Inspection Report Summary
Most inspections found no deficiencies, with the facility consistently maintaining up-to-date staff training, proper resident assessments, and timely communication with physicians and families. The most recent report from October 1, 2025, had no deficiencies and focused on legal and compliance issues with all trainings completed. Past deficiencies mainly involved medication management errors, care and supervision issues related to fall prevention, and some maintenance concerns like a faulty call signal system, but these were addressed over time. Several complaint investigations were unsubstantiated, and enforcement actions included a $250 fine in March 2023 for repeated medication errors and a noncompliance conference in late 2023 addressing care and supervision deficiencies. Overall, the facility’s recent inspections show improvement and compliance with regulatory requirements.
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/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
82% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Census: 46
Capacity: 56
Deficiencies: 0
Date: Oct 1, 2025
Visit Reason
The visit was an unannounced case management inspection focused on legal and non-compliance issues, conducted as a quarterly visit by the Licensing Program Analyst.
Findings
The Licensing Program Analyst reviewed staff training records and found all trainings up to date and completed. The visit emphasized ensuring completed staff training, proper resident assessments, timely communication with physicians and families, and ongoing medication training and reporting requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Margaret Chappell | Administrator | Met with Licensing Program Analyst during the inspection visit. |
| Kesha Lewis | Licensing Program Analyst | Conducted the unannounced quarterly visit and inspection. |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 44
Capacity: 56
Deficiencies: 0
Date: Jul 8, 2025
Visit Reason
The inspection was an unannounced Required 1 Year Annual Inspection Visit conducted to ensure compliance with Title 22 regulations.
Findings
The facility was found to be in compliance with regulations including adequate food supply, sanitary resident rooms, current fire safety equipment, staff certifications, and proper documentation. No immediate or direct risks were noted.
Report Facts
Food supply duration: 7
Food supply duration: 2
Staff files reviewed: 7
Resident files reviewed: 7
Fire extinguisher inspection date: Oct 17, 2024
Hot water temperature: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Margaret Chappell | Administrator | Met with Licensing Program Analyst during inspection |
| Kesha Lewis | Licensing Program Analyst | Conducted the inspection |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 44
Capacity: 56
Deficiencies: 0
Date: Jul 8, 2025
Visit Reason
The visit was an unannounced case management inspection focused on legal and non-compliance issues, conducted as a quarterly visit by the Licensing Program Analyst.
Findings
The Licensing Program Analyst reviewed staff training records and found all trainings up to date and completed. The visit emphasized ensuring completed staff training on care and supervision, proper resident assessments, timely communication with physicians and families, and ongoing medication training and reporting requirements.
Report Facts
Capacity: 56
Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Margaret Chappell | Administrator | Met with Licensing Program Analyst during the inspection |
| Kesha Lewis | Licensing Program Analyst | Conducted the unannounced quarterly visit |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 56
Deficiencies: 0
Date: May 13, 2025
Visit Reason
The inspection was conducted as a case management incident inspection regarding incident reports received about a staff member threatening a resident on 2025-03-31.
Complaint Details
The complaint involved a staff member threatening a resident (R1). The staff member (S1) was suspended on 2025-03-31, terminated, and has not returned after 2025-04-04. The incident was investigated internally and all required reporting was completed timely.
Findings
No deficiencies were observed or cited during the case management inspection. The staff member involved was suspended and terminated, and all reporting was done on time and to the required departments.
Report Facts
Incident date: Mar 31, 2025
Suspension date: Mar 31, 2025
Termination effective date: Apr 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Margaret Chappell | Administrator | Met with Licensing Program Analyst during inspection |
| Kesha Lewis | Licensing Program Analyst | Conducted the case management incident inspection |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 56
Deficiencies: 0
Date: Apr 23, 2025
Visit Reason
The inspection was an unannounced case management incident inspection regarding incident reports received on 2025-02-11 about a witnessed fall on 2025-02-05 that resulted in a left hip fracture for resident R1.
