Deficiencies (last 4 years)

Deficiencies (over 4 years) 4.5 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

13% worse than California average
California average: 4 deficiencies/year

Deficiencies per year

8 6 4 2 0
2021
2023
2024
2025

Census

Latest occupancy rate 92% occupied

Based on a August 2025 inspection.

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

Occupancy over time

45 54 63 72 81 Aug 2021 Feb 2023 Aug 2023 Sep 2023 Aug 2024 Aug 2025

Inspection Report

Annual Inspection
Census: 69 Capacity: 75 Deficiencies: 1 Date: Aug 19, 2025

Visit Reason
The inspection was an unannounced required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools to evaluate compliance with licensing requirements.

Findings
The facility was found to have generally compliant infection control practices, operational requirements, physical plant safety, staffing, and resident rights. However, deficiencies were noted related to personnel records where the Executive Director and three staff members lacked valid health screening and TB test results in their files.

Deficiencies (1)
Executive Director, Staff #2, Staff #5, and Staff #6 files did not have valid Health Screening and TB test results, posing a potential health, safety, or personal rights risk to persons in care.
Report Facts
Census: 69 Total Capacity: 75 Staff Count: 44 Fire Extinguishers: 17 Resident Rooms: 31 Resident Rooms: 34 Resident Medications Reviewed: 8 Residents Receiving Home Health Services: 4 Residents Receiving Hospice Care: 5 Residents Using Oxygen: 7

Employees mentioned
NameTitleContext
Ken Patrick PadillaWellness DirectorMet with Licensing Program Analyst during inspection and received exit interview
Daniel KonishiLicensing Program AnalystConducted the inspection and authored the report
David SicairosSupervisorSupervisor of the licensing evaluation

Inspection Report

Annual Inspection
Census: 69 Capacity: 75 Deficiencies: 1 Date: Aug 19, 2025

Visit Reason
An unannounced required 1-year visit was conducted using the full Care Compliance and Regulatory Enforcement (CARE) Tools to evaluate compliance with licensing requirements.

Findings
The facility was inspected for infection control, operational requirements, physical plant safety, staffing, personnel records, resident rights, planned activities, food service, medication management, resident records, disaster preparedness, and residents with special health needs. One deficiency was cited related to missing health screening and TB test results in personnel files.

Deficiencies (1)
Executive Director, Staff #2, Staff #5, and Staff #6 files did not have valid Health Screening and TB test results, posing a potential health, safety, or personal rights risk to persons in care.
Report Facts
Residents under hospice care: 5 Residents bedridden: 0 Licensed capacity: 75 Current census: 69 Staff members: 44 Fire extinguishers: 17 Resident rooms on second floor: 31 Resident rooms on third floor: 34 Staff files reviewed: 7 Resident files reviewed: 7 Resident medications reviewed: 8 Perishables stored: 2 Oxygen users: 7 Residents receiving home health services: 4 Residents with hospice care: 5

Employees mentioned
NameTitleContext
Ken Patrick PadillaWellness DirectorMet with Licensing Program Analyst during inspection and received exit interview
Ralph BalbinAdministrator/DirectorNamed as facility administrator/director
Daniel KonishiLicensing Program AnalystConducted the inspection and signed the report
David SicairosLicensing Program ManagerNamed as Licensing Program Manager

Inspection Report

Complaint Investigation
Census: 66 Capacity: 75 Deficiencies: 0 Date: Feb 25, 2025

Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff spoke inappropriately to a resident, failed to meet residents' incontinence needs, and did not assist residents when responding to call buttons.

Complaint Details
The complaint involved allegations that staff member S6 spoke inappropriately to resident R1, refused to provide incontinence care, and intentionally deactivated call light pendants without assisting residents. Interviews with residents and staff, as well as police investigation, did not corroborate these allegations. The allegations were determined to be unsubstantiated.
Findings
The investigation included interviews with staff and residents, a facility tour, and record reviews. The allegations were found to be unsubstantiated due to lack of corroborating evidence from residents, staff, and police investigation. The staff member involved voluntarily resigned during the investigation.

