Deficiencies (last 5 years)
Deficiencies (over 5 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
82% occupied
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 105
Capacity: 128
Deficiencies: 1
Date: Nov 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-08-01 regarding staff supervision and resident care resulting in injury.
Complaint Details
The complaint alleged staff did not ensure care and supervision resulting in resident injury. The allegation was substantiated based on interviews, record reviews, and observations. Other allegations about reporting and room obstruction were unsubstantiated.
Findings
The investigation substantiated that staff failed to provide adequate supervision to a known fall-risk resident, resulting in a serious injury (left hip fracture). The facility did not revise the resident's care plan or implement additional safety measures despite multiple prior falls. An immediate civil penalty of $500 was assessed. Other allegations regarding reporting requirements and room obstruction were found unsubstantiated.
Deficiencies (1)
Facility staff failed to provide adequate supervision to meet resident needs resulting in a serious injury which poses an immediate safety risk to residents in care.
Report Facts
Civil penalty amount: 500
Capacity: 128
Census: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alona Gomez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Rachel Davis | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| William Grady | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 128
Deficiencies: 1
Date: Nov 5, 2025
Visit Reason
The inspection was an unannounced case management review related to complaint 15-AS-20240514173549, conducted to investigate issues regarding resident care.
Complaint Details
The visit was complaint-related, investigating complaint 15-AS-20240514173549. It was substantiated that the facility did not update the care plan for resident R1 after multiple falls on 6/10/2022, 1/9/2023, and 3/25/2024.
Findings
The investigation found that the facility failed to update a resident's care plan after multiple falls, which did not address the resident's change in condition and care needs, posing a potential safety risk.
Deficiencies (1)
Facility did not update residents care plan when there was a change in condition
Report Facts
Deficiency Plan of Correction Due Date: Nov 19, 2025
Capacity: 128
Census: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel Davis | Executive Director | Met with Licensing Program Analyst during inspection |
| Alona Gomez | Licensing Program Analyst | Conducted the inspection and investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 104
Capacity: 128
Deficiencies: 0
Date: Jul 9, 2025
Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.
Findings
The facility was found to be in compliance with no deficiencies cited. The inspection included a tour of resident apartments and common areas, review of staff and resident records, and verification of safety and environmental conditions.
Report Facts
Staff records reviewed: 6
Resident records reviewed: 6
Fire extinguisher last serviced: Feb 6, 2025
Disaster drill last conducted: May 12, 2025
Emergency disaster plan last reviewed: Apr 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachael Davis | Executive Director | Met with Licensing Program Analyst during inspection and involved in facility tour |
Inspection Report
Annual Inspection
Census: 104
Capacity: 128
Deficiencies: 0
Date: Jul 9, 2025
Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.
Findings
The facility was found to be in compliance with no deficiencies cited. The inspection included a tour of resident apartments and common areas, review of staff and resident records, and verification of safety and environmental conditions.
Report Facts
Staff records reviewed: 6
Resident records reviewed: 6
Fire extinguisher last serviced: Feb 6, 2025
Disaster drill last conducted: May 12, 2025
Emergency disaster plan last reviewed: Apr 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachael Davis | Executive Director | Met with Licensing Program Analyst during inspection and facility tour |
| A. Gomez | Licensing Program Analyst | Conducted the inspection visit |
| William Grady | Administrator/Director | Facility Administrator named in report header |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 128
Deficiencies: 0
Date: Jun 5, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2025-01-31 alleging issues such as unclean resident rooms, residents left in soiled clothing, and lack of feeding assistance.
Complaint Details
The complaint was unsubstantiated. No deficiencies were cited during the visit. The Licensing Program Analyst was unable to identify any concerns relating to the allegations due to anonymous complainant and lack of specific resident identification.
Findings
The investigation included interviews with a random sample of residents and review of their files. No concerns were identified, residents expressed satisfaction with care, and all rooms were observed sanitary. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Complaint Control Number: 15
Complaint Control Number Full: 20250131105419
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alona Gomez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Rachael Davis | Executive Director | Met with Licensing Program Analyst during investigation |
| Navjinder Kaur | Health & Wellness Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 128
Deficiencies: 0
Date: Jun 5, 2025
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations received on 2025-01-31 regarding resident care concerns including cleanliness, soiled clothing, and feeding assistance.