Complaint Details
The complaint involved a witnessed fall resulting in a left hip fracture for resident R1. The incident was reported timely, and the facility provided relevant documentation including physician's report, care notes, hospice records, and admission agreement. Resident R1 has not returned to the facility since the incident. The investigation is ongoing.
Findings
No deficiencies were observed or cited during the case management inspection. All reporting related to the incident was done on time and to the required departments. The matter remains under investigation.
Report Facts
Incident report date: Feb 11, 2025
Incident date: Feb 5, 2025
Inspection start time: 830
Inspection end time: 1030
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kesha Lewis | Licensing Program Analyst | Conducted the case management incident inspection |
| Mary Margaret Chappell | Administrator/Director | Facility administrator during inspection |
| Sara Mackedsy | Met with during inspection | |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 44
Capacity: 56
Deficiencies: 0
Date: Mar 5, 2025
Visit Reason
The visit was an unannounced quarterly case management inspection focused on legal and non-compliance issues.
Findings
The Licensing Program Analyst reviewed staff training records and found all trainings up to date and completed. The visit emphasized ensuring completed staff training, proper resident assessments, timely communication with physicians and families, and ongoing medication training and reporting.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kesha Lewis | Licensing Program Analyst | Conducted the unannounced quarterly visit and reviewed training records. |
| Mary Margaret Chappell | Administrator | Facility administrator met with Licensing Program Analyst during the visit. |
| Sara Mackedsy | Met with Licensing Program Analyst during the visit. |
Inspection Report
Census: 41
Capacity: 56
Deficiencies: 0
Date: Dec 17, 2024
Visit Reason
The visit was an unannounced quarterly case management inspection focused on legal and non-compliance issues, conducted by the Licensing Program Analyst.
Findings
The Licensing Program Analyst reviewed staff training records and found that all required trainings were up to date and completed. The visit included review of care and supervision training, resident assessments, communication protocols, and medication training.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kesha Lewis | Licensing Program Analyst | Conducted the unannounced quarterly visit and reviewed training records. |
| Mary Margaret Chappell | Administrator | Met with Licensing Program Analyst during the inspection. |
Inspection Report
Follow-Up
Capacity: 56
Deficiencies: 1
Date: Oct 16, 2024
Visit Reason
The visit was a follow-up Non-Compliance Conference conducted to follow up with the facility after an initial Non-Compliance Conference held on 11/30/2023.
Complaint Details
One new complaint was filed and found unsubstantiated against the facility since the last meeting.
Findings
Since the last meeting, one new complaint was filed and found unsubstantiated, and one Type A deficiency was cited related to maintenance and operation. The facility agreed to several corrective actions including submission of personnel summaries, ensuring annual medical assessments for residents with dementia, and providing training materials.
Deficiencies (1)
Type A deficiency cited related to maintenance and operation
Report Facts
Facility capacity: 56
Administrator presence hours: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Margaret Chappell | Administrator | Facility Administrator present during the inspection and named in the report |
| Liza King | Licensing Program Manager | Present at the Non-Compliance Conference and named in the report |
| Kesha Lewis | Licensing Program Analyst | Present at the Non-Compliance Conference and named in the report |
Inspection Report
Census: 45
Capacity: 56
Deficiencies: 0
Date: Sep 24, 2024
Visit Reason
The visit was an unannounced quarterly case management inspection conducted by Licensing Program Analyst Kesha Lewis to review staff training, resident assessments, communication protocols, and medication training.
Findings
The review found that all staff training records were up to date and completed. The visit included discussions on care and supervision, resident assessments, communication with physicians and families, and medication training requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kesha Lewis | Licensing Program Analyst | Conducted the unannounced quarterly visit and reviewed training records. |
| Mary Margaret Chappell | Administrator | Facility administrator met with the Licensing Program Analyst during the visit. |
| Sara Mackedsy | Met with Licensing Program Analyst during the inspection. |
Inspection Report
Census: 42
Capacity: 56
Deficiencies: 0
Date: Jun 12, 2024
Visit Reason
The visit was an unannounced quarterly case management inspection conducted by Licensing Program Analyst Kesha Lewis to review staff training, resident assessments, communication protocols, and medication training and reporting.
