Inspection Report Summary
Most inspections over the past several years found no deficiencies, including the most recent annual inspection on July 25, 2025, which was clean with no issues cited. Earlier complaint investigations frequently found allegations unsubstantiated, though some substantiated deficiencies involved resident care, medication management, and supervision, with a few posing immediate health and safety risks. Notably, serious abuse violations occurred in 2021 and early 2022, resulting in staff removal, training, and civil penalties totaling $10,000. More recent reports show improvement, with no deficiencies cited since July 2024 and several complaint investigations confirming no problems. Minor issues in staff training and resident care were isolated and addressed, indicating the facility has taken steps to resolve prior concerns.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 67
Capacity: 130
Deficiencies: 0
Jul 25, 2025
Visit Reason
The inspection was an unannounced required annual inspection conducted by the Licensed Program Analyst to evaluate compliance with licensing requirements.
Findings
The facility was found to be clean, in good repair, and odor free with no deficiencies observed during the inspection. Resident files, medication documentation, staff files, and facility safety measures were reviewed and found to be compliant.
Report Facts
Residents under hospice care: 12
Licensed bedridden capacity: 15
Hot water temperature: 109
Hot water temperature: 110
Food storage duration: 2
Food storage duration: 7
Fire extinguisher last serviced: Jan 14, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shari Kranig | Administrator | Met during inspection and named in report |
| Cody Schweitzberger | Maintenance Director | Met during inspection and named in report |
| Dianne Palmer | Health and Wellness Director | Met during inspection and named in report |
| Sabrina Calzada | Licensed Program Analyst | Conducted the inspection |
Inspection Report
Census: 88
Capacity: 130
Deficiencies: 0
Apr 3, 2025
Visit Reason
The visit was a case management visit regarding an Unusual Incident/Injury Report received by the Department on 2025-03-12 involving a resident who exited memory care and was found in the parking lot.
Findings
The resident was safely redirected back into the care home with no injuries observed. The facility reviewed and tested elopement policies and alarm doors, and conducted in-service training on elopement prevention and fire drills. No deficiencies were cited during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shari Kranig | Executive Director | Met during the visit and involved in incident review |
| Dianne Palmer | Health and Wellness Director | Met during the visit and involved in incident review |
| Angela Hood | Licensing Program Analyst | Conducted the case management visit |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 130
Deficiencies: 0
Sep 18, 2024
Visit Reason
The visit was a case management inspection regarding an Unusual Incident/Injury Report and SOC341 received by the Department on 9/16/24 and 9/17/24, following allegations of physical abuse and sexual assault reported by a resident.
Findings
The facility conducted an internal investigation and found the allegations to be unsubstantiated as the accused staff was not present during the alleged incident. The resident was treated for a UTI and showed a change in cognition. No deficiencies were cited during the visit.
Complaint Details
The complaint involved allegations by a resident of physical abuse and sexual assault by staff. The facility suspended the staff member pending investigation, which concluded the allegations were unsubstantiated. The resident refused further medical treatment initially but was later treated for a UTI. The facility reassessed the resident's condition and provided documentation to the Licensing Program Analyst.
Report Facts
Capacity: 130
Census: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Hood | Licensing Program Analyst | Conducted the case management visit and reviewed the internal investigation |
| Sharyl Kranig | Executive Director | Met with Licensing Program Analyst during the visit and provided information |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 130
Deficiencies: 0
Aug 7, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an anonymous report alleging that a staff member provided care under the influence of drugs and alcohol.
Findings
The investigation included records review and extensive interviews with staff and residents. The allegation was found to be unsubstantiated due to lack of preponderance of evidence, with no reports or documentation supporting the claim.
Complaint Details
The complaint alleged that a staff member was under the influence of drugs and alcohol while working. The investigation found no evidence to substantiate this allegation, and the complaint was determined to be unsubstantiated.