Complaint Details
The complaint involved multiple allegations about staff not ensuring residents' rooms were kept clean, leaving residents in soiled clothing for extended periods, and not providing feeding assistance. The complaint was found to be unsubstantiated.
Findings
The investigation included interviews with residents and file reviews, with no specific resident identified. All residents expressed satisfaction with care, and no concerns were observed. The allegations were unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited.
Report Facts
Capacity: 128
Census: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alona Gomez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Rachael Davis | Executive Director | Met with Licensing Program Analyst during investigation |
| Navjinder Kaur | Health & Wellness Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 128
Deficiencies: 0
Date: Aug 7, 2024
Visit Reason
The inspection was conducted as a result of a priority 1 complaint to perform a Health & Safety inspection.
Complaint Details
The visit was triggered by a priority 1 complaint. No deficiencies were cited during the visit.
Findings
The Licensing Program Analyst toured the facility and found no deficiencies. Hot water temperatures, food supplies, freezer and refrigerator temperatures, medication storage, smoke detectors, carbon monoxide detector, first-aid kit, fire extinguisher, and passageways were all in compliance.
Report Facts
Hot water temperature: 110.8
Hot water temperature: 113.2
Hot water temperature: 109.4
Food supply duration: 7
Food supply duration: 2
Freezer temperature: 0
Refrigerator temperature: 36
Fire extinguisher last serviced: Feb 6, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachael Davis | Executive Director | Met with Licensing Program Analyst during inspection |
| Alona Gomez | Licensing Program Analyst | Conducted the Health & Safety inspection |
| Yvonne Flores-Larios | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 128
Deficiencies: 0
Date: Aug 7, 2024
Visit Reason
The inspection was conducted as a result of a priority 1 complaint to perform a Health & Safety inspection.
Complaint Details
The visit was triggered by a priority 1 complaint. No deficiencies were cited during the visit.
Findings
The Licensing Program Analyst toured the facility and found no deficiencies. All safety measures including hot water temperature, food supplies, medication storage, smoke detectors, carbon monoxide detectors, first-aid kit, and fire extinguisher were in compliance.
Report Facts
Hot water temperature readings: 110.8
Hot water temperature readings: 113.2
Hot water temperature readings: 109.4
Food supply duration: 7
Food supply duration: 2
Freezer temperature: 0
Refrigerator temperature: 36
Facility capacity: 128
Facility census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachael Davis | Executive Director | Met with Licensing Program Analyst during inspection |
| Alona Gomez | Licensing Program Analyst | Conducted the Health & Safety inspection |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 102
Capacity: 128
Deficiencies: 0
Date: Jul 19, 2024
Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.
Findings
The facility was found to be in compliance with no deficiencies cited. The inspection included a tour of the facility, review of staff and resident records, and verification of safety measures such as fire clearance, emergency plans, and environmental conditions.
Report Facts
Hot water temperature: 112.6
Hot water temperature: 109.2
Hot water temperature: 108.9
Fire extinguisher last serviced: Feb 6, 2024
Disaster drill last conducted: Jul 18, 2024
Emergency disaster plan last reviewed: Oct 19, 2023
Freezer temperature: 0
Refrigerator temperature: 36
Staff records reviewed: 6
Residents records reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachael Davis | Executive Director | Met with Licensing Program Analyst during inspection |
| Alona Gomez | Licensing Program Analyst | Conducted the inspection |
| Yvonne Flores-Larios | Supervisor | Supervisor of Licensing Program Analyst |
| William Grady | Administrator/Director | Facility Administrator/Director |
Inspection Report
Annual Inspection
Census: 102
Capacity: 128
Deficiencies: 0
Date: Jul 19, 2024
Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate the facility's compliance with regulatory standards.
Findings
The facility was toured and inspected, including resident apartments and common areas. All safety measures such as fire clearance, lighting, temperature, and emergency preparedness were found to be adequate. No deficiencies were cited during the visit.
Report Facts
Hot water temperature: 112.6
Hot water temperature: 109.2
Hot water temperature: 108.9
Freezer temperature: 0
Refrigerator temperature: 36
Fire extinguisher last serviced: Feb 6, 2024
Disaster drill last conducted: Jul 18, 2024
Emergency disaster plan last reviewed: Oct 19, 2023
Staff records reviewed: 6
Staff with current first-aid training: 6
Resident records reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachael Davis | Executive Director | Met with Licensing Program Analyst during inspection and toured facility |
| 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
Capacity: 128
Deficiencies: 0
Date: Nov 1, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations regarding personal rights violations at Brookdale Diablo Lodge.
