Inspection Reports for
Brookdale Garden Grove

CA, 92840

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Deficiencies (last 6 years)

Deficiencies (over 6 years) 3.8 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

5% better than California average
California average: 4 deficiencies/year

Deficiencies per year

12 9 6 3 0
2021
2022
2023
2024
2025
2026

Occupancy

Latest occupancy rate 84% occupied

Based on a January 2026 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Occupancy rate over time

40% 60% 80% 100% Jun 2021 Dec 2023 Aug 2024 Mar 2025 Sep 2025 Jan 2026

Inspection Report

Complaint Investigation
Census: 118 Capacity: 140 Deficiencies: 0 Date: Jan 26, 2026

Visit Reason
This unannounced inspection was conducted to investigate a complaint received on 08/06/2021 regarding allegations including a resident sustaining unexplained injury, presence of bed bugs and pests in a resident's room, lack of toiletries, and staff not maintaining residents' hygiene.

Complaint Details
The complaint involved allegations that a resident sustained unexplained injury, had bed bugs and pests in their room, was not provided toiletries, and staff did not maintain residents' hygiene. The investigation included interviews with staff, residents, and responsible parties, review of service plans, progress notes, pest control invoices, and shower schedules. The allegations were found unsubstantiated.
Findings
The investigation found that although there were multiple falls by Resident #1 and a bed bug issue in their room that was addressed by the facility, there was insufficient evidence to substantiate the allegations. The facility provided appropriate medical care, pest control treatments, and toiletries, and residents reported no ongoing issues. The allegations were deemed unsubstantiated due to lack of preponderance of evidence.

Report Facts
Capacity: 140 Census: 118 Complaint received date: Aug 6, 2021 Fall date: May 11, 2021 Bed bug clearance date: Aug 6, 2021 Scheduled showers per week: 2

Employees mentioned
NameTitleContext
Sean HaddadLicensing Program AnalystConducted the complaint investigation
Brisseth ArrellanoAdministratorFacility administrator interviewed during investigation
Pamela BradleyAdministratorNamed as facility administrator in report header
Armando J LuceroSupervisorSupervisor overseeing the licensing evaluation

Inspection Report

Census: 114 Capacity: 140 Deficiencies: 0 Date: Dec 30, 2025

Visit Reason
This unannounced Case Management – Other inspection was conducted by Licensing Program Analyst Sean Haddad for the purpose of delivering amended findings for Complaint Control Number 22-AS-20210726164318.

Complaint Details
The inspection was related to amended findings for Complaint Control Number 22-AS-20210726164318.
Findings
During the inspection, the Licensing Program Analyst and Staff #1 reviewed and discussed the previously delivered findings and the amended findings. The amended report was delivered to the facility representative.

Employees mentioned
NameTitleContext
Patricia JimenezStaff #1Met with Licensing Program Analyst during inspection and discussed findings.
Sean HaddadLicensing Program AnalystConducted the inspection and delivered amended findings.
Armando J LuceroLicensing Program ManagerNamed as Licensing Program Manager on the report.

Inspection Report

Complaint Investigation
Census: 114 Capacity: 140 Deficiencies: 2 Date: Dec 30, 2025

Visit Reason
This unannounced inspection was conducted to investigate complaints alleging that staff was rough with a resident resulting in injury and failure to report the incident properly.

Complaint Details
The complaint investigation was substantiated. Allegations included staff rough handling of a resident causing injury and failure to report the incident properly. The investigation confirmed bruising on Resident #1 due to forced care by staff and that the resident's responsible party was only verbally notified, not in writing as required.
Findings
The investigation substantiated that staff forcibly handled Resident #1 causing bruises and failed to follow proper reporting procedures to notify the resident's responsible party in writing. Staff involved were terminated and civil penalties were assessed. The facility did not have sufficient oversight to prevent such incidents.

Deficiencies (2)
Failure to ensure Resident #1 was free from abuse when staff forced care resulting in bruises, violating personal rights.
Failure to submit a written report to Resident #1’s responsible party regarding the incident of rough handling by staff.
Report Facts
Capacity: 140 Census: 114 Deficiencies cited: 2 Plan of Correction Due Dates: Dec 31, 2025 Plan of Correction Due Dates: Jan 27, 2026

Employees mentioned
NameTitleContext
Sean HaddadLicensing Program AnalystConducted the complaint investigation
Pamela BradleyAdministratorFacility administrator named in report
Ted DawitStaff member met with during inspection
Staff #1Staff terminated for rough handling and failure to report
Staff #2Staff terminated for rough handling
Armando J LuceroSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 114 Capacity: 140 Deficiencies: 0 Date: Dec 30, 2025

Visit Reason
This unannounced Case Management – Other inspection was conducted to deliver amended findings for Complaint Control Number 22-AS-20210726164318.

Complaint Details
The inspection was conducted for the purpose of delivering amended findings related to a complaint investigation identified by Complaint Control Number 22-AS-20210726164318.
Findings
During the inspection, the Licensing Program Analyst and facility staff reviewed and discussed previously delivered findings and amended findings. The amended report was delivered to the facility representative.