Findings
All staff training records were reviewed and found to be up to date and completed. The Licensing Program Analyst provided a copy of the report during the exit interview.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kesha Lewis | Licensing Program Analyst | Conducted the unannounced quarterly visit and reviewed training records. |
| Mary Margaret Chappell | Administrator | Facility administrator met with Licensing Program Analyst during the visit. |
| Sara Mackedsy | Met with Licensing Program Analyst during the visit. |
Inspection Report
Census: 42
Capacity: 56
Deficiencies: 0
Date: Jun 12, 2024
Visit Reason
The visit was a case management visit conducted as a result of an incident that took place on May 5, 2024, involving a resident with tarry stool and decreased appetite who was hospitalized and later passed away.
Findings
The department reviewed the resident's file including physician reports, hospice notes, and facility care notes. The facility did not initially report the resident's death but later provided confirmation that the required death report was faxed within the required reporting period.
Report Facts
Facility capacity: 56
Resident census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kesha Lewis | Licensing Program Analyst | Conducted the case management visit |
| Mary Margaret Chappell | Administrator/Director | Facility administrator named in the report |
| Sara Mackedsy | Met with Licensing Program Analyst during the visit | |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager in the report |
Inspection Report
Annual Inspection
Census: 42
Capacity: 56
Deficiencies: 1
Date: Jun 11, 2024
Visit Reason
The visit was an unannounced Required 1 Year Annual Inspection to evaluate compliance with Title 22 regulations at the facility.
Findings
The inspection found the facility generally compliant with regulations including adequate food supply, sanitary resident rooms, and proper certifications for staff. However, a deficiency was cited for the call signal system in room 5 which did not notify staff, posing an immediate health and safety risk.
Deficiencies (1)
Maintenance and Operation: Facilities shall have signal systems which shall meet the following criteria: Operate from each resident's living unit. This requirement was not met as evidenced by LPA pushing call buttons in multiple resident rooms. Room 5 the call system did not notify of an alert from a resident's room and which poses an immediate health safety and personal rights risk to residents in care.
Report Facts
Food supply: 7
Food supply: 2
Staff files reviewed: 15
Resident files reviewed: 9
Fire extinguisher inspection date: Oct 7, 2023
Fixed system inspection date: Apr 17, 2024
Last fire drill date (NOC shift): Jun 10, 2024
Last fire drill date (day shift): May 30, 2024
Call system test frequency: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kesha Lewis | Licensing Program Analyst | Conducted inspection and cited deficiency |
| Liza King | Licensing Program Manager | Conducted inspection and supervised visit |
| Mary Margaret Chappell | Administrator | Facility administrator met during inspection |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 56
Deficiencies: 0
Date: Apr 16, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to a complaint received on 03/19/2024 regarding personal rights allegations at Brookdale Kettleman Lane facility.
Complaint Details
Complaint was unsubstantiated. Although the allegation may have happened or is valid, there was not enough evidence to prove the alleged violation did or did not occur.
Findings
The complaint was found to be unsubstantiated due to lack of preponderance of evidence. The facility was observed to be clean, sanitary, and well-maintained with adequate food supply and proper safety measures in place.
Report Facts
Staffing levels: 14
Food supply duration: 7
Food supply duration: 2
Room temperature: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kesha Lewis | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Mary Margaret Chappell | Administrator | Facility administrator met during the investigation |
| Liza King | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 44
Capacity: 56
Deficiencies: 0
Date: Mar 20, 2024
Visit Reason
The visit was an unannounced quarterly case management visit conducted by Licensing Program Analyst Kesha Lewis to review staff training, resident assessments, communication protocols, and medication training and reporting requirements.
