Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. However, the facility had some substantiated issues in the past related primarily to staffing shortages, medication management, and failure to follow admission agreements. Serious events included substantiated findings of sexual assault by a staff member in 2023 and an immediate civil penalty assessed in 2023 for delayed medical care after a resident’s fall in late 2022. The most recent report from October 21, 2025, was a complaint investigation that found no deficiencies and deemed the complaint unsubstantiated. Overall, the facility appears to have improved over time, with the latest inspections showing compliance and no new citations.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Same as California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
92% occupied
Based on a October 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 143
Capacity: 155
Deficiencies: 0
Date: Oct 21, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility was not providing appropriate care for a resident.
Complaint Details
The complaint alleged the facility was not providing appropriate care for a resident. The allegation was unsubstantiated after investigation including interviews with 8 residents and 1 staff member, review of incident reports, and observation of the resident's environment and care plan.
Findings
The investigation included interviews, record reviews, and observations. Resident and staff interviews did not corroborate the allegation. Incident reports showed the resident had falls requiring medical attention, but the facility had taken steps to address safety concerns. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Resident interviews: 8
Staff interviews: 1
Resident falls: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine Rodriguez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Shannon Howell | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 150
Capacity: 155
Deficiencies: 0
Date: Aug 4, 2025
Visit Reason
The inspection was an unannounced required annual inspection of the facility conducted by Licensing Program Analyst Celine Rodriguez.
Findings
The facility was found to be in compliance with all applicable regulations with no deficiencies or citations issued. Safety equipment, resident rooms, and emergency preparedness measures were all observed to be in good condition and operational.
Report Facts
Capacity: 155
Census: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine Rodriguez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Sharin Belanger | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Mary Clark | Wellness Director | Met with Licensing Program Analyst during inspection |
| Carrie Galloway | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 155
Deficiencies: 0
Date: Aug 4, 2025
Visit Reason
The inspection was an unannounced case management visit to follow up on an incident reported on 2025-07-28 involving a resident's unwitnessed fall resulting in injury.
Complaint Details
The visit was triggered by a complaint regarding an incident where resident 1 sustained an unwitnessed fall on 2025-07-23 resulting in injury. The complaint was investigated and found to be an accidental fall with appropriate facility response and no citations issued.
Findings
The resident sustained an accidental unwitnessed fall causing a head injury and radial head fracture. The facility responded by contacting 911 and providing designated staff assistance post-hospital discharge. No health and safety concerns or citations were noted during the visit.
Report Facts
Capacity: 155
Census: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine Rodriguez | Licensing Program Analyst | Conducted the unannounced case management visit |
| Sharin Belanger | Business Office Manager | Met with Licensing Program Analyst during the visit |
| Mary Clark | Wellness Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 155
Deficiencies: 0
Date: Jun 11, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that facility staff did not handle a resident properly, resulting in injury.
Complaint Details
The complaint alleged improper handling of a resident by staff resulting in injury. The allegation was unsubstantiated after interviews, document review, and observations.
Findings
The investigation included six interviews with staff and residents, none of which corroborated the allegation. The resident with bruises confirmed the injuries were due to hospital treatment and blood thinner medication. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 155
Census: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine Rodriguez | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Sharin Belanger | Business Office Manager | Met with the Licensing Program Analyst during the visit and participated in the exit interview |
| Carrie Galloway | Administrator | Named as facility administrator |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 155
Deficiencies: 0
Date: Jun 11, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2024-05-03 regarding staff response times, behavior, food service, hygiene assistance, resident needs, and safeguarding of personal belongings.
Complaint Details
The complaint investigation was unsubstantiated as there was insufficient evidence to prove or refute the allegations. All resident and staff interviews, observations, and record reviews did not corroborate the complaints.
Findings
The investigation found that none of the allegations were corroborated by resident or staff interviews, record reviews, or observations. Staff were found to respond timely to call buttons, behave appropriately, provide adequate food service, assist with hygiene as needed, meet resident needs, and residents are responsible for their own belongings unless otherwise requested.
Report Facts
Resident interviews conducted: 10
Staff interviews conducted: 1
Response time to call button: 7
Response time to call button: 24
Response time to call button: 3
Response time to call button: 8
Facility capacity: 155
Facility census: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine Rodriguez | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Sharin Belanger | Business Office Manager | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Carrie Galloway | Administrator | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Census: 132
Capacity: 155
Deficiencies: 0
Date: Jan 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation initiated due to an allegation that the facility failed to provide reasonable accommodation to a resident's needs and preferences.