Report Facts
Complaint Control Number: 59
Capacity: 130
Census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation |
| Graham Gunby | Licensing Program Analyst | Conducted the complaint investigation |
| Dianne Palmer | Health and Wellness Director | Met with investigators during the visit |
| Kristine Clawson | Administrator | Facility administrator named in report |
| Maribeth Senty | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 130
Deficiencies: 3
Jul 22, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-04-08 regarding allegations of inadequate care including leaving a resident in soiled briefs for extended periods, unmet care needs, and insufficient staff training.
Findings
The investigation substantiated the allegations that resident care needs were not met, including failure to keep the resident clean and dry, failure to provide personal care such as wearing compression socks and medication administration, and insufficient staff training on dementia care. Multiple interviews, hospice records, and observations supported these findings.
Complaint Details
The complaint was substantiated based on evidence including staff interviews, hospice records, and observations. Allegations included leaving a resident (R1) in soiled briefs for extended periods, failure to meet care needs such as wearing compression socks and administering medication, and insufficient staff training. The resident was found to have dementia and exhibited combative behaviors complicating care. The facility failed to consistently provide care as required.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure incontinent residents are kept clean and dry, posing immediate health and safety risks. | Type A |
| Failure to provide personal assistance and care including ensuring compression socks were worn and medication administered as ordered. | Type A |
| Failure to complete required staff training annually, specifically dementia care training, posing potential health and safety risks. | Type B |
Report Facts
Deficiencies cited: 3
Capacity: 130
Census: 89
Plan of Correction Due Dates: 2024
Staff training records reviewed: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Maribeth Senty | Licensing Program Manager | Oversaw the complaint investigation. |
| Shari Kanig | Executive Director | Met with Licensing Program Analyst during inspection and provided information. |
| Kristine Clawson | Administrator | Facility Administrator at time of inspection, involved in interviews and findings. |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 130
Deficiencies: 0
Jul 18, 2024
Visit Reason
The inspection visit was conducted to follow up on an incident received by the Department on 2024-07-14 involving a resident found in distress in the courtyard.
Findings
The Licensing Program Analyst reviewed the resident's medical and care records, interviewed staff, and found that the resident has a routine of wandering. The facility has implemented alarms on courtyard doors to alert staff during excessive heat. No deficiencies were cited.
Complaint Details
The visit was complaint-related following an incident where a resident with dementia was found sweating and having labored breathing in the courtyard. Staff reported hourly checks but could not recall the exact last sighting time. The complaint was investigated and no deficiencies were cited.
Report Facts
Incident report date: Jul 14, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Parks | Licensing Program Analyst | Conducted the follow-up investigation and interviews |
| Kristine Clawson | Administrator | Facility administrator to whom the report was emailed |
| Shari Kranig | Person met with during the inspection |
Inspection Report
Annual Inspection
Census: 89
Capacity: 130
Deficiencies: 0
Jun 20, 2024
Visit Reason
The inspection was conducted as a Required-1 Year Inspection to ensure compliance with Title 22 regulations during an unannounced visit.
Findings
The facility was found to be in compliance with no deficiencies cited. Observations included properly furnished apartments, sanitary bathrooms, safe food storage, and operational safety equipment.
Report Facts
Bedrooms observed: 4
Bedrooms observed: 2
Bathrooms observed: 7
Food supply: 2
Food supply: 7
Staff files reviewed: 6
Resident files reviewed: 5
Hot water temperature: 105.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Hood | Licensing Program Analyst | Conducted the inspection and signed the report |
| Carla Marks | Resident Care Coordinator | Met with Licensing Program Analyst during inspection |
| Sharisse Toves | Health and Wellness Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Routine
Census: 89
Capacity: 130
Deficiencies: 0
Jun 13, 2024
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted by the Licensing Program Analyst to review resident and staff files and assess compliance with regulations.
Findings
No deficiencies were cited during this visit per California Code of Regulations, Title 22. The Licensing Program Analyst will return at a later time to complete the annual inspection.