Report Facts
Capacity: 75 Census: 66 Staff interviewed: 6 Residents interviewed: 7 Suspension date: Feb 13, 2025 Resignation date: Feb 25, 2025

Employees mentioned
NameTitleContext
Erik ZaragozaLicensing Program AnalystConducted the complaint investigation
David SicairosLicensing Program ManagerOversaw the complaint investigation
Logan HarrisonExecutive DirectorFacility representative met during investigation
Ralph BalbinAdministratorFacility administrator named in report header

Inspection Report

Complaint Investigation
Census: 66 Capacity: 75 Deficiencies: 0 Date: Feb 25, 2025

Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations including inappropriate staff behavior towards a resident, failure to meet residents' incontinence needs, and failure to assist residents when responding to call buttons.

Complaint Details
The complaint investigation was unsubstantiated based on interviews with residents and staff, review of records, and the Monrovia Police Department's closure of their investigation. Allegations involved inappropriate remarks by staff member S6, refusal to provide incontinence care, and failure to respond to call lights. S6 voluntarily resigned during the investigation.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with residents and staff did not corroborate the complaints, and the facility's internal investigation found no evidence of violations. The allegations were determined to be unsubstantiated.

Report Facts
Capacity: 75 Census: 66 Staff interviewed: 6 Residents interviewed: 7 Suspension date: Feb 13, 2025 Investigation receipt date: Feb 21, 2025

Employees mentioned
NameTitleContext
Erik ZaragozaLicensing Program AnalystConducted the complaint investigation
David SicairosLicensing Program ManagerOversaw the complaint investigation
Logan HarrisonExecutive DirectorFacility representative met during investigation
Ralph BalbinAdministratorFacility administrator named in report header

Inspection Report

Annual Inspection
Census: 67 Capacity: 75 Deficiencies: 1 Date: Aug 6, 2024

Visit Reason
An unannounced required 1-year visit was conducted using the full Care Compliance and Regulatory Enforcement (CARE) Tools to evaluate compliance with licensing regulations.

Findings
The facility was found to be generally compliant with infection control, operational requirements, physical plant safety, staffing, resident rights, planned activities, food service, medical and dental care, resident records, and disaster preparedness. However, a deficiency was cited for personnel requirements due to five out of six staff files lacking valid/current First aid/CPR training certificates.

Deficiencies (1)
Five out of six staff files reviewed did not have a valid/current First aid/CPR training certificates on file, posing a potential health, safety or personal rights risk to residents.
Report Facts
Residents under hospice care: 4 Staff members: 44 Staff files reviewed: 6 Staff without valid First aid/CPR training: 5 Fire extinguishers: 17 Hot water temperature tested rooms: 8 Licensed capacity: 75 Current census: 67

Employees mentioned
NameTitleContext
Logan HarrisonExecutive Director/AdministratorMet with Licensing Program Analyst and named in exit interview
Bennette PenaLicensing Program AnalystConducted the inspection and authored the report
David SicairosSupervisorSupervisor overseeing the licensing evaluation
Dedearie VillanuevaStaff scheduled for First aid/CPR training as part of Plan of Correction
Tamaria McraeStaff scheduled for First aid/CPR training as part of Plan of Correction
Kathryn SandovalStaff scheduled for First aid/CPR training as part of Plan of Correction
Carina GrahamStaff scheduled for First aid/CPR training as part of Plan of Correction
Dylaney EdingerStaff scheduled for First aid/CPR training as part of Plan of Correction

Inspection Report

Annual Inspection
Census: 67 Capacity: 75 Deficiencies: 1 Date: Aug 6, 2024

Visit Reason
An unannounced required 1-year visit was conducted using the full Care Compliance and Regulatory Enforcement (CARE) Tools to evaluate compliance with licensing regulations.