Complaint Details
The complaint alleged that the facility failed to provide reasonable accommodation to a resident's needs and preferences. The investigation included interviews with staff and residents, review of documents, and confirmed that the facility complied with medical orders. The complaint was found to be unfounded.
Findings
The investigation found that the facility followed doctor's orders regarding the resident's alcohol consumption and enrolled the resident in an Alcohol Rehab Program. The allegation was determined to be unfounded, meaning it was false or without reasonable basis.
Report Facts
Capacity: 155
Census: 132
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lydia Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Lourdes Montoya | Licensing Program Manager | Named in report as Licensing Program Manager |
| Sharin Belanger | Business Office Manager | Met with Licensing Program Analyst during investigation |
| Shannon Howell | Executive Director | Interviewed via telephone during investigation |
Inspection Report
Capacity: 155
Deficiencies: 0
Date: Dec 13, 2024
Visit Reason
The visit was an unannounced case management inspection conducted by Licensing Program Analyst Michael Tea.
Findings
The Licensing Program Analyst amended a previous report dated 09/13/2024 and reviewed the amended report with the Executive Director. An exit interview was conducted and a copy of the report was provided to the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Tea | Licensing Program Analyst | Conducted the unannounced visit and amended the previous report. |
| Shannon Howell | Executive Director | Greeted the Licensing Program Analyst and participated in the exit interview. |
| Carrie Galloway | Administrator | Named as facility administrator. |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 155
Deficiencies: 2
Date: Dec 13, 2024
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that facility staff did not follow the admission agreement.
Complaint Details
The complaint was substantiated. The allegation that facility staff did not follow the admission agreement was found valid based on records and interviews. The responsible party was not given notice or did not sign the updated personal service plan for resident R1 between April 14, 2023, and October 20, 2023.
Findings
The investigation determined that the facility staff did not follow the admission agreement because the responsible party was not given notice or did not sign the updated personal service plan dated April 14, 2023, resulting in a substantiated violation.
Deficiencies (2)
Rate increase due to change in level of resident care; notice requirement not met as the licensee did not provide written notice of the rate increase within two business days after initially providing services at the new level of care.
Responsible party of resident R1 stated they did not receive notice or sign or agree with Personal Service Plan updates. No signed copy of Personal Service Plan for disputed charges on April 14, 2023 service plan updates.
Report Facts
Capacity: 155
Census: 85
Deficiencies cited: 2
Plan of Correction Due Date: Dec 27, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Tea | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Shannon Howell | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 155
Deficiencies: 1
Date: Nov 8, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2024-06-19 alleging that the facility lacks sufficient staff.
Complaint Details
The complaint was substantiated. The allegation that the facility lacks staff was found valid based on staff interviews and evidence gathered during the investigation.
Findings
The investigation found that the facility was understaffed based on interviews with staff and residents. Four out of four staff stated the facility is understaffed, and one out of nine residents agreed. The complaint was substantiated, indicating a valid violation.
Deficiencies (1)
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The Licensee did not comply due to 4 out of 4 staff stating the facility is understaffed, posing a potential health, safety or personal rights risk to residents.
Report Facts
Capacity: 155
Census: 131
Staff hired since June 2024: 12
Staff stating understaffed: 4
Residents stating understaffed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dwayne L Mason | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation |
| Iris Nunez | Resident Care Coordinator | Met with Licensing Program Analyst during the inspection |
| Carrie Galloway | Administrator | Facility Administrator interviewed during the investigation |
Inspection Report
Annual Inspection
Census: 119
Capacity: 155
Deficiencies: 2
Date: Sep 13, 2024
Visit Reason
The inspection was an unannounced visit conducted for the purpose of the Required Annual Inspection of the facility.
Findings
The facility was generally found to be in good repair with operational safety equipment and adequate supplies. However, deficiencies were issued for missing Health Screening Reports in staff records and the absence of a required complaint poster accessible to residents.
Deficiencies (2)
Five of five staff records reviewed did not include a Health Screening Report.
The facility did not have the required Residential Care Facility for the Elderly (RCFE) Complaint Poster posted in areas accessible to residents.
Report Facts
Staff on duty: 21
Residents licensed capacity: 155
Residents census: 119
Health Screening Reports missing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alvaro Ramirez Jr. | Licensing Program Analyst | Conducted the inspection and documented findings |
| Sharin Belanger | Business Office Manager | Facility representative who met with the Licensing Program Analyst during the inspection |
| Sheila Santos | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Capacity: 155
Deficiencies: 0
Date: Sep 13, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that facility staff charged for services not rendered.