Report Facts
Resident files reviewed: 5
Staff files reviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Hood | Licensing Program Analyst | Conducted the Required-1 Year Inspection and met with Business Office Manager |
| Maurissa Eidenshink | Business Office Manager | Met with Licensing Program Analyst during the inspection |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 130
Deficiencies: 1
Apr 25, 2024
Visit Reason
The visit was an unannounced case management inspection conducted due to an incident report received by the Department on 2024-04-15 regarding a resident found outside the facility unassisted.
Findings
The facility was found deficient for failing to properly supervise resident R1, who was found AWOL outside the facility, posing an immediate health, safety, and personal rights risk. The deficiency was cited under California Code of Regulations, Title 22, Section 87464(f)(1).
Complaint Details
The visit was triggered by a complaint/incident report received on 2024-04-15 concerning resident R1 found outside the facility unassisted. The complaint was substantiated by the finding of deficient supervision.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure proper supervision of resident R1 resulting in AWOL, posing immediate health, safety, and personal rights risk. | Type A |
Report Facts
Capacity: 130
Census: 86
Deficiencies cited: 1
Plan of Correction Due Date: Due date is 04/26/2024 as stated in text but not numeric format
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Hood | Licensing Program Analyst | Conducted the inspection and cited the deficiency |
| Sharisse Toves | Health & Wellness Director | Met with Licensing Program Analyst during inspection |
| Maribeth Senty | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 130
Deficiencies: 1
Mar 6, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility mismanaged a resident's medications.
Findings
The investigation found discrepancies in medication counts for three residents, including medications over and under the documented amounts, and delays in receiving new prescriptions. The allegation was substantiated, and a deficiency was cited for failure to ensure residents received medications as prescribed, posing an immediate health and safety risk.
Complaint Details
The complaint investigation was substantiated based on medication count and records reviewed. The allegation was that the facility mismanaged resident's medications.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not ensure that residents (R1, R2, & R3) were receiving medications as prescribed, posing an immediate health, safety, and personal rights risk. | Type A |
Report Facts
Census: 93
Total Capacity: 130
Medication discrepancies: 12
Plan of Correction Due Date: Mar 7, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Hood | Licensing Program Analyst | Conducted the complaint investigation and medication count |
| Kristine Clawson | Executive Director | Met with Licensing Program Analyst during investigation |
| Maribeth Senty | Licensing Program Manager | Oversaw complaint investigation report |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 130
Deficiencies: 0
Feb 21, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2024-02-14 alleging that staff did not issue a resident a refund.
Findings
The Licensing Program Analyst reviewed staff and facility records, conducted interviews, and found that the facility met Title 22 requirements. The complaint was found to be unfounded and was dismissed.
Complaint Details
The complaint alleging staff did not issue a resident a refund was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
Report Facts
Complaint Control Number: 59
Capacity: 130
Census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kristine Clawson | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Census: 91
Capacity: 130
Deficiencies: 0
Jan 29, 2024
Visit Reason
The visit was an unannounced case management follow-up regarding an SOC341 received by the Department on 2024-01-09 related to a resident allegation of rough treatment by staff.
Findings
The facility conducted an internal investigation and found no abuse by the staff member. The staff member was suspended and later terminated due to other performance issues. No deficiencies were cited during the visit.
Report Facts
Incident report number: 2312140053
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristine Clawson | Executive Director | Named in relation to reporting and handling the resident allegation |
| Sharisse Toves | Health and Wellness Director | Met with Licensing Program Analyst during the visit and provided information about the case |
| Angela Hood | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Census: 96
Capacity: 130
Deficiencies: 0
Jan 12, 2024
Visit Reason
The visit was an unannounced case management visit conducted regarding an SOC341 received by the Department on 2024-01-09.
Findings
During the visit, the Licensing Program Analyst conducted an interview and requested pertinent documentation. No deficiencies were cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristine Clawson | Executive Director | Met with Licensing Program Analyst during the case management visit. |
| Angela Hood | Licensing Program Analyst | Conducted the case management visit and interview. |
| Maribeth Senty | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 130
Deficiencies: 0
Oct 4, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-07-18 alleging inadequate supervision of residents resulting in one resident hitting another.