Employees mentioned
NameTitleContext
Patricia JimenezStaff #1Met with Licensing Program Analyst during inspection and discussed findings.
Sean HaddadLicensing Program AnalystConducted the inspection and delivered amended findings.
Armando J LuceroLicensing Program ManagerNamed as Licensing Program Manager on the report.

Inspection Report

Complaint Investigation
Census: 114 Capacity: 140 Deficiencies: 2 Date: Dec 30, 2025

Visit Reason
This unannounced inspection was conducted to investigate complaints alleging that staff was rough with a resident resulting in injury and failure to report the incident properly.

Complaint Details
The complaint investigation was substantiated. Allegations included staff rough handling of a resident causing injury and failure to report the incident properly. The investigation found that staff forcibly changed Resident #1 causing bruises and did not provide a written notification to the resident’s responsible party as required.
Findings
The investigation substantiated that staff forcibly changed Resident #1 resulting in bruises and that the incident was not properly reported in writing to the resident's responsible party. Staff involved were terminated, and civil penalties were assessed. The facility failed to prevent the incident through adequate staff oversight.

Deficiencies (2)
Failure to ensure Resident #1 was free from abuse when staff forced care resulting in bruises.
Failure to submit a written report to Resident #1’s responsible party regarding the incident of rough handling.
Report Facts
Capacity: 140 Census: 114 Deficiencies cited: 2 Plan of Correction Due Dates: Dec 31, 2025 Plan of Correction Due Dates: Jan 27, 2026

Employees mentioned
NameTitleContext
Sean HaddadLicensing Program AnalystConducted the complaint investigation
Pamela BradleyAdministratorFacility administrator named in report header
Ted DawitStaff member met with during inspection
Armando J LuceroSupervisorSupervisor overseeing the investigation
Staff #1Staff terminated for rough handling and failure to report
Staff #2Staff terminated for rough handling

Inspection Report

Complaint Investigation
Census: 119 Capacity: 140 Deficiencies: 0 Date: Dec 4, 2025

Visit Reason
This unannounced Case Management – Incident inspection was conducted to conclude the investigation into a self-reported incident regarding missing cash reported by a resident on November 7, 2025.

Complaint Details
The complaint involved a resident reporting $850 missing from their room, alleging a staff member took it. The police reviewed evidence but were unable to confirm theft and closed the investigation.
Findings
The investigation found conflicting information regarding the alleged theft, and the police determined the money was lost and not stolen. No deficiencies were observed or cited during the inspection.

Report Facts
Missing cash amount: 850

Employees mentioned
NameTitleContext
Ted DawitStaffMet with Licensing Program Analyst during inspection
Brisseth ArrellanoAdministratorInterviewed via telephone during inspection
Sean HaddadLicensing Program AnalystConducted the inspection and investigation

Inspection Report

Complaint Investigation
Census: 119 Capacity: 140 Deficiencies: 0 Date: Nov 24, 2025

Visit Reason
This unannounced Case Management – Incident inspection was conducted to follow up on a self-reported incident involving Resident #1 who sustained a right toe fracture after a fall on October 18, 2025.

Complaint Details
The visit was triggered by a self-reported incident of a fall resulting in a fracture. The investigation did not corroborate lack of care or supervision causing the fall, and the complaint was effectively addressed by updated care plans and additional assistance.
Findings
The inspection found that the facility regularly updated Resident #1's Personal Service Plans and added assistance as necessary to address the resident's chronic and evolving fall risk. No deficiencies were observed or cited during the inspection.

Report Facts
Facility capacity: 140 Resident census: 119 Incident date: Oct 18, 2025 Incident report received date: Oct 23, 2025 Home health visits per week: 3

Employees mentioned
NameTitleContext
Brisseth ArrellanoAdministratorInterviewed regarding Resident #1's care and incident
Ted DawitStaff #1Interviewed during inspection related to Resident #1's incident
Sean HaddadLicensing Program AnalystConducted the inspection and investigation

Inspection Report

Follow-Up
Census: 119 Capacity: 140 Deficiencies: 0 Date: Nov 24, 2025

Visit Reason
This unannounced Case Management – Incident inspection was conducted to follow up on a self-reported incident involving missing cash reported by a resident on November 7, 2025.

Findings
The investigation did not corroborate the presence of the missing money in the resident's room, and conflicting information was obtained regarding the alleged theft. No deficiencies were observed or cited during the inspection.

Report Facts
Missing cash amount reported: 850 Missing cash amount claimed by resident: 1000

Employees mentioned
NameTitleContext
Sean HaddadLicensing Program AnalystConducted the inspection and investigation
Brisseth ArrellanoAdministratorInterviewed during inspection and involved in investigation

Inspection Report

Complaint Investigation
Census: 121 Capacity: 140 Deficiencies: 0 Date: Oct 14, 2025

Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff stole money from a resident and were going through residents' personal belongings without consent.

Complaint Details
The complaint involved allegations that staff stole money from a resident and went through residents' personal belongings without consent. The allegations were investigated through interviews with residents and staff and record review. The findings were that the allegations were unfounded and could not be corroborated.
Findings
The investigation found that the allegation of staff stealing $70 from a resident was unfounded as the resident later found the money misplaced. The allegation of staff going through residents' personal belongings without consent was also unsubstantiated based on interviews and record review. Therefore, all allegations were deemed unfounded.