Complaint Details
The complaint alleged that facility staff charged for services not rendered. Interviews revealed that Resident 2 interfered with Resident 1's personal services, but staff attempted to provide the services despite interference. Resident 1 reported satisfaction with services. The allegation was found unsubstantiated.
Findings
The investigation included interviews with residents and staff, review of resident files and reports, and determined that the allegation was unsubstantiated due to insufficient evidence to prove the violation occurred. No deficiencies were cited.
Report Facts
Facility capacity: 155
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Tea | Licensing Program Analyst | Conducted the complaint investigation and made findings |
| Shannon Howell | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 155
Deficiencies: 3
Date: May 16, 2024
Visit Reason
The visit was an office meeting related to a substantiated complaint alleging that facility staff sexually assaulted a resident in care. The meeting included review of the complaint, importance of immediate action on inappropriate behaviors, and quality assurance procedures.
Complaint Details
Complaint 22-AS-20221003131319 alleging facility staff sexually assaulted resident in care. Complaint was substantiated on June 2, 2023.
Findings
The investigation found that during the employment of staff member S1, despite complaints of inappropriate behaviors and intoxication, management failed to exercise proper supervision, initiate disciplinary action, and allowed S1 to continue working. This posed a potential health and safety risk to residents. Additional deficiencies included failure to ensure personnel were physically and mentally capable, and failure of the administrator to perform required duties.
Deficiencies (3)
Failure of licensee to exercise general supervision over the facility and staff, allowing S1 to continue working despite complaints and sexual harassment allegations.
Personnel requirements not met: S1 reported coming to work intoxicated and facility failed to ensure physical and mental capability to provide care.
Administrator failed to perform duties and initiate disciplinary action despite complaints and intoxication of staff.
Report Facts
Capacity: 155
Census: 86
Plan of Correction Due Date: May 30, 2024
Deficiency Count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Howell | Executive Director Specialist | Met with during inspection and received report |
| Sheila Santos | Licensing Program Manager | Conducted review and issued citations |
| Celine DePerio | Licensing Program Analyst | Issued citations and signed report |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 155
Deficiencies: 0
Date: Apr 30, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that a resident sustained an injury from a fall while in care.
Complaint Details
The complaint alleged that a resident sustained an injury from a fall while in care. The investigation included interviews, hospital records, and facility documents. The allegation was found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation concluded that there was insufficient evidence to prove or refute the allegation, and therefore the complaint was deemed unsubstantiated. The resident had multiple hospitalizations and care plan updates, and the facility was transparent with the resident's decision-maker about the need for a higher level of care.
Report Facts
Facility capacity: 155
Resident census: 93
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation report |
| Sharrin Belenger | Business Office Manager | Met with Licensing Program Analyst during the investigation |
| Michael Arceo | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 155
Deficiencies: 0
Date: Oct 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-07-26 regarding allegations about improper notice and explanations of rate increases, incorrect billing for medications, and failure to follow medication doctor's orders.
Complaint Details
The complaint included allegations that staff did not give proper notice or explanations to the resident's designated representative about rate increases, incorrectly billed the resident for medications, and did not follow the resident's medication doctor's orders. The complaint was deemed unsubstantiated after investigation.
Findings
The investigation found that the allegations were unsubstantiated. Interviews and record reviews showed that proper notices and explanations regarding rate increases were provided, medication billing was consistent with physician orders, and medications were managed according to doctor's instructions.
Report Facts
Facility capacity: 155
Census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine DePerio | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Shannon Howell | Executive Director | Met with Licensing Program Analyst during the investigation and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 155
Deficiencies: 2
Date: Oct 9, 2023
Visit Reason
This unannounced inspection was conducted to investigate multiple complaints received regarding medication supply running out, lack of staffing, residents not receiving paid services, lack of care and supervision resulting in a resident's death, failure to report incidents, and falsification of records at the facility.
Complaint Details
The complaint investigation was substantiated for allegations that the facility allowed residents' medication supply to run out and lacked sufficient staffing. The allegations that residents were not receiving services paid for, lack of care and supervision resulting in a resident's death, failure to report incidents, and falsification of records were unsubstantiated or unfounded.
Findings
The investigation substantiated allegations that the facility allowed residents' medication supply to run out and had insufficient staffing resulting in long wait times for assistance. Other allegations regarding residents not receiving paid services, lack of care resulting in a resident's death, failure to report incidents, and falsification of records were found to be unsubstantiated or unfounded.