Complaint Details
The complaint investigation was triggered by allegations of personal rights violations including inadequate record keeping, failure to address medical condition changes, injuries from falls, failure to follow care plans, improper incident reporting, inadequate care and supervision, and questionable death. The complaint was ultimately found to be unsubstantiated or unfounded.
Findings
The investigation reviewed multiple allegations including inadequate record keeping, failure to address changes in medical condition, injuries from falls, failure to follow care plans, improper incident reporting, inadequate care and supervision, and questionable death. After interviews and document reviews, all allegations were found to be unsubstantiated or unfounded due to lack of preponderance of evidence or false claims.
Report Facts
Facility capacity: 128
Dates of resident falls: Multiple unwitnessed falls on 2022-01-28, 2022-03-17, 2022-08-12, and 2022-08-14
Date of hospice admission: Resident admitted to hospice on 2022-07-25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lizette Francisco | Evaluator / Associate Governmental Program Analyst | Conducted the complaint investigation and delivered findings |
| Paula Arce | Life Enrichment Manager | Met with evaluator during investigation and received report |
| William Grady | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 0
Date: Nov 1, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to multiple allegations regarding personal rights violations at Brookdale Diablo Lodge.
Complaint Details
The complaint investigation was unsubstantiated for all allegations including inadequate record keeping, failure to address medical condition changes, injuries from falls, failure to follow care plans, improper incident reporting, inadequate care and supervision. The allegation of questionable death was found to be unfounded based on the death certificate indicating death due to chronic congestive heart failure and coronary artery disease, unrelated to neglect by the facility.
Findings
The investigation reviewed multiple allegations including inadequate record keeping, failure to address medical condition changes, injuries from falls, failure to follow care plans, improper incident reporting, inadequate care and supervision, and questionable death. After interviews and document reviews, all allegations were found to be unsubstantiated or unfounded due to lack of preponderance of evidence.
Report Facts
Facility capacity: 128
Dates of resident falls: Multiple unwitnessed falls on 1/28/22, 3/17/22, 8/12/22, and 8/14/22
Investigation visit time: Visit began at 12:45 PM and completed at 1:30 PM on 11/01/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lizette Francisco | Associate Governmental Program Analyst | Conducted the complaint investigation |
| Paula Arce | Life Enrichment Manager | Met with investigator during the visit |
| William Grady | Administrator | Facility administrator named in report header |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 99
Capacity: 128
Deficiencies: 2
Date: Oct 19, 2023
Visit Reason
The inspection was an unannounced 1-Year Annual Required visit conducted by Licensing Program Analysts to evaluate compliance with regulatory standards.
Findings
The facility was generally compliant with safety and operational standards, including fire clearance, medication storage, and staff training. However, deficiencies were observed related to residents storing PRN medications in their apartments, which posed immediate health and safety risks.
Deficiencies (2)
Miralax was observed in Resident 4's apartment, which is not compliant with medication storage regulations.
TUMS was observed in Resident 5's apartment, which is not compliant with medication storage regulations.
Report Facts
Capacity: 128
Census: 99
POC Due Date: Plan of Correction due date is 2023-10-20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachael Davis | Executive Director | Met with Licensing Program Analysts during inspection and exit interview |
| William Grady | Administrator | Named as facility administrator responsible for compliance |
Inspection Report
Annual Inspection
Census: 99
Capacity: 128
Deficiencies: 2
Date: Oct 19, 2023
Visit Reason
The inspection was an unannounced 1-Year Annual Required visit conducted to evaluate compliance with regulatory requirements at the facility.
Findings
The facility was generally compliant with safety and operational standards, including fire clearance, medication storage, and staff training. However, deficiencies were noted regarding the improper storage of PRN medications in residents' apartments, posing immediate health and safety risks.
Deficiencies (2)
Miralax was found in Resident 4's apartment, which is not compliant with centrally stored medication requirements.
TUMS was found in Resident 5's apartment, which is not compliant with centrally stored medication requirements.
Report Facts
Capacity: 128
Census: 99
Plan of Correction Due Date: Oct 20, 2023
Plan of Correction Submission Date: Nov 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William Grady | Administrator | Facility administrator named in the report |
| Rachael Davis | Executive Director | Met with Licensing Program Analysts during inspection |
| Alona Gomez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Yvonne Flores-Larios | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 128
Deficiencies: 0
Date: Jul 10, 2023
Visit Reason
An unannounced complaint investigation was conducted to investigate allegations regarding the facility elevator backup power, staff emergency procedures during a power outage, and staff training on those procedures.
