Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. The most recent report from June 25, 2024, was clean with no deficiencies noted, showing continued compliance. Earlier complaint investigations found some substantiated issues, including failure to notify families of falls, failure to report hospitalizations, and staff threatening a resident in April 2023, as well as insufficient staffing and delayed call button responses in 2021 and 2022. These findings involved resident safety, communication, and staff responsiveness, but no fines or enforcement actions were listed in the available reports. The facility appears to have improved over time, with the latest inspections showing no deficiencies and most complaints found unsubstantiated.
Deficiencies per Year
4
3
2
1
0
Moderate
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 58
Capacity: 82
Deficiencies: 0
Jun 25, 2024
Visit Reason
An unannounced required annual inspection was conducted by the Licensing Program Manager and Licensing Program Analyst to evaluate compliance with regulatory standards.
Findings
The facility was found to be well maintained with no citations issued. Physical plant, food service, record review, medication storage, and staff and resident interviews all met regulatory requirements with no concerns observed.
Report Facts
Food supply: 2
Food supply: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Garcia | Executive Director | Met with Licensing Program Manager and Analyst during inspection |
| Tricia Danielson | Licensing Program Manager | Conducted the unannounced annual inspection |
| Stephanie Martinez | Licensing Program Analyst | Conducted the unannounced annual inspection and inspected medication room |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 82
Deficiencies: 0
Dec 1, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were overcharging a resident and not providing an itemized list of charges.
Findings
The investigation included observations, interviews, and records review. It was found that the allegations were unfounded as the resident was provided explanations and documentation of charges, and no discrepancies or rate increases were found during the period in question.
Complaint Details
The complaint alleged staff were overcharging a resident and not providing an itemized list of charges. The complaint was investigated and found to be unfounded, meaning the allegations were false or without reasonable basis.
Report Facts
Capacity: 82
Census: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Shaw Ross | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jazmond D Harris | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Celia Saldivar | Business Office Manager | Met with the Licensing Program Analyst during the investigation and involved in the findings |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 82
Deficiencies: 0
Jul 5, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that facility staff failed to respond to a resident's call button in a timely manner.
Findings
The investigation found no deficiencies or civil penalties. Based on staff and resident interviews, record reviews, and observations, there was insufficient evidence to substantiate the allegation, and it was deemed unfounded.
Complaint Details
The complaint alleged that facility staff failed to respond to a resident's call button in a timely manner. After investigation, including interviews and record review, the allegation was found to be unfounded due to lack of evidence.
Report Facts
Staff present: 45
Residents present: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Venus Mixson | Licensing Program Analyst | Conducted the complaint investigation and evaluation |
| Queen Ayers | Administrator | Facility administrator met during the investigation |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 62
Capacity: 82
Deficiencies: 0
Jun 22, 2023
Visit Reason
An unannounced annual required visit was conducted to evaluate the facility's compliance with licensing requirements.
Findings
No deficiencies were observed during the visit. A Technical Advisory was issued noting the need for refresher training on Personal Rights/Reporting Requirements for staff.
Report Facts
Hospice residents: 8
Hospice waiver capacity: 9
Bedridden residents capacity: 10
Apartments: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Garcia | Executive Director | Met with Licensing Program Analyst during the inspection |
| Janette Romero | Licensing Program Analyst | Conducted the inspection visit |
| Joel Esquivel | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 82
Deficiencies: 0
Jun 12, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate multiple allegations including staff neglect resulting in malnourishment and dehydration, failure to follow resident's plan of care, deprivation of oxygen, unsanitary conditions, insufficient staffing, pressure injury, and unqualified staff caring for a resident.
Findings
The investigation found no preponderance of evidence to substantiate the allegations related to malnourishment, dehydration, oxygen deprivation, unsanitary conditions, and staffing issues, resulting in an unsubstantiated finding. The complaint regarding staff neglect causing a pressure injury and unqualified staff caring for a resident was found to be unfounded.
Complaint Details
The complaint investigation was unsubstantiated for allegations of neglect, failure to follow care plans, oxygen deprivation, unsanitary conditions, and staffing inadequacies. The complaint regarding pressure injury and unqualified staff was unfounded, meaning the allegations were false or without reasonable basis.