Findings
The review of random training records showed that all staff trainings were up to date and completed. Trainings were emailed to the Licensing Program Analyst on the day of the visit. An exit interview was conducted and a copy of the report was given.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Margaret Chappell | Administrator | Met with Licensing Program Analyst during the visit |
| Kesha Lewis | Licensing Program Analyst | Conducted the quarterly visit and review |
| Liza King | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 56
Deficiencies: 1
Date: Dec 14, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-08-24 regarding allegations of improper food storage and provision of expired food to residents.
Complaint Details
The complaint investigation was substantiated for improper food storage but unsubstantiated for providing expired food. The substantiated allegation involved uncovered prepared desserts in the refrigerator.
Findings
The allegation that staff did not properly store food was substantiated based on observation of prepared desserts stored uncovered in the refrigerator. The allegation that staff provided expired food was unsubstantiated as no expired food was observed during the inspection.
Deficiencies (1)
All readily perishable foods shall be stored in covered containers at appropriate temperatures. This requirement was not met as food was stored uncovered in the refrigerator.
Report Facts
Capacity: 56
Census: 40
Deficiency Type: 1
Plan of Correction Due Date: Dec 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Renee Campbell | Licensing Program Analyst | Conducted the complaint investigation and made observations related to food storage |
| Nicole Bacon | Assistant Executive Director | Met with the Licensing Program Analyst during the inspection and discussed allegations |
Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 2
Date: Nov 30, 2023
Visit Reason
The visit was a Noncompliance Conference (NCC) conducted to discuss the facility's substantiated noncompliance related to care and supervision, medication, dental care, reporting requirements, and document furnishing.
Complaint Details
The visit was complaint-related with substantiated noncompliance. Citations included 5 A citations in care and supervision, medication, and dental care; 1 B citation in reporting requirements; and 1 B citation in furnishing documents on request.
Findings
The facility had multiple citations over the past 3 years including 5 A citations in care and supervision, medication, and dental care, and B citations in reporting and document furnishing. Specific issues included inadequate supervision, delayed medical care post-fall, and deficiencies in staff training and communication.
Deficiencies (2)
Failure to provide care and supervision as necessary to meet the client’s needs, resulting in resident receiving medical care one day post fall and hip fracture.
Issues related to care and supervision, medication, dental care, reporting requirements, and furnishing documents on request.
Report Facts
Capacity: 56
Citations in past 3 years: 5
Citations in past 3 years: 2
Administrator presence hours: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Margaret Chappell | Administrator | Facility representative and named in relation to findings and administrative process |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager involved in the Noncompliance Conference |
| Kesha Lewis | Licensing Program Analyst | Named as Licensing Program Analyst involved in the Noncompliance Conference |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 56
Deficiencies: 2
Date: Oct 25, 2023
Visit Reason
The visit was an unannounced case management follow-up to an incident report submitted to the Department regarding multiple falls sustained by a resident (R1). The purpose was to investigate the incident and assess compliance with care and supervision requirements.
Complaint Details
The complaint investigation was substantiated based on findings that the licensee failed to provide adequate fall prevention and failed to update care plans after multiple falls of resident R1.
Findings
The investigation substantiated that the licensee failed to ensure sufficient provision to aid in fall prevention for R1, who sustained multiple falls over seven months resulting in injury. Deficiencies were cited related to basic service requirements and failure to update the resident's needs and services plan after the falls.
Deficiencies (2)
Failure to provide appropriate care and supervision to prevent multiple falls of R1 over seven months, resulting in injury.
Failure to update the pre-admission appraisal and needs and services plan for R1 after multiple falls.
Report Facts
Capacity: 56
Census: 41
Plan of Correction Due Date: Oct 27, 2023
Plan of Correction Due Date: Oct 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kesha Lewis | Licensing Program Analyst | Conducted the case management visit and investigation |
| Liza King | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the investigation |
| Mary Margaret Chappell | Administrator | Facility administrator met during the visit |
Inspection Report
Annual Inspection
Census: 40
Capacity: 56
Deficiencies: 0
Date: May 30, 2023
Visit Reason
An unannounced Annual 1-Year Required visit was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was toured and reviewed for compliance including safety, staffing, training, and resident accommodations. No deficiencies were cited during this inspection.