Findings
The investigation found no evidence that the facility was negligent or failed to adequately supervise residents. Staff were present during the incident and redirected residents immediately. The allegation was determined to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that staff did not adequately supervise residents, resulting in a resident hitting another resident. The investigation included interviews and review of documentation such as physician reports, service plans, staff schedules, and a police report. The allegation was found to be unsubstantiated.
Report Facts
Complaint control number: 59-AS-20230718132033
Facility capacity: 130
Census: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation and met with facility staff |
| Anthony Perez | Licensing Program Manager | Named in report as Licensing Program Manager |
| Sharisse Toves | Health and Wellness Director | Met with Licensing Program Analyst during investigation |
| Kristine Clawson | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Capacity: 130
Deficiencies: 0
Aug 16, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-01-17 alleging improper medication assistance, multiple falls, and staff leaving a resident unattended.
Findings
The investigation found all allegations to be unsubstantiated after reviewing medical records, interviewing staff and hospice nurse, and assessing facility procedures. No deficiencies were cited during the visit.
Complaint Details
The complaint alleged that staff did not provide proper medication assistance to a resident, the resident sustained multiple falls, and staff left the resident unattended. The investigation included review of physician reports, medication administration records, incident reports, and interviews with six staff members, the Executive Director, and the hospice nurse. The findings concluded that the facility followed proper procedures, communicated with responsible parties and hospice, and implemented fall prevention plans. The Department found insufficient evidence to substantiate the allegations.
Report Facts
Facility capacity: 130
Number of falls: 6
Number of staff interviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristine Clawson | Executive Director | Met with Licensing Program Analyst during investigation and provided interview statements |
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation visit |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 99
Capacity: 130
Deficiencies: 0
Jul 26, 2023
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted to evaluate the health and safety conditions of the facility and ensure compliance with regulatory standards.
Findings
The Licensing Program Analyst toured the facility, reviewed resident and staff records, and found the facility to be in compliance with no deficiencies cited. Medications were properly stored and administered, and the facility was clean and well-maintained.
Report Facts
Resident files reviewed: 5
Staff records reviewed: 5
Residents compared for medication accuracy: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristine Clawson | Executive Director | Met with Licensing Program Analyst during inspection |
| Sarena Keosavang | Licensing Program Analyst | Conducted the inspection |
| Anthony Perez | Licensing Program Manager | Named in report header |
Inspection Report
Census: 94
Capacity: 130
Deficiencies: 0
Mar 8, 2023
Visit Reason
The visit was an unannounced Case Management - Health Checks inspection conducted to ensure the health and safety of residents in care.
Findings
The facility was toured including common areas, resident bedrooms, bathrooms, and kitchen. No immediate health, safety, or personal rights violations were observed, and the facility was found to be in substantial compliance with no deficiencies cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristine Clawson | Executive Director | Met with Licensing Program Analyst during the inspection. |
| Sarena Keosavang | Licensing Program Analyst | Conducted the inspection and met with facility staff. |
| Sharisse Toves | Health and Wellness Director | Accompanied the Licensing Program Analyst during the facility tour. |
Inspection Report
Census: 104
Capacity: 130
Deficiencies: 0
Dec 8, 2022
Visit Reason
The inspection visit was an unannounced Case Management - Health Checks to ensure the health and safety of residents in care.
Findings
No immediate health, safety, or personal rights violations were observed during the tour of the facility. The facility was found to be in substantial compliance at the time of the visit and no deficiencies were cited.
Report Facts
Resident census: 104
Total capacity: 130
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristine Clawson | Executive Director | Met with Licensing Program Analyst during the inspection |
| Sarena Keosavang | Licensing Program Analyst | Conducted the inspection visit |
| Sharisse Toves | Health and Wellness Director | Accompanied the Licensing Program Analyst during the facility tour |
| Anthony Perez | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 130
Deficiencies: 0
Jul 28, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations including failure to meet residents' showering needs and mismanagement of residents' medications.