Report Facts
Amount of money allegedly stolen: 70 Number of residents present: 121 Facility capacity: 140 Number of staff interviewed: 5 Number of residents interviewed: 2

Employees mentioned
NameTitleContext
Fred AriasLicensing Program AnalystConducted the complaint investigation visit and interviews
Jeri MilesAdministratorFacility administrator named in the report
Alisa OrtizLicensing Program ManagerNamed as Licensing Program Manager overseeing the investigation

Inspection Report

Complaint Investigation
Census: 124 Capacity: 140 Deficiencies: 1 Date: Sep 30, 2025

Visit Reason
This unannounced Case Management – Deficiencies inspection was conducted to issue citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20250924155802.

Complaint Details
Investigation was triggered by Complaint Control No. 22-AS-20250924155802. The deficiency related to failure to report Resident #1's hospitalization was substantiated.
Findings
The licensee failed to report Resident #1's hospitalization on September 5, 2025, to the licensing agency as required, posing a potential safety risk to persons in care. Civil penalties for repeat violations are being assessed.

Deficiencies (1)
Failure to submit a written report to the licensing agency within seven days of Resident #1's hospitalization on September 5, 2025.
Report Facts
Capacity: 140 Census: 124 Plan of Correction Due Date: Oct 21, 2025

Employees mentioned
NameTitleContext
Sean HaddadLicensing Program AnalystConducted the inspection and issued the report
Brisseth ArrellanoAdministratorMet with Licensing Program Analyst during inspection and admitted to the failure to report hospitalization

Inspection Report

Complaint Investigation
Census: 124 Capacity: 140 Deficiencies: 0 Date: Sep 30, 2025

Visit Reason
An unannounced complaint investigation was conducted to investigate the allegation that the facility did not maintain a clean and sanitary environment.

Complaint Details
The complaint alleged that Resident #1 had gastrointestinal issues causing odor that affected other residents. The investigation included facility inspection, interviews with administrator, residents, and staff, and review of Resident #1's medical records. No corroborating evidence was found and the complaint was determined to be unfounded.
Findings
The investigation found no evidence to support the allegation. Inspections, interviews, and medical record reviews revealed no bad odors or gastrointestinal issues related to Resident #1, and no residents were bothered by odors or became ill. The allegation was found to be unfounded.

Report Facts
Facility capacity: 140 Resident census: 124

Employees mentioned
NameTitleContext
Sean HaddadLicensing Program AnalystConducted the complaint investigation
Armando J LuceroLicensing Program ManagerOversaw the complaint investigation
Brisseth ArrellanoAdministratorInterviewed during the investigation

Inspection Report

Complaint Investigation
Census: 124 Capacity: 140 Deficiencies: 1 Date: Sep 30, 2025

Visit Reason
This unannounced Case Management – Deficiencies inspection was conducted to issue citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20250924155802.

Complaint Details
The inspection was triggered by a complaint investigation into Complaint Control No. 22-AS-20250924155802. The complaint was substantiated by the finding that Resident #1's hospitalization was not reported as required.
Findings
The licensee failed to report Resident #1's hospitalization on September 5, 2025, as required by licensing regulations, posing a potential safety risk. Civil penalties for repeat violations were assessed.

Deficiencies (1)
Failure to submit a written report to the licensing agency within seven days of a serious injury, specifically not reporting Resident #1's hospitalization on September 5, 2025.
Report Facts
Deficiencies cited: 1 Capacity: 140 Census: 124

Employees mentioned
NameTitleContext
Sean HaddadLicensing Program AnalystConducted the inspection and issued citations
Brisseth ArrellanoAdministratorInterviewed during inspection and involved in findings

Inspection Report

Complaint Investigation
Census: 123 Capacity: 140 Deficiencies: 0 Date: Sep 17, 2025

Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff did not adequately supervise a resident resulting in the resident's injury.

Complaint Details
The complaint alleged inadequate supervision of a resident resulting in injury. The allegation was unsubstantiated based on interviews, document review, and observations.
Findings
The investigation found that 12 out of 12 resident interviews and 2 out of 2 staff interviews did not corroborate the allegation. Documentation showed the resident had a history of falls and sustained a bruise but no injury from the fall. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.

Report Facts
Capacity: 140 Census: 123

Employees mentioned
NameTitleContext
Celine RodriguezLicensing Program AnalystConducted the complaint investigation and unannounced visit
Brisseth ArrellanoExecutive DirectorMet with Licensing Program Analyst during the investigation and exit interview
Pamela BradleyAdministratorNamed as facility administrator
Sheila SantosLicensing Program ManagerNamed as Licensing Program Manager overseeing the investigation

Inspection Report

Follow-Up
Census: 123 Capacity: 140 Deficiencies: 1 Date: Sep 11, 2025

Visit Reason
The visit was an unannounced follow-up inspection to verify correction of a Type B deficiency issued during the Annual Inspection on August 28, 2025.

Findings
The facility was found to be in compliance with the terms of the Plan of Correction for the cited Type B deficiency 87303(a) after inspection of the apartment unit of Resident #1 with the Maintenance Supervisor. A Letter of Deficiency Citations Cleared was provided at the end of the visit.