Report Facts
Bedrooms: 30
Residents files reviewed: 4
Staff files reviewed: 4
Fire drill date: Mar 30, 2023
Fire extinguisher service date: Oct 12, 2022
Emergency Disaster Plan update date: May 29, 2023
Hot water temperature: 105
Room temperature: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Pleasette Bacon | Administrator | Met and toured with Licensing Program Analyst during inspection |
| Renee Campbell | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 56
Deficiencies: 0
Date: Apr 28, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2023-03-06 regarding allegations that staff denied a resident phone access and visitors.
Complaint Details
The complaint was unsubstantiated. Although the allegations may have happened or be valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur.
Findings
The investigation found that the resident was placed under Conservatorship which restricted phone and visitor access at the Conservator's request, not the facility's. Therefore, the complaint was unsubstantiated due to lack of evidence proving a violation by the facility.
Report Facts
Capacity: 56
Census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Margaret Chappell | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Renee Campbell | Licensing Program Analyst | Conducted the complaint investigation |
| Emerita Curiel | Licensing Program Manager | Named in report header |
Inspection Report
Census: 40
Capacity: 56
Deficiencies: 0
Date: Mar 14, 2023
Visit Reason
The Licensing Program Analyst conducted an unannounced case management visit to follow up on various incident reports received at the facility.
Findings
Several residents received immediate medical care due to incidents including an unwitnessed fall with vaginal bleeding, nausea and vomiting related to Norovirus, and edema. All affected residents returned to baseline and remained in care at the facility.
Report Facts
Residents affected by nausea and vomiting: 12
Residents testing positive for Norovirus: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Olvera | Business Manager | Met with Licensing Program Analyst during the visit and provided information about incidents. |
| Nicole Bacon | Associate Executive Director | Met with Licensing Program Analyst during the visit and provided information about incidents. |
| Renee Campbell | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 56
Deficiencies: 1
Date: Mar 1, 2023
Visit Reason
The visit was an unannounced case management inspection conducted to investigate incidents reported on 1-9-23 and 1-10-23 involving failure to assist residents with prescribed medications.
Complaint Details
The complaint investigation was substantiated based on incidents where residents R1 and R2 did not receive their prescribed medications due to facility staff error.
Findings
The facility failed to assist two residents (R1 and R2) with administering prescribed medications, posing an immediate health and safety risk. The facility was otherwise clean, sanitary, and compliant with safety equipment and staffing levels. A civil penalty of $250 was issued due to repeat violations within 12 months.
Deficiencies (1)
Failure to assist residents R1 and R2 with self-administered medications as prescribed by physician, posing immediate health and safety risk.
Report Facts
Civil penalty amount: 250
Staffing levels: 2
Staffing levels: 3
Staffing levels: 3
Staffing levels: 4
Staffing levels: 1
Medication dosage: 5
Medication dosage: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gretchen Monares | Health and Wellness Director | Met with Licensing Program Analyst during inspection and involved in incident review |
| Michael Bilger | Licensing Program Analyst | Conducted the case management visit and inspection |
| Liza King | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 2
Date: Jan 17, 2023
Visit Reason
The visit was a case management investigation regarding incidents submitted to the Community Care Licensing Division on 11/25/22, 11/27/22, and 12/07/22 involving resident safety concerns.
Complaint Details
The visit was triggered by incidents reported involving residents R1, R2, R3, and R4, including concerns about access to toxins, breathing difficulties, falls, and missing pre-admission appraisals. The complaint investigation substantiated deficiencies related to resident safety and care.
Findings
The investigation found deficiencies related to residents R1 and R2 having access to personal grooming products despite being at risk, and missing pre-admission appraisals for residents R3 and R4, posing potential health and safety risks. A deficiency was cited under California Code of Regulations, Title 22.