Findings
The investigation found the allegation regarding showering needs to be unsubstantiated due to lack of evidence, and the medication mismanagement allegation was found to be unfounded after a medication audit and interviews. No deficiencies were cited.
Complaint Details
The complaint investigation was triggered by allegations that facility staff failed to meet residents' showering needs and mismanaged residents' medications. The showering needs allegation was unsubstantiated, and the medication mismanagement allegation was unfounded.
Report Facts
Capacity: 130
Census: 105
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Conducted complaint investigation and delivered findings |
| Kristine Clawson | Administrator | Facility administrator met during investigation and received report |
| Troy Ordonez | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 130
Deficiencies: 0
Jul 28, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to a complaint received on 2022-04-15 alleging staff did not distribute resident's self-administered medications as prescribed and staff did not observe resident for change in condition.
Findings
The investigation found that staff appeared to administer medications as prescribed, but there was unclear evidence regarding one resident's medication administration; the allegation was unsubstantiated. Regarding observation of resident condition changes, staff documentation and actions were appropriate, and the allegation was unfounded. No deficiencies were cited.
Complaint Details
The complaint investigation was unannounced and involved review of medication documentation for 10 residents and interviews. The allegation that staff did not distribute medications as prescribed was found unsubstantiated due to lack of preponderance of evidence. The allegation that staff did not observe resident for change in condition was found unfounded based on documentation and hospital transfer.
Report Facts
Complaint Control Number: 25
Residents reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Conducted complaint investigation and delivered findings |
| Kristine Clawson | Administrator | Facility administrator met during investigation |
| Troy Ordonez | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 130
Deficiencies: 0
Jul 28, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations received on 2022-05-24 regarding medication training, control drug counts, medication placement, and medication distribution practices at the facility.
Findings
All allegations were investigated and found to be unfounded, meaning the complaints were false, could not have happened, or were without reasonable basis. No deficiencies were cited based on the investigation.
Complaint Details
The complaint included allegations that staff dispensing medications lacked proper medication training, control drug counts were inaccurate, medications were found on the floor and other inappropriate locations, and staff did not distribute residents' self-administered medications as prescribed. All allegations were found to be unfounded.
Report Facts
Residents reviewed for control medication records: 10
Residents reviewed for medication administration records: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted complaint investigation and reviewed training records |
| Laura Munoz | Licensing Program Manager | Accompanied Licensing Program Analyst during complaint investigation |
| Troy Ordonez | Licensing Program Manager | Named in report signature and management |
| Kristine Clawson | Administrator | Facility administrator met during investigation |
Inspection Report
Annual Inspection
Census: 105
Capacity: 130
Deficiencies: 0
Jul 28, 2022
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted to assess infection control and overall health and safety compliance at the facility.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristine Clawson | Administrator | Met with Licensing Program Analyst and Licensing Program Manager during inspection. |
| Lavinia Muscan | Licensing Program Analyst | Conducted the inspection and met with facility administrator. |
| Laura Munoz | Licensing Program Manager | Conducted the inspection alongside Licensing Program Analyst. |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 130
Deficiencies: 0
Apr 14, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations including resident injury, staff response times, facility response system disrepair, and staffing adequacy.
Findings
The investigation found all allegations to be unsubstantiated based on interviews, call button records, and staff schedules. While some residents reported delayed responses at times, there was insufficient evidence to prove neglect or inadequate staffing.
Complaint Details
The complaint involved allegations that a resident sustained a fracture while in care, staff were not responding to call buttons timely, the facility's response system was in disrepair, and inadequate staffing to meet resident needs. All allegations were found to be unsubstantiated after investigation.
Report Facts
Facility capacity: 130
Resident census: 104
Caregiver staffing: 2
Med tech staffing: 1
Mid-shift caregiver hours: 8
Fall incident wait time: 60
Call button history review period: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kristine Clawson | Administrator | Facility administrator interviewed during investigation |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Follow-Up
Census: 97
Capacity: 130
Deficiencies: 2
Feb 15, 2022
Visit Reason
This was a case management visit to follow-up on a complaint investigation regarding physical abuse of a resident by facility staff, originally investigated in September 2021.