Findings
The facility was found to be generally compliant with infection control, operational, physical plant, staffing, resident rights, activities, food service, medication management, and emergency preparedness requirements. However, a deficiency was cited due to five out of six staff files lacking valid/current First aid/CPR training certificates.

Deficiencies (1)
Five out of six staff files reviewed did not have a valid/current First aid/CPR training certificates on file, posing a potential health, safety or personal rights risk to residents.
Report Facts
Residents under hospice care: 4 Staff members: 44 Staff files reviewed: 6 Staff without valid First aid/CPR certificates: 5 Fire extinguishers: 17 Hot water temperature rooms tested: 8 Licensed capacity: 75 Current census: 67 Liability insurance per occurrence: 2250000 Liability insurance total annual aggregate: 20000000 Residents using oxygen: 5 Residents receiving home health services: 4

Employees mentioned
NameTitleContext
Logan HarrisonExecutive Director/AdministratorMet with Licensing Program Analyst during inspection and named in deficiency exit interview
Bennette PenaLicensing Program AnalystConducted the inspection and authored the report
David SicairosSupervisorSupervisor overseeing the inspection
Dedearie VillanuevaStaff member scheduled for First aid/CPR training as part of plan of correction
Tamaria McraeStaff member scheduled for First aid/CPR training as part of plan of correction
Kathryn SandovalStaff member scheduled for First aid/CPR training as part of plan of correction
Carina GrahamStaff member scheduled for First aid/CPR training as part of plan of correction
Dylaney EdingerStaff member scheduled for First aid/CPR training as part of plan of correction

Inspection Report

Complaint Investigation
Census: 57 Capacity: 75 Deficiencies: 0 Date: Nov 13, 2023

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility failed to adhere to the admission agreement.

Complaint Details
The complaint alleged the facility failed to credit the correct amount of Resident #1's refundable community fee ($2,000), claiming an 80% credit was due but only 60% was provided. The investigation concluded the 60% credit was appropriate based on the timing of the resident's notice to vacate and admission agreement terms. The allegation was unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found that the facility credited Resident #1 with 60% of the refundable community fee as per the admission agreement for a resident leaving within the second month of residency. Interviews with staff and residents supported that the facility was responsive and fair regarding fees and credits. There was insufficient evidence to substantiate the allegation, and it was determined to be unsubstantiated.

Report Facts
Refundable community fee: 2000 Credit percentage given: 60 Credit percentage alleged due: 80 Facility capacity: 75 Resident census: 57

Employees mentioned
NameTitleContext
Logan HarrisonExecutive DirectorInterviewed regarding admissions, discharge, refunds, and credit issues
Tena HerreraLicensing Program AnalystConducted the complaint investigation visit
David SicairosLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Complaint Investigation
Census: 57 Capacity: 75 Deficiencies: 0 Date: Nov 13, 2023

Visit Reason
The visit was an unannounced initial 10-day complaint investigation conducted in response to a complaint alleging that the facility failed to adhere to the admission agreement.

Complaint Details
The complaint alleged the facility failed to credit the correct amount of Resident #1’s refundable community fee ($2,000), expecting an 80% credit but receiving only 60%. The investigation concluded the 60% credit was appropriate based on the timing of the resident's notice to vacate and admission agreement terms. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that the facility credited Resident #1 with 60% of the refundable community fee as per the admission agreement for a resident leaving within the second month of residency. Interviews with residents and staff supported that the facility was responsive and fair regarding fees and credits. There was insufficient evidence to substantiate the allegation, and it was determined to be unsubstantiated.