Deficiencies (2)
Failure to ensure residents with dementia (R1 and R2) did not have access to personal grooming and hygiene items despite documented risk, posing immediate health and safety risks.
Failure to complete pre-admission appraisals for residents R3 and R4, preventing determination of residents' needs upon arrival and posing potential health and safety risks.
Report Facts
Facility capacity: 56
Plan of Correction Due Date: 2023
Plan of Correction Due Date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kesha Lewis | Licensing Program Analyst | Conducted case management visit and signed report |
| Albert Johnson | Licensing Program Analyst | Conducted case management visit |
| Mary Margaret Chappell | Administrator | Facility administrator met with analysts during visit |
| Liza King | Licensing Program Manager | Named in report and supervisor |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 56
Deficiencies: 3
Date: Nov 21, 2022
Visit Reason
The visit was a case management incident investigation conducted as a result of an incident on November 8, 2022, involving a resident (R1) being given an extra dose of a PRN medication and issues related to treatment and reporting of a rash later identified as scabies.
Complaint Details
The visit was triggered by a complaint/incident involving a resident receiving an extra dose of PRN medication and delayed reporting of a serious incident related to scabies. The complaint was substantiated with cited deficiencies.
Findings
The facility failed to have a current PRN letter for R1, administered an extra dose of Seroquel not in accordance with physician orders, and delayed reporting a serious incident involving scabies. Deficiencies were cited related to medication administration and incident reporting.
Deficiencies (3)
Once ordered by the physician, nonprescription PRN medications shall be given in accordance with the physician’s directions. This requirement was not met as evidenced by LPA receiving SIR for R1 being given an extra dose of medication.
If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, facility staff must contact the resident's physician prior to each dose and document directions. This requirement was not met as the facility did not have a current list of PRN medications signed by the physician for R1 and administered Seroquel twice as a PRN not as written.
A written report shall be submitted to the licensing agency within seven days of any incident threatening resident welfare, including psychological abuse or unexplained absence. This requirement was not met as the facility delayed sending a serious incident report for R1's scabies diagnosis until 10/04/2022, despite rash being identified on June 30, 2022.
Report Facts
Deficiencies cited: 3
Plan of Correction Due Date: Dec 3, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Margaret Chappell | Administrator | Met with Licensing Program Analysts during the visit and involved in interviews related to findings |
| Kesha Lewis | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Albert Johnson | Licensing Program Analyst | Conducted the case management visit |
| Liza King | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 1
Date: Oct 12, 2022
Visit Reason
The visit was a case management visit conducted to investigate medication errors reported in incidents submitted to the Community Care Licensing Division on 07/17/22, 08/15/22, and 08/20/22 involving residents not receiving correct medication dosages.
Complaint Details
The visit was triggered by complaints regarding medication errors involving three residents. The complaint was substantiated based on incident reports and medication logs reviewed during the visit.
Findings
The investigation found that medication was missed or given incorrectly on multiple occasions, posing a potential health, safety, or personal rights risk to residents. A deficiency was cited under California Code of Regulations, Title 22, for failure to assist residents with self-administered medications properly.
Deficiencies (1)
Failure to assist residents with self-administered medications as required, evidenced by missed and incorrect medication administration on 07/17/22, 08/15/22, and 08/20/22.
Report Facts
Facility capacity: 56
Medication dosage errors: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Delma De la Pena | Med Tech | Spoke with Licensing Program Analyst regarding medication error incidents |
| Mary Margaret Chappell | Administrator | Facility administrator named in the report header |
| Renee Campbell | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Liza King | Licensing Program Manager | Named as supervisor and licensing program manager in the report |
Inspection Report
Census: 39
Capacity: 56
Deficiencies: 1
Date: Oct 12, 2022
Visit Reason
The visit was a case management follow-up on an incident report submitted by the facility regarding an unwitnessed fall of a resident on 07/15/22.