Deficiencies (1)
Type B deficiency 87303(a) previously cited during the Annual Inspection
Report Facts
Capacity: 140 Census: 123

Employees mentioned
NameTitleContext
Jessica ChoLicensing Program AnalystConducted the unannounced follow-up visit
Patty JimenezBusiness Office ManagerMet with the Licensing Program Analyst during the visit and exit interview
Francisco SarabiaMaintenance SupervisorParticipated in the inspection of Resident #1's apartment unit

Inspection Report

Annual Inspection
Census: 124 Capacity: 140 Deficiencies: 1 Date: Aug 28, 2025

Visit Reason
The inspection was an unannounced Required 1-Year annual evaluation using the Care Inspection Tool to assess compliance with licensing requirements.

Findings
The facility was generally clean, sanitary, and in good repair except for one unit where mold was observed on a ceiling panel caused by a water pipe drip. The ceiling panel was removed and replaced during the visit. All other areas including bedrooms, bathrooms, common areas, and safety equipment were found to be in compliance.

Deficiencies (1)
One out of twelve units inspected had mold on a ceiling panel caused by a water pipe drip, posing a potential health, safety, or personal rights risk to persons in care.
Report Facts
Capacity: 140 Census: 124 Deficiencies cited: 1 Plan of Correction Due Date: Sep 5, 2025

Employees mentioned
NameTitleContext
Jessica ChoLicensing Program AnalystConducted the inspection and signed the report
Brisseth ArrellanoExecutive DirectorMet with Licensing Program Analyst during inspection and involved in exit interview
Patricia JimenezBusiness Office ManagerMet with Licensing Program Analyst during inspection and involved in exit interview

Inspection Report

Complaint Investigation
Census: 109 Capacity: 140 Deficiencies: 0 Date: Apr 22, 2025

Visit Reason
This unannounced inspection was conducted to investigate a complaint alleging that the facility's air conditioning units were in disrepair, resulting in poor performance, outages, and uncomfortable temperatures.

Complaint Details
The complaint alleged that the facility’s AC system was not properly maintained causing poor performance and uncomfortable temperatures. The investigation was unsubstantiated as no evidence confirmed the allegation.
Findings
The investigation found no health or safety issues related to the air conditioning system. Interviews with residents and staff, inspection of temperatures in resident rooms, and review of maintenance records showed that the facility has been diligently working to diagnose and fix the air conditioning issues, and residents were not impacted by uncomfortable temperatures. The allegation was deemed unsubstantiated due to lack of sufficient evidence.

Report Facts
Residents interviewed: 11 Rooms temperature checked: 12

Employees mentioned
NameTitleContext
Sean HaddadLicensing Program AnalystConducted the complaint investigation
Armando J LuceroLicensing Program ManagerOversaw the complaint investigation
Francisco SarabiaMaintenance SupervisorInterviewed regarding the air conditioning system maintenance and issues

Inspection Report

Complaint Investigation
Census: 112 Capacity: 140 Deficiencies: 0 Date: Mar 24, 2025

Visit Reason
This unannounced inspection was conducted to investigate complaints alleging that a resident sustained a head injury and multiple falls due to lack of supervision.

Complaint Details
The complaint alleged that a resident sustained a head injury and multiple falls due to lack of supervision. The investigation included interviews with staff, residents, and review of medical and care records. The allegations were unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that while the resident had multiple falls, none resulted in serious injury or hospitalization. The facility had updated the resident's care plan and conducted staff training to address fall risks. There was insufficient evidence to substantiate the allegations, and the complaint was deemed unsubstantiated.

Report Facts
Facility capacity: 140 Resident census: 112 Number of residents interviewed: 12 Number of care staff interviewed: 2

Employees mentioned
NameTitleContext
Sean HaddadLicensing Program AnalystConducted the complaint investigation
Jeri MilesAdministratorInterviewed during investigation regarding resident care and falls
Armando J LuceroLicensing Program ManagerOversaw the complaint investigation

Inspection Report

Complaint Investigation
Census: 115 Capacity: 140 Deficiencies: 1 Date: Mar 3, 2025

Visit Reason
This unannounced Case Management – Deficiencies inspection was conducted to issue citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20250205085503.

Complaint Details
Investigation was triggered by Complaint Control No. 22-AS-20250205085503. The deficiency related to failure to report Resident #1's fall on February 1, 2025, was substantiated based on documents and admission by the administrator.
Findings
The inspection found that Resident #1 had multiple unwitnessed falls in early February 2025, including one on February 1 that was not reported to licensing as required, posing a potential safety risk. Deficiencies were cited per Title 22 Division 6 of the California Code of Regulations.

Deficiencies (1)
Failure to submit a written report to the licensing agency within seven days of a serious injury occurrence, specifically the failure to report Resident #1's fall on February 1, 2025.
Report Facts
Capacity: 140 Census: 115 Deficiency count: 1 Plan of Correction Due Date: Mar 17, 2025

Employees mentioned
NameTitleContext
Jeri MilesAdministratorMet with Licensing Program Analyst during inspection and admitted failure to report fall
Sean HaddadLicensing Program AnalystConducted the inspection and issued citations
Armando J LuceroLicensing Program ManagerSupervisor and Licensing Program Manager overseeing the inspection

Inspection Report

Complaint Investigation
Census: 115 Capacity: 140 Deficiencies: 1 Date: Mar 3, 2025

Visit Reason
This unannounced Case Management – Deficiencies inspection was conducted to issue citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20250205085503.