Findings
The Department substantiated that a staff member physically abused a resident, violating residents' personal rights. A civil penalty of $9,500 was issued for the physical abuse violation.
Complaint Details
The complaint investigation substantiated that a facility staff (S1) physically abused a resident (R1) as evidenced by video surveillance showing slapping, hair pulling, and rough handling. The complaint was received on September 7, 2021, and completed on September 10, 2021.
Deficiencies (2)
| Description |
|---|
| Violation of California Code of Regulations, Title 22 Division 6, Chapter 8, §87468.1(a)(1) regarding residents' right to dignity in personal relationships. |
| Violation of California Code of Regulations, Title 22 Division 6, Chapter 8, §87468.1(a)(3) regarding residents' right to be free from punishment, humiliation, intimidation, abuse, or punitive actions. |
Report Facts
Civil penalty amount: 9500
Civil penalty amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristine Clawson | Administrator | Named as facility administrator during the inspection and recipient of report and penalty notices |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the inspection and signed the report |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager overseeing the case |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 130
Deficiencies: 1
Jan 10, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-09-10 regarding resident care and staffing issues at Brookdale Folsom facility.
Findings
The investigation found two allegations unsubstantiated: that a resident was left unattended on the floor after a fall and that the facility did not have sufficient staff to meet residents' needs. One allegation, that a resident was not treated with dignity due to rough treatment by staff, was substantiated, resulting in staff removal, training, and a citation.
Complaint Details
The complaint investigation addressed three main allegations: 1) Resident left unattended on floor after fall, 2) Insufficient staffing to meet resident needs, and 3) Resident not treated with dignity. The first two allegations were found unsubstantiated after interviews, video review, and documentation. The third allegation was substantiated based on video evidence and staff interviews, leading to staff removal and facility citation.
Severity Breakdown
Substantiated: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident was not treated with dignity; staff observed hitting resident, pulling hair, roughly placing resident in bed, and other inappropriate actions. | Substantiated |
Report Facts
Capacity: 130
Census: 91
Staff scheduled: 2
Staff scheduled: 1
Staff scheduled: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kristine Clawson | Administrator | Facility administrator met during investigation and provided information |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 130
Deficiencies: 1
Jan 10, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2021-11-03 regarding timely access to resident records and signed admission agreements.
Findings
The investigation found two allegations unfounded: staff did not make resident records available in a timely manner and the facility did not have a signed admission agreement. One allegation was substantiated: resident records were incomplete as the facility did not provide all resident documents to the responsible party.
Complaint Details
The complaint investigation was initiated due to allegations that staff did not make resident records available timely, the facility lacked a signed admission agreement, and resident records were incomplete. The first two allegations were found unfounded after interviews and document review. The third allegation was substantiated as the facility failed to provide all resident documents to the responsible party on September 23, 2021.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not release all resident records which poses a potential health and safety risk to residents in care. | Type B |
Report Facts
Capacity: 130
Census: 91
Deficiencies cited: 1
Plan of Correction Due Date: Jan 17, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kristine Clawson | Administrator | Facility administrator interviewed during investigation |
| Troy Ordonez | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 130
Deficiencies: 2
Sep 30, 2021
Visit Reason
The visit was an unannounced case management inspection to issue citations and assess civil penalties related to staffing and abuse complaints. It included substantiated complaint allegations of staff abuse and failure to report abuse.
Findings
The facility allowed a staff member to work without criminal record clearance, posing an immediate health and safety risk. Additionally, substantiated complaints found staff physically abused a resident and another staff member failed to report the abuse as mandated. Civil penalties were assessed.