Findings
The licensee failed to immediately call 911 after a resident's fall resulting in a small laceration, instead contacting the resident's responsible party who transported the resident to the hospital. This deficiency was cited under California Code of Regulations, Title 22.
Deficiencies (1)
Failure to immediately telephone 9-1-1 after an injury or circumstance resulting in an imminent threat to a resident's health.
Report Facts
Capacity: 56
Census: 39
Plan of Correction Due Date: Oct 26, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Margaret Chappell | Administrator | Met with during the case management visit and mentioned in the narrative |
| Renee Campbell | Licensed Program Analyst | Conducted the case management visit and authored the report |
| Liza King | Licensing Program Manager | Supervisor mentioned in the report and deficiency section |
Inspection Report
Annual Inspection
Census: 42
Capacity: 56
Deficiencies: 3
Date: Jul 5, 2022
Visit Reason
An unannounced Annual 1-Year Required visit was conducted to evaluate compliance with licensing regulations and facility standards.
Findings
The facility was toured and observed to maintain safe and comfortable conditions, including adequate lighting, temperature, and safety features. However, deficiencies were found related to personnel records, including lack of signed employee rights forms in all staff files, one staff member not associated with the facility, and one staff member lacking a health screening.
Deficiencies (3)
1 of 5 staff not associated to the facility.
No signed employee rights forms in 5 of 5 staff personnel files.
1 out of 5 staff did not have a health screening.
Report Facts
Census: 42
Total Capacity: 56
Deficiencies cited: 3
Inspection Report
Complaint Investigation
Census: 41
Capacity: 56
Deficiencies: 1
Date: Jun 6, 2022
Visit Reason
The visit was a case management inspection conducted in response to an incident report submitted on 2022-04-05 regarding a medication error at the facility.
Complaint Details
The visit was complaint-related based on an incident report of a medication error submitted on 2022-04-05. The medication error was substantiated as Resident #1 received two doses of Linezolide. The resident showed no distress and the physician and family were notified.
Findings
The inspection found that a medication error occurred where Resident #1 received two doses of Linezolide due to staff miscommunication and failure to check the medication count sheet. No signs of distress were noted in the resident, but the incident posed an immediate health and safety risk.
Deficiencies (1)
Failure to comply with 87465(c)(2): Medication was not given according to physician's directions, resulting in Resident #1 receiving medication twice.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gretchen Monares | Health and Wellness Director | Met during inspection and involved in incident discussion |
| Treana White | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Liza King | Licensing Program Manager | Supervisor named in report |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 56
Deficiencies: 1
Date: Feb 16, 2022
Visit Reason
The visit was a case management investigation regarding an incident submitted to the Community Care Licensing Division on 2022-01-29 involving a medication error.
Complaint Details
The visit was complaint-related based on an incident report of a medication error. The medication error was substantiated with documentation and interviews confirming the error and subsequent actions taken.
Findings
A medication error occurred on 2022-01-24 where a resident received methadone twice due to a timing error in administration. The facility failed to comply with medication administration regulations, posing potential health and safety risks. Staff involved were reassigned or no longer employed at the facility.
Deficiencies (1)
Failure to administer medication according to physician's directions resulting in a medication error where a resident received medication twice.
Report Facts
Deficiencies cited: 1
Capacity: 56
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Margaret Chappell | Executive Director | Met during visit and involved in incident discussion |
| Treana White | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Liza King | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Follow-Up
Census: 42
Capacity: 56
Deficiencies: 1
Date: Jan 25, 2022
Visit Reason
The visit was an unannounced case management follow-up on an incident report received on 12/29/2021 regarding an altercation between two residents on 12/19/2021.
Complaint Details
The visit was complaint-related, following up on an incident report of resident aggression. The complaint was substantiated as the facility failed to report the incident within the required timeframe.
Findings
The facility has a history of aggressive behavior in one resident and has proposed an appropriate plan to prevent further incidents. However, the facility failed to meet the 7-day reporting requirement for special incident reports, submitting the report 10 days after the incident.