Complaint Details
The visit was complaint-related, investigating Complaint Control No. 22-AS-20250205085503. The complaint involved failure to report Resident #1's fall on February 1, 2025. The deficiency was substantiated based on incident reports and the administrator's admission.
Findings
The inspection found that the facility failed to report a resident's fall on February 1, 2025, as required by regulations, posing a potential safety risk to persons in care. Deficiencies were cited under Title 22 Division 6 of the California Code of Regulations.

Deficiencies (1)
Failure to submit a written report to the licensing agency within seven days of a serious injury occurrence, specifically the failure to report Resident #1's fall on February 1, 2025.
Report Facts
Capacity: 140 Census: 115 Plan of Correction Due Date: Due date for correcting the cited deficiency is March 17, 2025

Employees mentioned
NameTitleContext
Jeri MilesAdministratorMet with Licensing Program Analyst during inspection and admitted to failure to report fall
Sean HaddadLicensing Program AnalystConducted the inspection and issued citations
Armando J LuceroSupervisorSupervisor overseeing the inspection

Inspection Report

Complaint Investigation
Census: 104 Capacity: 140 Deficiencies: 2 Date: Feb 13, 2025

Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that facility staff falsified a resident's Physician Report and that a resident was unlawfully retained in Memory Care.

Complaint Details
The complaint investigation was substantiated. The allegations included falsification of the resident's Physician Report and unlawful retention of the resident in Memory Care. The preponderance of evidence standard was met based on interviews and document reviews.
Findings
The investigation substantiated the allegations that the facility staff falsified the resident's Physician Report and unlawfully retained the resident in Memory Care. Documentation and interviews revealed conflicting Physician Reports and lack of communication with the resident's authorized representative prior to placement in Memory Care.

Deficiencies (2)
False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. The Physician report dated 02/11/24 was not filled out by Scan's Nurse Practitioner as Nurse Practitioner was not working on 02/11/24. This poses an immediate risk to resident’s health and safety.
Personal Rights. Residents in residential care facilities for the elderly shall have personal rights including communication with their authorized representative. The facility did not communicate with R1's Authorized Representative prior to placing R1 in Memory Care, despite Physician report dated 02/12/24 indicating R1 does not have a diagnosis of Dementia and is able to leave the facility unassisted.
Report Facts
Capacity: 140 Census: 104 Plan of Correction Due Date: Feb 14, 2025 Plan of Correction Due Date: Feb 20, 2025

Employees mentioned
NameTitleContext
Alvaro Ramirez Jr.Licensing Program AnalystConducted the complaint investigation and authored the report
Jeri MilesAdministratorFacility Administrator met during the investigation and named in findings
Sheila SantosLicensing Program ManagerNamed as Licensing Program Manager overseeing the investigation

Inspection Report

Complaint Investigation
Census: 103 Capacity: 140 Deficiencies: 0 Date: Feb 5, 2025

Visit Reason
An unannounced complaint investigation visit was conducted to follow up on an allegation that staff do not ensure the facility is free from mold.

Complaint Details
The complaint alleged that staff do not ensure the facility is free from mold. The allegation was found to be unsubstantiated after investigation including tours, interviews, and review of the facility.
Findings
The investigation included tours of the facility, resident interviews, and review of physical plant areas. Evidence showed a past water damage incident with adequate containment and no current mold presence. The allegation was found to be unsubstantiated due to insufficient evidence.

Report Facts
Resident interviews conducted: 6 Units inspected: 7

Employees mentioned
NameTitleContext
Kevin Saborit-GuaschLicensing Program AnalystConducted the complaint investigation and inspection
Jeri MilesExecutive DirectorFacility administrator who met with the Licensing Program Analyst
Francisco SarabiaFacility Maintenance DirectorAccompanied the Licensing Program Analyst during the facility tour
Sheila SantosLicensing Program ManagerNamed in the report as Licensing Program Manager

Inspection Report

Complaint Investigation
Census: 94 Capacity: 140 Deficiencies: 3 Date: Nov 25, 2024

Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on April 17, 2024, regarding the facility's failure to provide requested records to an authorized representative, failure to allow resident participation in care planning, and failure to allow the resident to choose a healthcare provider.

Complaint Details
The complaint investigation was substantiated. Allegations included failure to provide requested records to the authorized representative, failure to allow resident participation in care planning, and failure to allow resident to choose healthcare provider. Evidence included document reviews and interviews confirming these issues.
Findings
The investigation substantiated all allegations, finding that the facility did not provide requested records for March 2024 to the authorized representative, did not arrange a meeting with the resident and authorized representative for care planning, and did not allow the resident to choose their healthcare provider. These deficiencies pose potential risks to persons in care.