Deficiencies (2)
The licensee did not ensure 2 out of 3 residents received assistance with medications when the facility ran out of supply, posing an immediate health risk.
The licensee did not ensure sufficient staffing when residents had to wait up to 1 hour and 15 minutes for assistance after calling, posing a potential health risk.
Report Facts
Missed medication doses: 9
Staffing wait time: 75
Residents interviewed: 10
Staff interviewed: 3
Physician reports reviewed: 13
Medication Administration Records reviewed: 10
Weights and Vitals Summaries reviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sean Haddad | Licensing Program Analyst | Conducted the complaint investigation |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation |
| Michael Arceo | Administrator | Facility administrator interviewed during investigation |
| Sharin Belanger | Business Office Manager | Interviewed during investigation |
| Shannon Howell | Administrator | Interviewed during investigation |
Inspection Report
Census: 77
Capacity: 155
Deficiencies: 0
Date: Sep 11, 2023
Visit Reason
An unannounced visit was made to deliver an amended report dated 07/26/2023 in conjunction with complaint 22-AS-20230724102229.
Complaint Details
Visit was related to complaint 22-AS-20230724102229; no substantiation status stated.
Findings
The Licensing Program Analyst met with the Executive Director, conducted an exit interview, and provided a copy of the report at the time of exit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Howell | Executive Director | Met with Licensing Program Analyst during the visit and exit interview. |
| Alvaro Ramirez Jr. | Licensing Program Analyst | Conducted the unannounced visit and delivered the amended report. |
| Alisa Ortiz | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 155
Deficiencies: 0
Date: Sep 11, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 07/24/2023 regarding pest presence and inadequate food service at the facility.
Complaint Details
The complaint investigation was unsubstantiated due to lack of preponderance of evidence to prove or refute the allegations of pests and inadequate food service.
Findings
The investigation found conflicting information regarding the allegations. Pest control reports confirmed pest activity and rat traps were observed, but most residents denied seeing pests. Regarding food service, most residents reported adequate and warm food, though some noted food could be cold sometimes. Due to conflicting evidence, the allegations were deemed unsubstantiated.
Report Facts
Capacity: 155
Census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alvaro Ramirez Jr. | Licensing Program Analyst | Conducted the complaint investigation visit |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
| Shannon Howell | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 155
Deficiencies: 1
Date: Aug 9, 2023
Visit Reason
The visit was a case management inspection conducted in conjunction with complaint 22-AS-20221220140629 to investigate compliance with licensing requirements and document provision.
Complaint Details
The visit was conducted in conjunction with complaint 22-AS-20221220140629. Citations were issued due to failure to provide requested documents. Substantiation status is not explicitly stated.
Findings
The licensee failed to provide requested documents including facility internal investigation, pendant reports, resident care notes, and resident signed waiver, resulting in citations issued and a potential health and safety risk to residents.
Deficiencies (1)
Licensee did not comply with the regulation requiring provision of requested documents to Community Care Licensing staff.
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Aug 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the case management visit and investigation |
| Shannon Howell | Executive Director | Facility representative met during the visit and exit interview |
| Luz Adams | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 155
Deficiencies: 2
Date: Aug 3, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-12-20 alleging failure to obtain timely medical care for a resident who sustained serious injuries after an unwitnessed fall and that the resident was left unattended for an extended period of time.
Complaint Details
The complaint was substantiated. The resident (R1) fell on December 15, 2022, and was not checked on until December 17, 2022. Staff admitted being too busy and unaware of the safety check policy. The resident sustained serious injuries and delayed medical care. An immediate civil penalty was assessed.
Findings
The investigation substantiated the allegations that staff failed to obtain timely medical care for a resident who fell and was left unattended from December 15 to December 17, 2022, resulting in serious injuries including blunt head trauma, concussion, lacerations, and decubitus ulcers. Staff were unaware of the facility's safety check policy requiring regular resident checks, posing an immediate health and safety risk.
Deficiencies (2)
Facility did not obtain timely medical care for seriously injured resident.
Facility failed to ensure that the resident was regularly checked.
Report Facts
Capacity: 155
Census: 65
Deficiency count: 2
Plan of Correction Due Date: Aug 4, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine DePerio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Luz Adams | Licensing Program Manager | Oversaw the complaint investigation |
| Shannon Howell | Executive Director | Facility representative interviewed during investigation and exit interview |
Inspection Report
Plan of Correction
Census: 80
Capacity: 155
Deficiencies: 1
Date: Jun 14, 2023
Visit Reason
An unannounced Plan of Correction (POC) visit was conducted based on deficiencies cited in a prior inspection on 06/02/2023.