Report Facts
Refundable community fee: 2000 Credit issued: 1200 Capacity: 75 Census: 57

Employees mentioned
NameTitleContext
Tena HerreraLicensing Program AnalystConducted the complaint investigation
Logan HarrisonExecutive DirectorFacility representative interviewed during investigation
David SicairosLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Complaint Investigation
Census: 57 Capacity: 75 Deficiencies: 0 Date: Sep 26, 2023

Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 09/18/2023 regarding staff not cleaning resident rooms, inadequate staffing, unqualified staff performing glucose testing, improper staff training, and failure to administer medication.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not cleaning resident rooms, inadequate staffing leading to neglect, unqualified staff performing glucose testing, improper staff training on injectable medication, and failure to administer injectable medication. All allegations were not corroborated by resident or staff interviews or record reviews.
Findings
The investigation found no corroboration for any of the allegations after resident and staff interviews, facility tours, and record reviews. Staff were found to clean rooms regularly, adequately staff the facility, not perform glucose testing themselves, be properly trained, and administer medications appropriately. The allegations were determined to be unsubstantiated due to lack of evidence.

Report Facts
Residents interviewed: 7 Staff interviewed: 6 Facility capacity: 75 Facility census: 57

Employees mentioned
NameTitleContext
Bonnie TaoLicensing Program AnalystConducted the complaint investigation
Fernando FierrosLicensing Program ManagerOversaw the complaint investigation
Logan HarrisonAdministratorMet with Licensing Program Analyst during investigation

Inspection Report

Annual Inspection
Census: 57 Capacity: 75 Deficiencies: 0 Date: Sep 26, 2023

Visit Reason
The inspection was an unannounced required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools to evaluate compliance with regulatory standards.

Findings
The facility was found to be in compliance with no deficiencies cited. Infection control practices, operational requirements, physical plant safety, staffing, personnel records, resident records, food service, and disaster preparedness were all reviewed and found satisfactory.

Report Facts
Staff members: 42 Resident files reviewed: 7 Resident medications reviewed: 6 Residents on Hospice: 5 Residents on Home Health: 8 Fire clearance capacity: 75 Non ambulatory residents allowed: 34 Bedridden residents allowed: 0 Perishables food supply: 2 Non-perishables food supply: 7

Employees mentioned
NameTitleContext
Jose VillalobosLicensing Program AnalystConducted the inspection and named in findings
Ashley CalderonLicensing Program AnalystConducted the inspection and named in findings
Logan HarrisonAdministratorMet with during inspection and named in findings
Fernando FierrosSupervisorNamed as supervisor on report

Inspection Report

Complaint Investigation
Census: 57 Capacity: 75 Deficiencies: 0 Date: Sep 26, 2023

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 09/18/2023 regarding inadequate cleaning, staffing, unqualified staff performing glucose testing, improper staff training, and failure to administer medication.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not cleaning resident rooms, inadequate staffing, unqualified staff performing glucose testing, improper staff training, and failure to administer medication. Interviews and reviews found no corroboration of these allegations.
Findings
The investigation included resident and staff interviews, facility tours, and record reviews. All allegations were unsubstantiated as residents and staff denied the claims, and no evidence was found to support the allegations. Staff met residents' needs, no residents were on injectable medication, and glucose testing was conducted by residents themselves.

Report Facts
Capacity: 75 Census: 57 Staff interviewed: 6 Residents interviewed: 7

Employees mentioned
NameTitleContext
Logan HarrisonAdministratorMet with Licensing Program Analyst during investigation
Bonnie TaoLicensing Program AnalystConducted the complaint investigation
Fernando FierrosLicensing Program ManagerOversaw the complaint investigation report

Inspection Report

Annual Inspection
Census: 57 Capacity: 75 Deficiencies: 0 Date: Sep 26, 2023

Visit Reason
An unannounced required 1-year visit was conducted using the full Care Compliance and Regulatory Enforcement (CARE) Tools to evaluate the facility's compliance with regulatory standards.

Findings
The inspection found no deficiencies cited under California Code of Regulations, Title 22. The facility demonstrated compliance in infection control, operational requirements, physical plant safety, staffing, personnel records, resident records, food service, and disaster preparedness.