Deficiencies (3)
Facility did not provide Resident 1's records for March 2024 to the authorized representative, violating confidentiality requirements.
Facility failed to arrange a meeting with Resident 1 and their authorized representative prior to placing Resident 1 in Memory Care, violating resident participation in decision-making requirements.
Facility did not allow Resident 1 to fully participate in planning their care, including attending meetings or communications regarding care and services, as evidenced by a telemedicine visit with a provider not chosen by the resident.
Report Facts
Capacity: 140 Census: 94 Deficiency count: 3 Plan of Correction Due Date: Nov 29, 2024

Employees mentioned
NameTitleContext
Alvaro Ramirez Jr.Licensing Program AnalystConducted the complaint investigation and authored the report
Jeri MilesAdministratorFacility administrator met during the investigation and exit interview
Sheila SantosLicensing Program ManagerOversaw the complaint investigation

Inspection Report

Annual Inspection
Census: 92 Capacity: 140 Deficiencies: 1 Date: Aug 9, 2024

Visit Reason
This unannounced inspection was conducted as a Required – 1 Year Inspection to evaluate compliance with licensing regulations.

Findings
The inspection included a facility tour, review of infection control, resident and staff file reviews, and medication inspections. One deficiency was cited related to water temperature taps exceeding safe limits in memory care rooms, posing an immediate safety risk. The licensee adjusted the temperature during the inspection and submitted a plan of correction.

Deficiencies (1)
Faucets in rooms 103, 104, 115, and 243 tested at temperatures above 125 degrees F, posing an immediate safety risk to residents in memory care.
Report Facts
Water temperature readings: 126 Water temperature readings: 133 Water temperature readings: 124 Water temperature readings: 129 Resident rooms total: 115 Resident bedrooms inspected: 12 Resident files reviewed: 6 Staff files reviewed: 6 Residents interviewed: 6 Staff interviewed: 6 Medications inspected: 6

Employees mentioned
NameTitleContext
Jeri MilesAdministratorMet with Licensing Program Analysts during inspection and discussed inspection purpose
Sean HaddadLicensing Program AnalystConducted inspection and signed report
Armando J LuceroLicensing Program ManagerSupervised inspection and signed report

Inspection Report

Census: 89 Capacity: 140 Deficiencies: 0 Date: Jun 24, 2024

Visit Reason
The visit was a case management inspection conducted to discuss an amended report related to a complaint control #22-AS-20240226102932 dated 2024-06-21.

Complaint Details
The visit was related to complaint control #22-AS-20240226102932 dated 2024-06-21. The report discussed was an amended complaint report.
Findings
The Licensing Program Analyst called the facility administrator to discuss the amended complaint report and conducted an exit interview by telephone. The administrator agreed to print, sign, and email the amended report and case management report back to the analyst.

Employees mentioned
NameTitleContext
Jeri MilesAdministratorFacility administrator involved in discussion and exit interview regarding amended complaint report.
Rosie QuirozLicensing Program AnalystConducted telephone discussion and exit interview with facility administrator.
Alisa OrtizLicensing Program ManagerNamed as Licensing Program Manager on the report.

Inspection Report

Complaint Investigation
Census: 89 Capacity: 140 Deficiencies: 2 Date: Jun 21, 2024

Visit Reason
The visit was an unannounced complaint investigation conducted in response to complaints received on 2024-02-26 regarding inadequate supervision resulting in a resident wandering away, failure to notify the resident's authorized representative of a placement change, inappropriate placement of a resident in a locked unit, and untimely reappraisal following a change in resident's condition.

Complaint Details
The complaint investigation was substantiated for allegations of inadequate supervision leading to a resident wandering away, failure to notify the authorized representative of placement changes, and inappropriate placement in a locked unit. The allegation of untimely reappraisal was unsubstantiated.
Findings
The investigation substantiated that staff did not provide adequate supervision resulting in a resident wandering away, failed to notify the authorized representative of a change in placement, and inappropriately placed a resident in a locked unit without proper notice. The allegation regarding untimely reappraisal following a change in condition was unsubstantiated.

Deficiencies (2)
Facility did not provide the resident and responsible party with a 30 day notice and did not communicate with the authorized representative prior to placing the resident in delayed egress memory care unit, substituting supervision needed to meet resident's needs.
Facility failed to provide safe, healthful, and comfortable accommodations and care and supervision as required, posing potential risk to residents in care.
Report Facts
Capacity: 140 Census: 89 Staffing: 2 Staffing: 2 Plan of Correction Due Date: Jun 25, 2024

Employees mentioned
NameTitleContext
Jeri MilesExecutive DirectorMet during investigation and named in findings related to deficiencies and plan of correction
Brisseth RiveraHealth and Wellness DirectorMet during investigation and named in findings related to deficiencies and plan of correction
Rosie QuirozLicensing Program AnalystConducted the complaint investigation
Alisa OrtizLicensing Program ManagerOversaw the complaint investigation

Inspection Report

Complaint Investigation
Census: 89 Capacity: 140 Deficiencies: 1 Date: Jun 21, 2024

Visit Reason
The visit was conducted as a subsequent investigation related to a complaint (Complaint Control #22-AS-20240226102932) regarding the facility's compliance with resident rights.