Findings
The previously cited deficiency under Health and Safety Code 1569.50 (a)(3) was cleared after the Executive Director conducted in-service training for staff and provided proof of training. No new citations were issued during this visit.
Deficiencies (1)
Deficiency cited under Health and Safety Code 1569.50 (a)(3) has been cleared.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Howell | Executive Director | Met with during the visit and conducted in-service training related to the cleared deficiency. |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 155
Deficiencies: 1
Date: Jun 2, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following an allegation that facility staff sexually assaulted a resident in care.
Complaint Details
The complaint was substantiated. It was found that caregiver S1 sexually assaulted resident R1 by touching her vaginal area in a sexual manner. S1 was previously known by management to have a history of inappropriate behavior but was not disciplined or reported. S1's employment was terminated on 9/18/22.
Findings
The investigation substantiated that caregiver S1 engaged in sexual conduct with resident R1, constituting an act inimical to the health, safety, and welfare of the resident. Former management failed to report or discipline S1 despite prior knowledge of inappropriate behavior.
Deficiencies (1)
Conduct which is inimical to the health, morals, welfare or safety of either an individual in or receiving services from the facility or the people from the State of California.
Report Facts
Capacity: 155
Census: 83
Plan of Correction Due Date: Jun 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine DePerio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Shannon Howell | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Luz Adams | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 155
Deficiencies: 0
Date: Mar 16, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff are not properly trained.
Complaint Details
The complaint alleged that facility staff were not properly trained. After investigation, including 10 interviews and document reviews, the allegation was found unsubstantiated.
Findings
The investigation included record reviews and interviews with staff and residents. None of the interviews corroborated the allegation; all indicated staff were knowledgeable and well trained. Training is provided for all positions, including shadowing for tasks outside designated roles. The allegation was deemed unsubstantiated due to lack of evidence.
Report Facts
Number of residents present: 80
Facility capacity: 155
Number of interviews conducted: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lilit Mnatsakanyan | West Division Operations Specialist / Executive Director | Met with Licensing Program Analyst during the visit and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 155
Deficiencies: 0
Date: Mar 3, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit initiated due to a complaint received on 2023-02-21 alleging that residents are not being accorded with dignity and respect.
Complaint Details
The complaint alleged that residents were not being accorded with dignity and respect. The investigation included interviews with 10 staff and residents, all of whom corroborated positively regarding staff behavior. The resident council praised the staff member named in the allegation. The resident involved reported no complaints. The allegation was found unsubstantiated.
Findings
After conducting 10 interviews with staff and residents, reviewing relevant documents, and interviewing the resident council and the staff member named in the allegation, the Licensing Program Analyst was unable to substantiate the complaint due to lack of preponderance of evidence; therefore, the allegation was deemed unsubstantiated.
Report Facts
Number of interviews conducted: 10
Number of residents on hospice: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lilit Mnatsakanyan | West Division Operations Specialist/Executive Director | Met with the Licensing Program Analyst during the visit and participated in the exit interview |
| Carrie Galloway | Administrator | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 155
Deficiencies: 0
Date: Jan 23, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-11-15 regarding allegations about staffing adequacy, food service, administrator presence, and facility disrepair.
Complaint Details
The complaint investigation addressed allegations that the facility lacked adequate staffing, did not provide adequate food service, lacked an administrator during operating hours, and was in disrepair. All allegations were deemed unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Staffing was generally adequate except for some dining room shortages covered by management, the administrator was present during operating hours, and the facility's elevator repair was timely with an alternate elevator available. No deficiencies were issued.
Report Facts
Residents on hospice: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lilit Mnatsakanyan | Operations Specialist/Executive Director | Facility representative met during the investigation and exit interview |
| Luz Adams | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 155
Deficiencies: 2
Date: Jan 19, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations including staff not being properly trained, staff not following physician's orders, and staff not responding to residents' call lights in a timely manner.
Complaint Details
The complaint investigation was initiated based on allegations received on 05/06/2022. The allegation that staff were not properly trained was found to be unfounded. The allegations that staff did not follow physician's orders and did not respond to residents' call lights in a timely manner were substantiated. Evidence included conflicting physician orders, observations of alcohol being served to a resident against orders, and delayed emergency response times. The preponderance of evidence standard was met.
