to meet residents' hygiene and care needs, residents' personal items were not properly safeguarded, residents' rooms were locked without keys provided to most residents, and reporting requirements were not followed timely. Some allegations related to unexplained fractures, residents being left soiled, and lack of activities were unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations including inadequate resident hygiene, failure to safeguard personal items, locked resident rooms without keys, failure to follow reporting requirements, and insufficient staffing. Allegations regarding unexplained fractures, residents left soiled, and lack of activities were unsubstantiated.
Severity Breakdown
Type B: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Residents' rooms were locked and most residents did not have a key, posing a potential health and safety risk. | Type B |
| Facility did not safeguard residents' cash, personal property, and valuables, posing a potential health and safety risk. | Type B |
| Inadequate staffing to meet residents' care and hygiene needs. | Type B |
| Failure to notify residents' responsible parties in a timely manner regarding changes in residents' conditions. | Type B |
Report Facts
Capacity: 42
Census: 21
Deficiencies cited: 4
Plan of Correction Due Date: Apr 19, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Truong | Executive Director | Interviewed during investigation; acknowledged staffing shortages and issues with resident care and reporting |
| Alona Gomez | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Oversaw complaint investigation report |
Inspection Report
Complaint Investigation
Census: 21
Capacity: 42
Deficiencies: 1
Apr 10, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that staff did not inform a resident's physician of a change in condition and did not ensure resident's medication supply was available at the facility.
Findings
The investigation found that physicians were not notified in a timely manner as required and medication supply was mismanaged. The Health and Wellness director responsible for medication availability was not performing duties and was subsequently dismissed.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. Allegations included failure to notify physicians of resident condition changes and failure to ensure medication availability. The Health and Wellness director was found responsible and dismissed.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop and implement a plan for incidental medical and dental care, including assistance in obtaining care and ensuring medication availability. | Type B |
Report Facts
Facility capacity: 42
Census: 21
Deficiency count: 1
Plan of Correction due date: Apr 19, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Truong | Executive Director | Interviewed during investigation; confirmed issues with physician notification and medication management |
| Alona Gomez | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Annual Inspection
Census: 24
Capacity: 42
Deficiencies: 3
Nov 27, 2023
Visit Reason
The inspection was an unannounced 1-Year Annual Required visit conducted to evaluate compliance with licensing regulations.
Findings
The inspection found deficiencies related to incomplete employee files, missing first aid training for required staff, and missing resident file documents including safeguards for property, consent form, and personal rights.
Deficiencies (3)
| Description |
|---|
| Resident file missing Safeguards for Property/Valuables, Consent Form, and Personal Rights. |
| All employee files were observed incomplete. |
| Required staff are missing first aid training. |
Report Facts
Deficiencies cited: 3
POC Due Date: Dec 4, 2023
Facility Capacity: 42
Census: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jasmine Seiffert | Executive Director | Met with inspectors during the visit and responsible for plan of correction. |
| Yvonne Flores-Larios | Licensing Program Manager | Conducted the inspection and signed the report. |
| Alona Gomez | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Cheyenne Flores | Health and Wellness Director | Present during the facility tour. |
Inspection Report
Routine
Census: 26
Capacity: 42
Deficiencies: 0
Jul 27, 2021
Visit Reason
The visit was an unannounced infection control inspection conducted as a required one-year routine check.
Findings
The inspection found the facility compliant with infection control standards, including proper PPE use, adequate food supply, and effective screening procedures. No deficiencies were cited during the visit.
Report Facts
PPE supply duration: 30
Food supply duration - perishable: 2
Food supply duration - non-perishable: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenda Bertucci | Executive Director | Met with Licensing Program Analysts during inspection |
| Lizette Francisco | Licensing Program Analyst | Conducted the infection control inspection |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
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