Report Facts
Staff members: 42 Resident files reviewed: 7 Resident medications reviewed: 6 Residents on Hospice: 5 Residents on Home Health: 8 Fire clearance capacity: 75 Non ambulatory residents allowed: 34 Bedridden residents allowed: 0 Perishables supply duration: 2 Non-perishables supply duration: 7

Employees mentioned
NameTitleContext
Jose VillalobosLicensing Program AnalystConducted the inspection
Ashley CalderonLicensing Program AnalystConducted the inspection
Logan HarrisonExecutive DirectorMet with inspectors during the visit
Fernando FierrosSupervisorSupervised the inspection

Inspection Report

Complaint Investigation
Census: 51 Capacity: 75 Deficiencies: 1 Date: Aug 31, 2023

Visit Reason
The inspection was an unannounced follow-up complaint investigation conducted due to multiple allegations including improper staff training, presence of pests, residents' personal items posing hazards, and glucose testing being administered by unqualified personnel.

Complaint Details
The complaint investigation was triggered by allegations received on 04/07/2022 regarding staff training, pest presence, hazards from residents' personal items, and improper glucose testing. The glucose testing allegation was substantiated; others were unsubstantiated.
Findings
The investigation found the allegations of improper staff training, pest issues, and residents hoarding personal items to be unsubstantiated based on interviews and record reviews. However, the allegation that glucose testing was being administered by med techs instead of appropriately skilled professionals was substantiated, posing an immediate risk to residents.

Deficiencies (1)
Glucose testing was administered by unqualified med techs instead of appropriately skilled professionals, violating CCR 87628(a).
Report Facts
Capacity: 75 Census: 51 Deficiencies cited: 1 Plan of Correction Due Date: Sep 1, 2023

Employees mentioned
NameTitleContext
Erik ZaragozaLicensing Program AnalystConducted the complaint investigation
David SicairosLicensing Program ManagerOversaw the complaint investigation
Logan HarrisonAdministratorFacility administrator met during investigation
Ralph BalbinAdministratorNamed as facility administrator in report header

Inspection Report

Complaint Investigation
Census: 51 Capacity: 75 Deficiencies: 1 Date: Aug 31, 2023

Visit Reason
This was an unannounced complaint investigation visit conducted in response to allegations received on 04/07/2022 regarding staff training, pest issues, resident personal item hazards, and glucose testing administration.

Complaint Details
The complaint investigation was triggered by allegations that staff were not properly trained, the facility had pests, residents' personal items posed hazards, and glucose testing was improperly administered by med techs. The glucose testing allegation was substantiated; others were unsubstantiated.
Findings
The investigation found the allegations of improper staff training, pest problems, and resident personal item hazards to be unsubstantiated based on interviews and record reviews. However, the allegation that glucose testing was being administered by med techs instead of appropriately skilled professionals was substantiated.

Deficiencies (1)
Failure to ensure that only appropriately skilled professionals administer glucose testing, as evidenced by med tech S7 conducting glucose testing for resident R3 who cannot perform their own testing.
Report Facts
Capacity: 75 Census: 51 Deficiencies cited: 1 Plan of Correction Due Date: Sep 1, 2023

Employees mentioned
NameTitleContext
Erik ZaragozaLicensing Program AnalystConducted the complaint investigation
David SicairosLicensing Program ManagerOversaw the complaint investigation
Logan HarrisonAdministratorFacility administrator met during investigation and exit interview
Ralph BalbinAdministratorNamed as facility administrator in report header

Inspection Report

Complaint Investigation
Census: 51 Capacity: 75 Deficiencies: 0 Date: Aug 25, 2023

Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 09/28/2022 concerning resident falls due to lack of supervision, delayed response to call buttons, and residents receiving cold meals.

Complaint Details
The complaint was unsubstantiated after investigation. Allegations included a resident sustaining a fall due to lack of supervision, staff not answering call buttons timely, and residents receiving cold meals. Interviews and document reviews did not corroborate these claims.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with residents and staff indicated that falls were promptly assisted, call light requests were answered timely with an effective notification system, and food was generally served warm with procedures in place to maintain temperature.