Findings
The allegation that staff were not properly trained was found to be unfounded. However, allegations that staff did not follow physician's orders and did not respond timely to call lights were substantiated. Specifically, a resident was served alcohol contrary to physician orders, and emergency pendant response times ranged from 23 minutes to one hour with one instance of no response, posing health and safety risks.
Deficiencies (2)
Licensee failed to ensure care and supervision was provided to residents; emergency pendant response times ranged between 23 minutes and 1 hour with no staff response in 1 out of 5 pulls, posing an immediate health and safety risk.
Licensee failed to ensure a resident was provided safe and healthful accommodations; resident was served alcohol despite physician order indicating no alcohol, posing a potential health and safety risk.
Report Facts
Response times: 40
Response time range (minutes): 23
Response time range (minutes): 60
Residents present: 82
Facility capacity: 155
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alisa Ortiz | Licensing Program Manager | Named in relation to the complaint investigation and deficiency citations |
| Carrie Galloway | Administrator | Facility administrator mentioned in the report |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 155
Deficiencies: 1
Date: Jan 19, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff did not respond to a resident's call for assistance in a timely manner.
Complaint Details
The complaint alleging staff did not respond to resident's call for assistance in a timely manner was substantiated based on pendant call log reviews and staff interviews.
Findings
The investigation found that staff response times to resident calls were between 23-44 minutes, exceeding the expected response time of under 15 minutes. Staff did not respond to several test pendant calls, and kitchen staff lacked pagers to hear calls, resulting in a substantiated finding of inadequate care and supervision posing an immediate health and safety risk.
Deficiencies (1)
Basic services shall at a minimum include care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not being met as evidenced by 102 staff pendant responses between 23-44 minutes and staff not responding to test pulls, posing an immediate health and safety risk to residents.
Report Facts
Staff pendant response times: 102
Facility census: 82
Facility capacity: 155
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alisa Ortiz | Licensing Program Manager | Named in relation to the deficiency and report |
| Lilit Mnatsakanyan | Operations Specialist | Met with during the investigation |
| Carrie Galloway | Administrator | Facility administrator who provided information on expected response times |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 155
Deficiencies: 1
Date: Jan 19, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff were not meeting residents' hygiene needs.
Complaint Details
The complaint was substantiated based on evidence that a resident was not receiving scheduled showers two times a week as required. Staffing shortages and working alone on shifts were contributing factors.
Findings
The investigation substantiated that the facility failed to ensure a resident received scheduled showers twice a week as per their personal service plan, posing an immediate health and safety risk. Staffing shortages were noted as a contributing factor.
Deficiencies (1)
Failure to ensure residents receive showers and hygiene care as scheduled, violating personal rights of residents in privately operated residential care facilities for the elderly.
Report Facts
Capacity: 155
Census: 82
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
| Lilit Mnatsakanyan | Operations Specialist | Met with during the investigation visit |
| Carrie Galloway | Administrator | Facility Administrator named in report |
Inspection Report
Census: 85
Capacity: 155
Deficiencies: 0
Date: Dec 21, 2022
Visit Reason
An unannounced case management visit was conducted to perform health and safety checks at the facility.
Findings
The facility was observed to be in good repair with no immediate threats to resident health and safety. All safety equipment including smoke detectors, carbon monoxide detectors, fire extinguishers, and evacuation chairs were operational. No citations were issued.
Report Facts
Licensed capacity: 155
Current census: 85
Hospice residents allowed: 15
Hospice residents present: 4
Water temperature: 113.6
Fire inspection date: Nov 12, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the unannounced visit and inspection |
| Lilit Mnatsakanyan | Operations Specialist / Acting Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 155
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that facility staff were under the influence when providing care to residents.
Complaint Details
The complaint alleged that facility staff were under the influence while providing care. The investigation included interviews with multiple staff and a resident, review of staff records, and observation. Documentation of staff training on drug-free policies and random checks were provided. The allegation was found unsubstantiated.
Findings
After reviewing records, conducting interviews, and touring the facility, the allegation was deemed unsubstantiated due to lack of preponderance of evidence to prove the alleged violation occurred.
Report Facts
Capacity: 155
Census: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation visit |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
| Carrie Galloway | Administrator | Facility administrator mentioned in the report |
| Lilit Mnatsakanyan | Operations Specialist | Met with Licensing Program Analyst during the visit |
| Phat Nguyen | Executive Director | Met with Licensing Program Analyst during the visit |
| Stacey Handy | Health and Wellness Director | Met with Licensing Program Analyst during the visit |
| Joshua Oliver | Business Office Manager | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 155
Deficiencies: 0
Date: Nov 17, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to complaints received on 08/23/2022 alleging insufficient staffing to meet residents' needs and failure to abide by resident admission agreements.