Complaint Details
The complaint involved allegations that the facility elevator did not meet backup power requirements, staff did not follow emergency procedures during a power outage, and staff were not trained on emergency procedures during a power outage. The complaint was found to be unsubstantiated.
Findings
The investigation found that the facility elevator meets backup power requirements, staff followed emergency procedures during the power outage on 07/01/2023, and staff were extensively trained on emergency procedures. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 128
Census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| Rachel Davis | Executive Director | Met with Licensing Program Analyst during investigation |
| Jinder Kaur | Health & Wellness Director | Met with Licensing Program Analyst during investigation |
| William Grady | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 128
Deficiencies: 0
Date: Jul 10, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations regarding the facility elevator backup power, staff emergency procedures during a power outage, and staff training on those procedures.
Complaint Details
The complaint included allegations that the facility elevator does not meet backup power requirements, staff did not follow emergency procedures during a power outage, and staff were not trained on emergency procedures during a power outage. The complaint was found to be unsubstantiated.
Findings
The investigation found that the facility elevator does meet backup power requirements, staff followed emergency procedures during the power outage on 07/01/2023, and staff were extensively trained on emergency procedures. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 128
Census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| Rachel Davis | Executive Director | Interviewed during investigation |
| Jinder Kaur | Health & Wellness Director | Interviewed during investigation |
| William Grady | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 128
Deficiencies: 0
Date: Mar 30, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff did not assist a resident with her incontinence and that the temperature was below the regulated limit.
Complaint Details
The complaint was unsubstantiated based on interviews, observations, and lack of evidence to prove the alleged violations occurred.
Findings
The investigation found no substantiated evidence to support the allegations. Staff interviews confirmed residents are checked every two hours and respond to call buttons. Temperature controls in resident apartments were observed to be within regulated limits, with smart thermostats set between 65 and 81 degrees Fahrenheit.
Report Facts
Capacity: 128
Census: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lizette Francisco | Licensing Program Analyst | Conducted the complaint investigation |
| Rachael Davis | Executive Director | Met with Licensing Program Analyst during investigation |
| William Grady | Administrator | Facility administrator named in report header |
| Harpreet Humpal | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 128
Deficiencies: 0
Date: Mar 30, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility did not have proper provisions for residents in the event of a power outage.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence proving the alleged violation did or did not occur.
Findings
The investigation found that the facility implemented its Emergency Disaster Plan during the power outage and residents were provided back-up oxygen tanks. There was insufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Report Facts
Capacity: 128
Census: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lizette Francisco | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Rachael Davis | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 128
Deficiencies: 0
Date: Mar 30, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging the facility did not have proper provisions for residents in the event of a power outage.
Complaint Details
The complaint alleged that the facility did not have proper provisions for residents during a power outage. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that the facility had implemented its Emergency Disaster Plan during the power outage and residents were provided with back-up oxygen tanks. There was insufficient evidence to substantiate the allegation, and the complaint was determined to be unsubstantiated.
Report Facts
Capacity: 128
Census: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lizette Francisco | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Rachael Davis | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 128
Deficiencies: 0
Date: Mar 30, 2023
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 2021-11-29 alleging staff did not assist a resident with her incontinence and that the temperature was below the regulated limit.
Complaint Details
The complaint was unsubstantiated based on investigation findings, including staff interviews and observations of temperature controls. No violation was proven.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff interviews indicated residents are checked every two hours and respond to call buttons, and temperature controls in apartments were within regulated limits with smart thermostats set between 65 and 81 degrees Fahrenheit.
Report Facts
Complaint received date: Nov 29, 2021
Facility capacity: 128
Facility census: 101
Inspection start time: 1415
Inspection end time: 1720
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lizette Francisco | Licensing Program Analyst | Conducted the complaint investigation |
| Rachael Davis | Executive Director | Met with Licensing Program Analyst during investigation |
| William Grady | Administrator | Facility administrator named in report header |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 128
Deficiencies: 2
Date: Jan 19, 2023
Visit Reason
The inspection was conducted as a result of a Priority 1 complaint to perform a Health & Safety inspection at the facility.