Report Facts
Facility capacity: 75 Resident census: 51 Call light response time: 3 Call light delay allegation: 30 Call light delay allegation: 42 Resident interviews: 8 Staff interviews: 6

Employees mentioned
NameTitleContext
Erik ZaragozaLicensing Program AnalystConducted the complaint investigation
David SicairosLicensing Program ManagerOversaw the complaint investigation
Mia NakamatzuBusiness Office ManagerMet with Licensing Program Analyst during investigation
Ralph BalbinAdministratorFacility administrator at time of investigation

Inspection Report

Complaint Investigation
Census: 51 Capacity: 75 Deficiencies: 0 Date: Aug 25, 2023

Visit Reason
This was an unannounced complaint investigation visit conducted in response to allegations including a resident sustaining a fall due to lack of supervision, staff not answering call buttons timely, and residents not receiving hot meals.

Complaint Details
The complaint investigation was unsubstantiated based on interviews with residents, staff, and review of records. Allegations included lack of supervision leading to falls, delayed response to call buttons, and cold food delivery, none of which were corroborated by sufficient evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with residents and staff indicated that falls were promptly assisted, call light requests were answered timely, and food was generally served warm. The allegations were therefore unsubstantiated.

Report Facts
Capacity: 75 Census: 51 Call light response time: 3 Call light alleged delay: 30 Call light alleged delay: 42

Employees mentioned
NameTitleContext
Erik ZaragozaLicensing Program AnalystConducted the complaint investigation
David SicairosLicensing Program ManagerOversaw the complaint investigation
Mia NakamatzuBusiness Office ManagerMet with Licensing Program Analyst during investigation
Logan HarrisonAdministratorArrived during the investigation visit

Inspection Report

Complaint Investigation
Census: 51 Capacity: 75 Deficiencies: 0 Date: Mar 14, 2023

Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 03/10/2023 regarding allegations that the facility failed to refill a resident's prescription and failed to inform the responsible party that the prescription was not filled.

Complaint Details
The complaint involved two allegations: 1) Facility failed to refill a resident's prescription; 2) Facility failed to inform the responsible party that the prescription was not filled. Both allegations were investigated and found unsubstantiated.
Findings
The investigation included interviews with residents, staff, and review of records. All interviewed residents and staff denied the allegations, and medication records were found to be current and updated. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

Report Facts
Capacity: 75 Census: 51

Employees mentioned
NameTitleContext
Christine WongLicensing Program AnalystConducted the complaint investigation
David SicairosLicensing Program ManagerOversaw the complaint investigation
Danny VeraExecutive DirectorFacility representative who assisted with the visit and received the report
Mia NakamatzuBusiness Office ManagerAllowed entry to the facility and explained the reason for the visit

Inspection Report

Complaint Investigation
Census: 51 Capacity: 75 Deficiencies: 0 Date: Mar 14, 2023

Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2023-03-10 regarding allegations that the facility failed to refill a resident's prescription and failed to inform the responsible party that the prescription was not filled.

Complaint Details
The complaint involved two allegations: 1) Facility failed to refill a resident's prescription; 2) Facility failed to inform the responsible party that the prescription was not filled. Both allegations were found unsubstantiated after investigation.
Findings
The investigation included interviews with residents, staff, and review of records. All interviewed residents and staff denied the allegations, and medication records were found to be current and updated. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

Report Facts
Capacity: 75 Census: 51

Employees mentioned
NameTitleContext
Christine WongLicensing Program AnalystConducted the complaint investigation
Danny VeraExecutive DirectorFacility representative who assisted with the visit and received the report
Mia NakamatzuBusiness Office ManagerAllowed entry to the facility and explained the reason for the visit

Inspection Report

Annual Inspection
Census: 54 Capacity: 75 Deficiencies: 2 Date: Feb 13, 2023

Visit Reason
The inspection was a Required - 1 Year unannounced visit to evaluate compliance with licensing regulations, focusing on infection control.