Complaint Details
The visit was triggered by a complaint investigation (Complaint Control #22-AS-20240226102932). The deficiency was substantiated as the facility did not provide the required written notice to Resident 1's responsible party within 30 days of the room change.
Findings
The facility failed to provide the required 30-day written notice to Resident 1 and their responsible party prior to moving the resident from Assisted Living to the Memory Care unit, posing a potential risk to residents in care.

Deficiencies (1)
Failure to provide 30-day written notice to Resident 1 and their responsible party prior to moving from Assisted Living to Memory Care unit.
Report Facts
Capacity: 140 Census: 89 Plan of Correction Due Date: Jun 25, 2024

Employees mentioned
NameTitleContext
Jeri MilesAdministratorMet during inspection and named in findings
Brisseth RiveraHealth and Wellness DirectorMet during inspection
Rosie QuirozLicensing Program AnalystConducted the inspection and signed the report
Alisa OrtizLicensing Program ManagerNamed as Licensing Program Manager and Supervisor

Inspection Report

Complaint Investigation
Census: 89 Capacity: 140 Deficiencies: 1 Date: Jun 21, 2024

Visit Reason
The visit was a subsequent inspection to cite a deficiency discovered during the investigation of Complaint Control #22-AS-20240226102932 regarding failure to provide required written notice to a resident prior to a room change.

Complaint Details
The visit was triggered by Complaint Control #22-AS-20240226102932. The deficiency was substantiated based on interviews and file review.
Findings
The facility failed to provide 30-day written notice to Resident 1 and their responsible party prior to moving the resident from Assisted Living to the Memory Care unit, posing a potential risk to residents in care.

Deficiencies (1)
Failure to provide 30-day written notice to Resident 1 and their responsible party prior to moving from Assisted Living to Memory Care unit.
Report Facts
Capacity: 140 Census: 89 Plan of Correction Due Date: Jun 25, 2024

Employees mentioned
NameTitleContext
Jeri MilesAdministratorNamed in relation to the deficiency and exit interview.
Brisseth RiveraHealth and Wellness DirectorMet with Licensing Program Analyst during inspection.
Rosie QuirozLicensing Program AnalystConducted the inspection and cited the deficiency.
Alisa OrtizSupervisorSupervisor overseeing the inspection.

Inspection Report

Complaint Investigation
Census: 92 Capacity: 140 Deficiencies: 1 Date: Apr 23, 2024

Visit Reason
The inspection was an unannounced complaint investigation initiated due to an allegation that the facility was not adhering to a resident's admission agreement.

Complaint Details
The complaint was substantiated. The allegation was that the facility was not adhering to the resident's admission agreement, specifically failing to issue a prorated refund after the resident moved out following hospitalization.
Findings
The investigation found that the facility did not adhere to the resident's admission agreement by failing to issue a prorated refund upon the resident's move-out, which was substantiated based on interviews and document reviews.

Deficiencies (1)
Facility did not comply with the admission agreement regarding refunds, posing a potential Personal Rights risk to persons in care.
Report Facts
Capacity: 140 Census: 92 Deficiency Type B: 1 Plan of Correction Due Date: Apr 30, 2024

Employees mentioned
NameTitleContext
Jessica ChoLicensing Program AnalystConducted the complaint investigation and authored the report
Jeri MilesExecutive DirectorFacility representative interviewed during investigation and named in findings

Inspection Report

Complaint Investigation
Census: 89 Capacity: 140 Deficiencies: 0 Date: Mar 20, 2024

Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that the facility did not provide requested records to an authorized representative.

Complaint Details
The complaint alleged the facility did not provide requested records to an authorized representative. The allegation was unsubstantiated after investigation.
Findings
The investigation found that the facility did not provide records initially because the requestor was not an authorized representative until a change of POA was received. Records were subsequently provided, and the allegation was deemed unsubstantiated due to lack of preponderance of evidence.

Report Facts
Capacity: 140 Census: 89

Employees mentioned
NameTitleContext
Ruth MartinezLicensing Program AnalystConducted the complaint investigation visit
Jeri MilesExecutive DirectorMet with Licensing Program Analyst during investigation
Armando J LuceroLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Complaint Investigation
Census: 87 Capacity: 140 Deficiencies: 0 Date: Dec 7, 2023

Visit Reason
The visit was an unannounced Case Management inspection conducted in connection to a complaint identified by Complaint Control Number 22-AS-20230919083629.

Complaint Details
The visit was triggered by a complaint with Control Number 22-AS-20230919083629. No substantiation status is provided in the report.
Findings
During the visit, the Licensing Program Analyst interviewed a resident and obtained records related to the complaint. An exit interview was conducted with the Executive Director, and a copy of the report was provided.

Employees mentioned
NameTitleContext
Jeri MilesExecutive DirectorMet with Licensing Program Analyst during the visit and exit interview.

Inspection Report

Complaint Investigation
Census: 96 Capacity: 140 Deficiencies: 0 Date: Nov 7, 2023

Visit Reason
An unannounced complaint investigation visit was conducted to follow up on allegations including inappropriate pushing of a resident, unexplained injuries, inappropriate staff speech, and multiple falls among residents.