Complaint Details
The visit was triggered by a Priority 1 complaint. The deficiency related to unlocked hazardous materials was substantiated and cited under CCR 87309(a).
Findings
The inspection found unlocked cleaning supplies, bug spray, bleach, gardening tools, oxyclean, and comet in residents' apartments, posing an immediate health and safety risk. Other areas such as hot water temperature, food supply, medication storage, smoke detectors, and fire safety equipment were found to be in compliance.
Deficiencies (2)
Unlocked cleaning supplies, bug spray, and bleach inside kitchen and bathroom cabinets in R1's apartment.
Unlocked gardening tools, oxyclean, and comet observed in R2's apartment.
Report Facts
Hot water temperature readings: 114
Hot water temperature readings: 115.1
Hot water temperature readings: 113.8
Food supply duration: 7
Food supply duration: 2
Facility capacity: 128
Facility census: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachael Davis | Executive Director | Met with Licensing Program Analysts during inspection |
| Lizette Francisco | Licensing Evaluator | Conducted the inspection and signed the report |
| Harpreet Humpal | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 128
Deficiencies: 1
Date: Jan 19, 2023
Visit Reason
The inspection was conducted as a result of a Priority 1 complaint to perform a Health & Safety inspection at the facility.
Complaint Details
The visit was triggered by a Priority 1 complaint. The deficiency related to unlocked hazardous items was cited and poses an immediate health and safety risk to persons in care.
Findings
The inspection found unlocked cleaning supplies, bug spray, bleach, gardening tools, oxyclean, and comet in residents' apartments, posing an immediate health and safety risk. Other areas such as hot water temperature, food supply, medication storage, smoke detectors, and fire extinguishers were compliant.
Deficiencies (1)
Unlocked cleaning supplies, bug spray, and bleach inside kitchen and bathroom cabinets in resident R1's apartment and unlocked gardening tools, oxyclean, and comet in resident R2's apartment.
Report Facts
Census: 98
Total Capacity: 128
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachael Davis | Executive Director | Met with Licensing Program Analysts during inspection |
| Lizette Francisco | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Harpreet Humpal | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Annual Inspection
Census: 96
Capacity: 128
Deficiencies: 1
Date: Sep 15, 2022
Visit Reason
The visit was an unannounced Infection Control Inspection conducted as a required one-year inspection to evaluate compliance with infection control and safety regulations.
Findings
The facility was found to have adequate infection control measures including screening, PPE supply, and sanitation practices. However, a deficiency was observed where two portable oxygen tanks in a resident's apartment were not secured with stands, posing a potential health and safety risk.
Deficiencies (1)
Two portable oxygen tanks in R1's apartment were observed without a stand, violating oxygen equipment safety requirements.
Report Facts
Staff records reviewed: 5
Staff records with health screening and TB test results: 5
Plan of Correction Due Date: Sep 19, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachael Davis | Executive Director | Met with Licensing Program Analysts during inspection |
| Najinder Kaur | Health and Wellness Director | Met with Licensing Program Analysts during inspection |
| William Grady | Administrator | Named in Plan of Correction agreement to obtain oxygen tank stands |
Inspection Report
Annual Inspection
Census: 96
Capacity: 128
Deficiencies: 1
Date: Sep 15, 2022
Visit Reason
Unannounced infection control inspection conducted as part of the required 1-year visit to assess compliance with infection control and safety regulations.
Findings
The facility generally complied with infection control protocols including PPE use, screening, and sanitation. One deficiency was observed: two portable oxygen tanks in a resident's apartment were not secured with stands, posing a potential health and safety risk.
Deficiencies (1)
Two portable oxygen tanks in R1's apartment were without a stand, violating oxygen equipment safety requirements.
Report Facts
Staff records reviewed: 5
Staff records with health screening and TB test results: 5
Facility capacity: 128
Facility census: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachael Davis | Executive Director | Met with Licensing Program Analysts during the inspection. |
| Najinder Kaur | Health and Wellness Director | Met with Licensing Program Analysts during the inspection. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 128
Deficiencies: 1
Date: Nov 18, 2021
Visit Reason
An unannounced case management visit was conducted to deliver findings related to a complaint investigation.
Complaint Details
The visit was complaint-related, conducted to deliver findings. The deficiency was substantiated as the licensee failed to associate S4 to the facility, posing a potential health and safety risk.