Complaint Details
The complaint alleged that the facility did not have sufficient staff to meet residents' needs and was not abiding by resident admission agreements, including not feeding and cleaning residents' pets. The staffing allegation was unsubstantiated due to lack of evidence, and the admission agreement allegation was unfounded and dismissed.
Findings
The investigation found insufficient evidence to substantiate the allegation of insufficient staffing, deeming it unsubstantiated. The allegation regarding failure to abide by resident admission agreements, specifically related to pet care, was found to be unfounded and dismissed. No citations were issued during the visit.
Report Facts
Residents on hospice: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and exit interview |
| Joshua Oliver | Business Office Manager | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 155
Deficiencies: 1
Date: Oct 20, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-07-21 alleging that staff was assisting residents while intoxicated.
Complaint Details
The complaint alleged that staff was assisting residents while intoxicated. The allegation was substantiated based on interviews and observations. The staff member admitted to going to dinner and then to work while intoxicated. Previous concerns and reports about this staff member's intoxication were noted, but no formal disciplinary records were found.
Findings
The complaint was substantiated based on interviews and record review, where 6 out of 9 interviews verified that a staff member was intoxicated while assisting residents. The facility failed to provide documentation of disciplinary action despite claims of a write-up. Citations were issued per Title 22 Division 6 of the California Code of Regulations.
Deficiencies (1)
Facility personnel were not competent to provide necessary services and were not physically and mentally capable of performing assigned tasks, posing an immediate threat to resident health and safety.
Report Facts
Deficiencies cited: 1
Plan of Correction due date: Oct 27, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lilit Mnatsakanyan | West Division Operations Specialist/Acting Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Carrie Galloway | Administrator | Facility administrator involved in the investigation and referenced in relation to prior reports about intoxicated staff |
| Luz Adams | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 94
Capacity: 155
Deficiencies: 0
Date: Oct 4, 2022
Visit Reason
Licensing Program Analyst Celine De Perio made an unannounced visit to conduct a case management and health and safety check at the facility.
Findings
The facility was observed to be in good repair with operational safety equipment and adequate emergency supplies. No immediate threats to resident health and safety were found, and no citations were issued.
Report Facts
Water temperature: 111.4
Facility capacity: 155
Resident census: 94
Fire inspection date: Nov 12, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the inspection and made observations |
| Lilit Mnatsakanyan | West Division Operations Specialist/Acting Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 155
Deficiencies: 0
Date: Aug 26, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff were not properly trained on emergency procedures and that there were not enough staff to ensure the safety of residents during a fire alarm event on 08/21/2021.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not properly trained on emergency procedures and insufficient staff to ensure resident safety during a fire alarm on 08/21/21. The investigation included interviews, record reviews, and on-site inspections on 08/27/21 and 10/19/21. No evidence was found to prove the allegations.
Findings
The investigation found that the fire alarm on 08/21/21 was a false alarm and that the facility staff responded according to their training. Staff training records and fire drill documentation were reviewed and confirmed. Interviews with residents and staff did not substantiate the allegations of insufficient staffing or improper emergency procedures. Therefore, the allegations were deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 155
Census: 101
Staff count on 08/21/21: 13
Residents present on 08/21/21: 118
Fire training sessions completed: 2
Resident interviews: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sean Haddad | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Carrie Galloway | Administrator | Interviewed regarding emergency procedures and staffing during the fire alarm |
| Becky Kruse | Wellness Director | Met with Licensing Program Analyst during the inspection |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 155
Deficiencies: 0
Date: Aug 26, 2022
Visit Reason
The inspection was an unannounced visit to investigate a complaint alleging that the facility was not answering communications promptly to the resident's representatives and was not providing resident's records to the resident's representatives.
Complaint Details
The complaint alleged that the facility was not answering communications promptly and not providing resident records to the resident's representatives. The investigation found these allegations to be unfounded.
Findings
The investigation found that the facility's privacy policy requires a signed release to provide resident records. The family member who requested records was not listed as an emergency contact or authorized representative, and the facility was not required to provide the records or continue communication. The allegations were found to be unfounded.