Complaint Details
On 09/10/2021, the Department substantiated complaint allegations that staff hit a resident, pulled a resident's hair, and mistreated a resident. Another staff member observed the abuse but failed to report it as required for a mandated reporter. Civil penalties of $500 were assessed for a resident sustaining serious bodily injury.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility allowed an individual to be employed and work with residents without being criminally record cleared. | Type A |
| Licensee staff member did not report suspected physical abuse as required by mandated reporter laws. | Type A |
Report Facts
Civil penalty amount: 500
Capacity: 130
Census: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kandice Taylor | Staff member allowed to work without criminal record clearance |
Inspection Report
Census: 94
Capacity: 130
Deficiencies: 0
Sep 30, 2021
Visit Reason
The visit was an unannounced Case Management visit to deliver an Order to Individual of Immediate Exclusion and an Order to Licensee/Facility of Immediate Exclusion due to prior employees not allowed to work or be present in the facility.
Findings
The Licensing Program Analysts delivered notice of Immediate Exclusion to the Administrator, explaining that prior employees Sharan Kaur and Kandice Taylor are prohibited from working, being present, or having contact with clients in any licensed residential or child day care facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristine Clawson | Administrator | Met with Licensing Program Analysts during the visit and received the Immediate Exclusion notice. |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the unannounced Case Management visit and delivered the Immediate Exclusion notice. |
| Jacob Williams | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Troy Ordonez | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 130
Deficiencies: 2
Sep 10, 2021
Visit Reason
Unannounced complaint investigation visit triggered by allegations of staff hitting, pulling hair, and mistreating a resident while in care.
Findings
Investigation substantiated the allegations based on surveillance video showing staff hitting and pulling a resident's hair, rough handling, and inappropriate actions. Staff involved were removed and training was conducted for all staff on abuse, neglect, and mandatory reporting.
Complaint Details
Complaint was substantiated based on evidence including surveillance video. Allegations included staff hitting a resident, pulling hair, and mistreatment. Staff involved were removed and authorities notified.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure residents were free from punishment, humiliation, intimidation, abuse, or other punitive actions, posing immediate health and safety risk. | Type A |
| Failure to ensure residents were treated with dignity, posing immediate health and safety risk. | Type A |
Report Facts
Capacity: 130
Census: 89
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation |
| Kristine Clawson | Administrator | Facility administrator involved in investigation and interview |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 79
Capacity: 130
Deficiencies: 0
Jun 28, 2021
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted to assess infection control compliance and overall health and safety of residents at the facility.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristine Clawson | Administrator | Met with Licensing Program Analyst during inspection and involved in facility tour. |
| Konnor Leitzell | Licensing Program Analyst | Conducted the Required-1 Year Inspection and infection control domain assessment. |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 130
Deficiencies: 1
Jun 27, 2021
Visit Reason
The visit was conducted as a case management visit to address a deficiency discovered during a complaint investigation regarding a resident being denied access to a phone.
Findings
The investigation found that a resident's personal cell phone was confiscated due to repeated loss and disruptive calling behavior, but no reassessment or needs and services plan was created to address the issue, resulting in a cited deficiency.
Complaint Details
The complaint investigation was triggered by an allegation that a resident was denied access to a phone (Complaint Control Number 27-AS-20201007154720).
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to conduct a reappraisal or implement a needs and services plan after behaviors were observed in resident R1, resulting in confiscation of the resident's personal phone. | Type B |
Report Facts
Capacity: 130
Census: 70
Deficiency count: 1
Plan of Correction Due Date: Jul 9, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Reber | Licensing Program Analyst | Conducted the inspection and authored the report |
| Alycia Berryman | Licensing Program Manager | Supervisor overseeing the inspection |
| Brianna Brown | Health & Wellness Director | Interviewed during the inspection |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 130
Deficiencies: 2
Jun 27, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 11/19/2020 regarding resident care, notification of representatives, supervision, and safeguarding of personal belongings at Brookdale Folsom facility.
Findings
The investigation found one allegation substantiated regarding failure to provide timely written notice of rate increase to the resident's authorized representative. Another allegation of lack of supervision resulting in resident injury was substantiated with deficiencies cited. Other allegations, including failure to notify representative of change in level of care and failure to safeguard personal belongings, were found to be unfounded or unsubstantiated. Deficiencies related to staffing and notification were cited with Type A and Type B severity.