Findings
The facility was inspected for infection control practices including COVID-19 signage, visitor screening, and staff mask usage. Deficiencies were cited related to maintenance and water temperature issues.

Deficiencies (2)
Room #122 shower facet is loose which poses potential health, safety or personal rights risk to persons in care.
Bathroom in first floor closer to reception desk had water temperature at 120.02 degrees F. Shower water in room 125 measured 98.1 degrees F. Room 234 water measured 121.1 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
Report Facts
Capacity: 75 Census: 54 Hospice Waiver Residents: 10 Deficiencies cited: 2 POC Due Date: Feb 20, 2023 POC Due Date: Feb 15, 2023

Employees mentioned
NameTitleContext
Alberto LopezLicensing Program AnalystConducted the inspection and authored the report
Danny VeraExecutive DirectorFacility representative met during inspection and exit interview
Lisa HicksSupervisorSupervisor overseeing the licensing evaluation

Inspection Report

Annual Inspection
Census: 54 Capacity: 75 Deficiencies: 2 Date: Feb 13, 2023

Visit Reason
The inspection was a Required - 1 Year unannounced visit conducted to evaluate the facility's compliance with licensing regulations, focusing on infection control.

Findings
The inspection found that the facility generally maintained infection control measures such as COVID-19 signage, visitor screening, and staff mask usage. However, deficiencies were cited related to maintenance and plumbing, including a loose shower facet in room #122 and improper water temperatures in several locations posing health and safety risks.

Deficiencies (2)
Room #122 shower facet is loose which poses potential health, safety or personal rights risk to persons in care.
Bathroom in first floor closer to reception desk had water temperature at 120.02 degrees F. Shower water in room 125 measured 98.1 degrees F. Room 234 water measured 121.1 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
Report Facts
Capacity: 75 Census: 54 Hospice Waiver Residents: 10 Ambulatory Residents: 41 Non-Ambulatory Residents: 34 Plan of Correction Due Date: Feb 20, 2023 Plan of Correction Due Date: Feb 15, 2023

Employees mentioned
NameTitleContext
Alberto LopezLicensing Program AnalystConducted the site visit and inspection
Danny VeraExecutive DirectorMet with Licensing Program Analyst during inspection and participated in exit interview

Inspection Report

Annual Inspection
Census: 62 Capacity: 75 Deficiencies: 4 Date: Dec 9, 2021

Visit Reason
The inspection was a Required - 1 Year unannounced visit to evaluate compliance with Title 22 regulations, focusing on infection control, physical plant conditions, medication, and food supplies.

Findings
The facility was generally compliant with regulations, but several deficiencies were noted including hot water temperatures exceeding regulatory limits in multiple resident rooms, disrepair of a wooden fence, a wall near room #112 with a hole, and a kitchen drawer in room #105 that would not open or close properly.

Deficiencies (4)
Hot water temperature in multiple rooms exceeded Title 22 limits, posing an immediate health and safety risk.
Wall near entrance of room #112 was in disrepair with a hole on the corner.
Kitchen top drawer next to the sink in room #105 was in disrepair and would not open or close properly.
Wooden fence by the east walkway was in disrepair with broken pieces and leaning forward, posing a potential health and safety risk.
Report Facts
Residents present: 62 Licensed capacity: 75 Hospice waiver residents: 10 Hot water temperature: 124 Hot water temperature: 122.2 Hot water temperature: 124.9 Hot water temperature: 123.1 Hot water temperature: 123.1 Hot water temperature: 121.2 Hot water temperature: 98.5 Hot water temperature: 97.2 Hot water temperature: 68.1

Employees mentioned
NameTitleContext
Joe KatrdzhyanLicensing EvaluatorConducted the inspection and signed the report
Wei Siew HoSupervisorSupervised the inspection
Diana MarquezBusiness Office ManagerMet with LPAs during the inspection
Danny VeraAssistant AdministratorAssisted with the inspection visit

Inspection Report

Annual Inspection
Census: 62 Capacity: 75 Deficiencies: 4 Date: Dec 9, 2021

Visit Reason
Licensing Program Analysts conducted a Required - 1 Year unannounced inspection to evaluate compliance with Title 22 regulations, focusing on infection control, physical plant conditions, medication, and food supplies.