Report Facts
Capacity: 155
Census: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sean Haddad | Licensing Program Analyst | Conducted the complaint investigation |
| Armando J Lucero | Licensing Program Manager | Named in report as Licensing Program Manager |
| Becky Kruse | Wellness Director | Interviewed during the investigation |
Inspection Report
Annual Inspection
Census: 100
Capacity: 155
Deficiencies: 0
Date: Aug 8, 2022
Visit Reason
An unannounced required annual inspection focusing primarily on Infection Control was conducted to evaluate compliance with regulatory standards.
Findings
The facility was found to be in compliance with no deficiencies or citations issued. Infection control measures, safety equipment, emergency supplies, and resident environment were all observed to be adequate and operational.
Report Facts
Staff on duty: 24
Water temperature: 113.4
Date of last fire inspection: Nov 12, 2021
Quarterly dietitian visit date: Apr 13, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carrie Galloway | Facility Administrator | Accompanied Licensing Program Analyst during inspection and named in report |
| Celine De Perio | Licensing Program Analyst | Conducted the inspection and authored the report |
| Luz Adams | Licensing Program Manager | Named as Licensing Program Manager in the report |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 155
Deficiencies: 0
Date: Jun 2, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit initiated due to an allegation that staff were not allowing residents' privately paid personal assistants to assist residents.
Complaint Details
The complaint alleged that staff were not allowing residents' privately paid personal assistants to assist residents. The allegation was investigated and deemed unfounded, meaning it was false or without reasonable basis.
Findings
The investigation found that the allegation was unfounded. The facility clarified that privately paid care companions are for companionship only and are not permitted to perform caregiving duties, which are provided by facility staff trained according to regulations.
Report Facts
Complaint Control Number: 22-AS-20220527153953
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Carrie Galloway | Administrator | Facility administrator present during the investigation. |
| Becky Kruse | Health and Wellness Director | Facility staff who greeted the investigator and explained the reason for the visit. |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 155
Deficiencies: 0
Date: Mar 16, 2022
Visit Reason
The visit was an unannounced case management follow-up on incident reports submitted to Community Care Licensing involving choking and wandering incidents with residents.
Complaint Details
The visit was triggered by complaints related to an incident where Resident 1 choked and later died, and another incident where two residents left the facility unassisted, one requiring medical attention after a fall. The facility investigation revealed a propped open back door and lack of supervision allowing residents to leave unassisted. Both residents were fitted with wander guards and the facility secured all doors except the front door.
Findings
The inspection found that Resident 1 choked and subsequently passed away, with no prior swallowing issues noted. Two residents were found outside the facility unassisted due to a propped open back door; the facility has since secured all doors except the front and implemented wander guards and daily checks.
Report Facts
Incident date: Mar 3, 2022
Incident date: Mar 6, 2022
Time: 1150
Time: 1153
Time: 1201
Time: 1212
Distance: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carrie Galloway | Executive Director | Greeted Licensing Program Analyst and involved in incident response |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Census: 114
Capacity: 155
Deficiencies: 0
Date: Feb 25, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on a death report submitted to Community Care Licensing on 02/24/2022.
Findings
The visit included a tour of the facility, interviews with the Executive Director, and review of pertinent documentation including a physician report. The resident was found unresponsive and pronounced dead following a medical emergency and resuscitation attempt was stopped due to a Do Not Resuscitate order on file.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carrie Galloway | Executive Director | Met with Licensing Program Analyst during the visit and provided information related to the death report. |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Alisa Ortiz | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 117
Capacity: 155
Deficiencies: 0
Date: Nov 19, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of illegal eviction received on 2021-11-03.
Complaint Details
The complaint alleged illegal eviction. The investigation concluded the allegation was unfounded, meaning it was false, could not have happened, or was without reasonable basis.
Findings
The investigation found the allegation of illegal eviction to be unfounded. The eviction was determined to be legal based on the resident's need for a higher level of care as documented by the resident's physician.
Report Facts
Capacity: 155
Census: 117
Complaint control number: 22-AS-20211103101156
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Reed | Licensing Program Analyst | Conducted the complaint investigation and made the unannounced visit |
| Carrie Galloway | Administrator | Facility administrator met during the investigation and was involved in interviews |
Inspection Report
Annual Inspection
Census: 118
Capacity: 155
Deficiencies: 0
Date: Oct 19, 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 regulations including COVID-19 protocols. No deficiencies were cited.
Report Facts
Staff present: 30
Residents present: 118
Food supply: 2
Food supply: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carrie Galloway | Administrator | Met with Licensing Program Analyst during inspection |
| Sean Haddad | Licensing Program Analyst | Conducted the inspection |
| Marina Stanic | Licensing Program Manager | Named in report header |
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