Complaint Details
The complaint investigation was triggered by allegations including failure to notify authorized representative of change in level of care, lack of supervision causing resident assault and injury, failure to provide timely written notice of rate increase, and failure to safeguard resident's personal belongings. The allegation of failure to notify representative of change in level of care was found unfounded. The lack of supervision and failure to provide timely written notice were substantiated. The failure to safeguard belongings was unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The facility did not address resident R2's aggressive behavior resulting in injury to R1, posing immediate risk to resident health and safety. | Type A |
| For any rate increase due to a change in the level of care, the licensee shall provide written notice to the resident and representative within two business days. The facility failed to provide timely written notice of rate increase to the resident's representative after moving to memory care unit. | Type B |
Report Facts
Capacity: 130
Census: 70
Deficiencies cited: 2
Plan of Correction Due Date: Jun 29, 2021
Plan of Correction Due Date: Jul 9, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Reber | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alycia Berryman | Licensing Program Manager | Oversaw the complaint investigation |
| Ed Silva | Administrator | Facility administrator named in the report |
| Maurissa Eidenshink | Business Office Coordinator | Met with analyst during investigation |
| Brianna Brown | Health and Wellness Director | Met with analyst during investigation |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 130
Deficiencies: 0
Jun 27, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2020-10-07 regarding resident injuries from a fall, safeguarding of resident belongings, and denial of phone access.
Findings
The investigation found insufficient evidence to substantiate the allegations of a fall caused by facility hazards, failure to safeguard resident belongings, and denial of phone access. The allegations were determined to be unsubstantiated or unfounded, and no deficiencies were cited.
Complaint Details
The complaint involved allegations that a resident sustained injuries due to a fall caused by facility hazards, the facility did not safeguard resident belongings (a missing $1,500 MacBook laptop), and the resident was denied access to a phone. The investigation included interviews and document reviews. The fall was unwitnessed and no evidence supported a wet floor as cause. The missing laptop could not be conclusively linked to facility negligence. The phone was taken from the resident due to repeated loss and interference with daily functioning, but the resident had access to a facility phone. The allegations were found unsubstantiated or unfounded.
Report Facts
Facility capacity: 130
Resident census: 70
Complaint control number: 27-AS-20201007154720
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Reber | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Maurissa Eidenshink | Business Office Coordinator | Met with the analyst during the investigation |
| Alycia Berryman | Licensing Program Manager | Oversaw the complaint investigation |
| Ed Silva | Administrator | Facility administrator mentioned in report header |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 130
Deficiencies: 0
May 10, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint alleging that staff did not keep a resident's room free from bugs.
Findings
The allegation was found to be unsubstantiated after review of documents, pest inspection reports, and staff interviews. The facility had removed the bug from the resident's room and retained ECO-Labs for ongoing bug control.
Complaint Details
The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged abuse occurred.
Report Facts
Capacity: 130
Census: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Konnor Leitzell | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kristine Clawson | Administrator | Met with Licensing Program Analyst during investigation |
| Ed Silva | Administrator | Named as facility administrator |
| Troy Ordonez | Licensing Program Manager | Named in report |
Inspection Report
Census: 78
Capacity: 130
Deficiencies: 0
Apr 15, 2021
Visit Reason
The visit was a case management incident conducted via telephone regarding a Death Report (LIC 624A) received by Community Care Licensing on 04/10/2021.
Findings
No deficiencies were cited as a result of the case management visit. The facility reported that a resident was found unresponsive and pronounced dead due to cardiac arrest, and relevant documents were requested for review.
Report Facts
Capacity: 130
Census: 78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Konnor Leitzell | Licensing Program Analyst | Conducted the case management visit |
| Kristine Clawson | Administrator | Facility representative met during the visit |
| Ed Silva | Administrator | Facility administrator named in the report header |
| Troy Ordonez | Licensing Program Manager | Named in the report |
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