Findings
The facility was generally compliant with health and safety regulations; however, several deficiencies were noted including hot water temperatures exceeding regulatory limits in multiple rooms, disrepair of a wooden fence, a damaged wall near room #112, and a malfunctioning kitchen drawer in room #105.

Deficiencies (4)
Hot water temperature in multiple rooms exceeded the maximum allowed temperature of 120 degrees F, posing an immediate health and safety risk.
Wooden fence by the east walkway was in disrepair with broken pieces and leaning forward, posing a potential health and safety risk.
Wall near the entrance of room #112 was in disrepair with a hole on the corner.
Kitchen top drawer next to the sink in room #105 was in disrepair and would not open or close properly.
Report Facts
Deficiencies cited: 4 Plan of Correction Due Date: Dec 10, 2021 Plan of Correction Due Date: Dec 16, 2021 Plan of Correction Due Date: Jan 10, 2022 Facility Capacity: 75 Resident Census: 62

Employees mentioned
NameTitleContext
Joe KatrdzhyanLicensing EvaluatorConducted the inspection and authored the report.
Wei Siew HoSupervisorSupervised the inspection process.

Inspection Report

Complaint Investigation
Census: 60 Capacity: 75 Deficiencies: 0 Date: Aug 4, 2021

Visit Reason
The inspection was an unannounced complaint investigation visit conducted to address allegations of resident mistreatment by staff and failure to safeguard a resident's personal property.

Complaint Details
The complaint investigation was triggered by allegations that a resident was mistreated by staff and that facility staff did not safeguard the resident's personal property. The allegations were found to be unsubstantiated based on interviews and prior investigations.
Findings
The investigation found insufficient evidence to substantiate the allegations of resident mistreatment and failure to safeguard personal property. The allegation of mistreatment was related to a dispute over reimbursement, and the facility had provided partial rent credit as a gesture of good faith. The property safeguarding allegation had been previously investigated and found unsubstantiated.

Report Facts
Capacity: 75 Census: 60 Rent credit amount: 350

Employees mentioned
NameTitleContext
Ralph BalbinFormer Executive DirectorNamed in allegation of resident mistreatment and interviewed by Licensing Program Analyst
Joe KatrdzhyanLicensing Program AnalystConducted the complaint investigation visit
Wei Siew HoLicensing Program ManagerNamed as Licensing Program Manager overseeing the investigation

Inspection Report

Complaint Investigation
Census: 60 Capacity: 75 Deficiencies: 0 Date: Aug 4, 2021

Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations of resident mistreatment by staff and failure to safeguard a resident's personal property.

Complaint Details
The complaint involved allegations that a resident was mistreated by staff and that facility staff did not safeguard the resident's personal property. The allegations were found to be unsubstantiated based on interviews and prior investigations.
Findings
The investigation found insufficient evidence to substantiate the allegations of resident mistreatment and failure to safeguard personal property. The resident denied abuse, and prior investigations had also found the property allegation unsubstantiated.

Report Facts
Capacity: 75 Census: 60 Rent credit amount: 350

Employees mentioned
NameTitleContext
Joe KatrdzhyanLicensing Program AnalystConducted the complaint investigation visit
Ralph BalbinFormer Executive DirectorNamed in resident mistreatment allegation and interviewed during investigation
Alison PastoresExecutive DirectorAssisted with the investigation visit

Report

October 2, 2025

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