Findings
A deficiency was observed where staff member S4 was not associated with the facility or sister facilities, violating California Code of Regulations Title 22. The licensee did not comply with criminal record clearance requirements, posing a potential health and safety risk.
Deficiencies (1)
Staff member S4 was not associated to the facility or other sister facilities, violating criminal record clearance requirements.
Report Facts
Deficiency Type: 1
Plan of Correction Due Date: Nov 24, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bill Grady | Executive Director | Met with Licensing Program Analyst during the visit and agreed to submit required documentation for S4. |
| Grace Luk | Licensing Program Analyst | Conducted the unannounced case management visit and identified the deficiency. |
| Harpreet Humpal | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 128
Deficiencies: 1
Date: Nov 18, 2021
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations received on 10/22/2020 regarding facility cleanliness and resident care.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility was not kept clean. Other allegations regarding failure to assist resident with hygiene needs and facility malodor were unsubstantiated.
Findings
The investigation substantiated the allegation that the facility was not kept clean, specifically that a resident's room was uncleaned posing a potential health and safety risk. Other allegations related to resident hygiene assistance and malodor were found unsubstantiated due to lack of sufficient evidence.
Deficiencies (1)
Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Licensee did not comply by having a resident's room uncleaned which poses a potential health and safety risk.
Report Facts
Capacity: 128
Census: 90
Plan of Correction Due Date: Nov 19, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bill Grady | Executive Director | Met with Licensing Program Analyst during investigation |
| Grace Luk | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Harpreet Humpal | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 128
Deficiencies: 1
Date: Nov 18, 2021
Visit Reason
An unannounced case management visit was conducted to deliver findings related to a complaint investigation.
Complaint Details
The visit was complaint-related and involved a complaint investigation to deliver findings. The deficiency was substantiated as the licensee did not comply with criminal record clearance requirements by not associating S4 to the facility.
Findings
A deficiency was observed where S4 was not associated with the facility or other sister facilities, violating California Code of Regulations, Title 22, posing a potential health and safety risk.
Deficiencies (1)
S4 was not associated to the facility or other sister facilities, violating criminal record clearance requirements.
Report Facts
Plan of Correction Due Date: Nov 24, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bill Grady | Executive Director | Met with Licensing Program Analyst during the visit |
| Grace Luk | Licensing Program Analyst | Conducted the case management visit and complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the visit |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 128
Deficiencies: 1
Date: Nov 18, 2021
Visit Reason
The inspection was an unannounced complaint investigation conducted due to allegations that the facility was not kept clean, staff did not assist a resident with hygiene needs, and the facility was malodorous.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility was not kept clean. The allegations that staff did not assist the resident with hygiene needs and that the facility was malodorous were unsubstantiated.
Findings
The investigation substantiated the allegation that the facility was not kept clean, specifically that a resident's room was uncleaned posing a potential health and safety risk. However, allegations regarding lack of hygiene assistance and malodorous conditions were unsubstantiated due to insufficient evidence.
Deficiencies (1)
Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Licensee did not comply by having a resident's room uncleaned which poses a potential health and safety risk.
Report Facts
Capacity: 128
Census: 90
Deficiency Type B: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William Grady | Executive Director | Met with Licensing Program Analyst during investigation |
| Grace Luk | Licensing Program Analyst | Conducted complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Routine
Census: 81
Capacity: 128
Deficiencies: 0
Date: Jul 28, 2021
Visit Reason
The visit was an unannounced Infection Control Inspection conducted as a required 1-year routine inspection.
Findings
The facility was found to have proper infection control measures including sufficient food supply, a central screening point with sign-in policy, proper PPE usage, and a mitigation plan with routine screening records. 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 |
|---|---|---|
| William Grady | Administrator | Met with Licensing Program Analyst during inspection |
| Rachel Davis | Business Office Manager | Met with Licensing Program Analyst during inspection |
Inspection Report
Routine
Census: 81
Capacity: 128
Deficiencies: 0
Date: Jul 28, 2021
Visit Reason
The visit was an unannounced Infection Control Inspection conducted as a required 1-year routine inspection.
Findings
The inspection found the facility to be compliant with infection control standards, including proper PPE use, adequate food supply, and universal 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 |
|---|---|---|
| William Grady | Administrator | Met with Licensing Program Analyst during inspection |
| Rachel Davis | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Lizette Francisco | Licensing Program Analyst | Conducted the Infection Control Inspection |
| Harpreet Humpal | Licensing Program Manager | Named in report header |
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