Complaint Details
The complaint involved allegations that a resident was inappropriately pushed, residents sustained unexplained injuries, staff spoke inappropriately to a resident, and residents sustained multiple falls. The investigation concluded these allegations were unsubstantiated.
Findings
The investigation included interviews with staff, residents, and witnesses, and a review of documentation. The allegations were found to be unsubstantiated due to lack of preponderance of evidence to prove the violations occurred.

Report Facts
Capacity: 140 Census: 96

Employees mentioned
NameTitleContext
Rosie QuirozLicensing Program AnalystConducted the complaint investigation
Patricia JimenezBusiness Office ManagerMet with investigator during inspection and exit interview
Robert JakiniAdministratorFacility administrator named in report header
Alisa OrtizLicensing Program ManagerNamed as Licensing Program Manager overseeing the investigation

Inspection Report

Annual Inspection
Census: 85 Capacity: 140 Deficiencies: 0 Date: Jul 25, 2022

Visit Reason
This unannounced inspection was conducted for the purpose of an Annual Inspection to evaluate compliance with regulations.

Findings
The inspection found no health and safety issues; the facility was clean, organized, and well-stocked with food supplies. No deficiencies were cited during this inspection.

Report Facts
Staff present: 15 Food supply duration: 2 Food supply duration: 7

Employees mentioned
NameTitleContext
Sean HaddadLicensing Program AnalystConducted the inspection
Jeri MilesAdministratorFacility representative met during inspection

Inspection Report

Complaint Investigation
Census: 82 Capacity: 140 Deficiencies: 0 Date: Dec 22, 2021

Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility failed to provide a refund.

Complaint Details
The complaint alleged the facility failed to provide a refund. The allegation was found to be unfounded, meaning it was false, could not have happened, or was without a reasonable basis.
Findings
The investigation revealed that the facility required payment of monthly rent despite the resident not admitting due to lack of a dementia diagnosis. The facility's admission agreement requires a thirty-day notice for a refund. The allegation was determined to be unfounded.

Report Facts
Refund amount requested: 5120 Capacity: 140 Census: 82

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the complaint investigation visit
Michael SokolowskiExecutive Director who greeted and granted entry to Licensing Program Analyst
Pamela BradleyAdministratorFacility administrator named in report header
Alisa OrtizLicensing Program ManagerNamed as Licensing Program Manager overseeing the investigation

Inspection Report

Annual Inspection
Census: 74 Capacity: 140 Deficiencies: 0 Date: Oct 14, 2021

Visit Reason
This unannounced inspection was conducted for the purpose of an Annual Inspection to evaluate compliance with regulations.

Findings
The inspection found no health and safety issues; the facility was clean, organized, and compliant with COVID-19 protocols. No deficiencies were cited during this inspection.

Report Facts
Staff present: 30 Residents in memory care unit: 18 Perishable food supply: 2 Non-perishable food supply: 7

Employees mentioned
NameTitleContext
Michael SokolowskiAdministratorMet with Licensing Program Analyst during inspection
Sean HaddadLicensing Program AnalystConducted the inspection
Marina StanicLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Complaint Investigation
Census: 74 Capacity: 140 Deficiencies: 1 Date: Jun 30, 2021

Visit Reason
The inspection visit was conducted as part of the investigation of complaint number 22-AS-20210623125429.

Complaint Details
The visit was complaint-related, investigating complaint number 22-AS-20210623125429. The report does not explicitly state substantiation status.
Findings
The licensing program analyst observed deficiencies related to the unsafe storage of centrally stored medicines, specifically an unlocked medication cart at the entrance to the dementia care unit, posing an immediate risk to resident health and safety.

Deficiencies (1)
Facility did not ensure that centrally stored medicines were kept safe, locked, and only accessible to persons responsible for the supervision of medications. The LPA observed medication cart unlocked at the entrance to dementia care unit.
Report Facts
Census: 74 Total Capacity: 140 Deficiencies cited: 1

Employees mentioned
NameTitleContext
Michael SokolowskiExecutive DirectorNamed in exit interview and report review
Norman WoodridgeLicensing Program AnalystObserved deficiencies and signed report
Marina StanicLicensing Program ManagerSupervisor and named in report

Inspection Report

Complaint Investigation
Census: 74 Capacity: 140 Deficiencies: 1 Date: Jun 30, 2021

Visit Reason
The inspection visit was conducted as part of an investigation of complaint number 22-AS-20210623125429 regarding regulatory compliance at the facility.

Complaint Details
The visit was complaint-related, investigating complaint number 22-AS-20210623125429. The deficiency was substantiated as noted in the report.
Findings
The licensing evaluator observed deficiencies related to the improper storage of centrally stored medicines, specifically an unlocked medication cart in the dementia care unit, posing an immediate risk to resident health and safety.

Deficiencies (1)
Facility did not ensure that centrally stored medicines were kept safe, locked, and only accessible to persons responsible for the supervision of medications. Medication cart was observed unlocked at the entrance to the dementia care unit.
Report Facts
Deficiencies cited: 1 Capacity: 140 Census: 74

Employees mentioned
NameTitleContext
Norman WoodridgeLicensing EvaluatorObserved deficiencies and conducted the inspection
Michael SokolowskiExecutive DirectorFacility representative present during exit interview

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