Deficiencies (1)
Facility did not submit a written special incident report to the licensing agency within seven days of the occurrence of the incident as required by California Code of Regulations, Title 22, Section 87211(a)(1).
Report Facts
Incident report submission delay: 10
Capacity: 56
Census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Margaret Chappell | Executive Director | Met with licensing program analysts during the visit |
| Maja Jensen | Licensing Program Analyst | Conducted the inspection and signed the report |
| Liza King | Licensing Program Manager | Named in relation to deficiency and report oversight |
Inspection Report
Monitoring
Census: 42
Capacity: 56
Deficiencies: 1
Date: Sep 30, 2021
Visit Reason
Case management visit regarding a COVID positive resident to assess compliance with reporting requirements.
Findings
The facility failed to notify the Community Care Licensing Division within 24 hours of a resident testing positive for COVID-19, which poses an immediate health and safety risk to residents.
Deficiencies (1)
Facility did not inform CCLD of COVID positive resident within 24 hours as required by California Code of Regulations, Title 22, section 87211(a)(2).
Report Facts
Capacity: 56
Census: 42
Plan of Correction Due Date: Oct 4, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Margaret Chappell | Executive Director | Spoke with Licensing Program Analyst regarding COVID positive resident and reporting. |
| Treana White | Licensing Program Analyst | Conducted the case management visit and authored the report. |
| Liza King | Licensing Program Manager | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 56
Deficiencies: 0
Date: Aug 4, 2021
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that facility staff were forging residents' medical assessments.
Complaint Details
The complaint alleged that facility staff were forging residents' medical assessments. Interviews with staff and residents' responsible parties, as well as document reviews, did not provide sufficient evidence to substantiate the allegations. The complaint was determined to be unsubstantiated.
Findings
The investigation found insufficient information to determine that facility staff were forging residents' medical assessments. The allegations were determined to be unsubstantiated, and no citations were issued.
Report Facts
Residents' medical assessments collected: 10
Staff interviewed: 2
Residents' responsible parties interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Margaret Chappell | Executive Director | Met with during investigation and exit interview |
| Treana White | Licensing Program Analyst | Conducted the complaint investigation |
| Liza King | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 41
Capacity: 56
Deficiencies: 0
Date: Jul 20, 2021
Visit Reason
The inspection was an unannounced required 1-year annual inspection conducted to evaluate the facility's compliance with licensing regulations.
Findings
The Licensing Program Analyst toured the facility and found all areas in compliance with no deficiencies cited. Safety equipment and emergency plans were up to date and operational.
Report Facts
Hot water temperature: 109.9
Hot water temperature: 107.2
Hot water temperature: 106.2
Food supply: 7
Food supply: 2
Facility capacity: 56
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Margaret Chappell | Executive Director | Met with Licensing Program Analyst during inspection |
| Treana White | Licensing Program Analyst | Conducted the inspection |
| Liza King | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 56
Deficiencies: 1
Date: Nov 16, 2020
Visit Reason
The visit was a Case Management - Incident Visit conducted via telephone due to COVID-19 precautions. It was triggered by an incident report submitted regarding a medication error where five medications were mistakenly given to the wrong resident.
Complaint Details
The incident regarding five medication errors given to Resident 1 was substantiated based on documentation and interviews. There was a preponderance of evidence proving the incident occurred as reported.
Findings
The investigation substantiated that five medications were erroneously administered to Resident 1, posing an immediate health and safety risk. The facility acknowledged the incident and a deficiency was cited under Title 22 Division 6 of the California Code of Regulations.
Deficiencies (1)
Failure to administer medications according to physician's directions, resulting in five medications given in error to Resident 1, posing an immediate health and safety risk.
Report Facts
Medications given in error: 5
Capacity: 56
Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Margaret Chappell | Administrator | Spoke with Licensing Program Analyst during the visit and involved in incident report |
| Ruth Wallace | Licensing Program Analyst | Conducted the case management incident visit and investigation |
| Krystall Moore | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
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