Report Facts
Capacity: 82
Census: 58
Number of staff interviews: 11
Number of resident interviews: 10
Number of witness interviews: 1
Number of staff/witnesses interviewed about oxygen use: 12
Number of staff reporting resident removed oxygen: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Danielson | Licensing Program Analyst | Conducted the complaint investigation |
| Hanofi Adogiawerie | Health and Wellness Director | Met with Licensing Program Analysts during investigation |
| Queen Ayers | Administrator | Facility administrator named in report |
| Jazmond D Harris | Licensing Program Manager | Oversaw complaint investigation |
| Staff #1 | Bus Driver | Alleged unqualified staff providing care; interviewed and found to have prior caregiver experience and training |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 82
Deficiencies: 3
Apr 10, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations including failure to notify resident's family of falls, failure to report falls to the facility, and staff threatening a resident.
Findings
The investigation substantiated that the facility failed to notify the resident's family of falls and failed to report falls to the facility. Staff threatening the resident was also substantiated. Allegations that staff dropped the resident during transfer, failed to seek timely medical attention for a broken hip, and handled the resident roughly were unsubstantiated.
Complaint Details
The complaint investigation was substantiated for failure to notify family of falls, failure to report falls, and staff threatening a resident. The allegations that staff dropped the resident, failed to seek timely medical attention for a broken hip, and handled the resident roughly were unsubstantiated.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to report resident's hospitalization to the licensing agency within 7 days as required. | Type B |
| Failure to report resident's hospitalization to the licensing agency within 7 days as required. | Type B |
| Failure to accord resident safe, healthful, and comfortable accommodations; resident felt retaliation if they spoke up. | Type B |
Report Facts
Capacity: 82
Census: 58
Deficiencies cited: 3
POC Due Date: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Queen Ayers | Administrator | Named in findings related to unreported falls |
| Cindy Garcia | Executive Director | Met during investigation and exit interview |
| Javina George | Licensing Program Analyst | Conducted the complaint investigation |
| Joel Esquivel | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 54
Capacity: 82
Deficiencies: 0
Jun 2, 2022
Visit Reason
The inspection was an unannounced required annual visit with emphasis on infection control.
Findings
The Licensing Program Analyst observed sufficient hand hygiene supplies, cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead responsible for tracking COVID-19 cases and maintaining PPE and cleaning supplies.
Report Facts
Residents present: 54
Caregivers present: 35
Facility capacity: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Celia Saldivar | Human Resources Director | Met with Licensing Program Analyst during inspection and discussed infection control practices |
| Venus Mixson | Licensing Program Analyst | Conducted the inspection visit |
| Jazmond D Harris | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 77
Capacity: 82
Deficiencies: 0
Jun 8, 2021
Visit Reason
Licensing Program Analyst Deborah Mullen conducted an unannounced annual inspection of the facility as part of the required 1-year visit.
Findings
The facility was found to be following current infection control practices for the safety of residents and staff. No deficiencies were observed at the time of the visit.
Report Facts
Hospice waiver residents: 9
Non-ambulatory residents licensed: 82
Bedridden residents allowed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Queen Ayers | Executive Director | Met with Licensing Program Analyst during inspection and discussed infection control practices |
| Jennifer Larson | Health and Wellness Director | Met with Licensing Program Analyst during inspection |
| Deborah Mullen | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Karen Clemons | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 82
Deficiencies: 1
Feb 26, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on 07/27/2020 regarding staff response times to call buttons and restrictions on residents' personal belongings.
Findings
The investigation substantiated that staff did not respond to a call button in a timely manner, posing a potential health and safety risk. Another allegation regarding staff not allowing family to bring personal belongings was found to be unfounded. No deficiencies were cited during the visit.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not respond to the call button in a timely manner, with response time well over 15 minutes. The allegation that staff would not let family bring residents' personal belongings was unfounded.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel were not sufficient in numbers and competent to provide necessary services, specifically failing to respond to the call button in a timely manner, posing a potential health risk to residents. | Type B |
Report Facts
Capacity: 82
Census: 69
Plan of Correction Due Date: Mar 5, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kiana Clark | Licensing Program Analyst | Conducted the complaint investigation and contacted the facility |
| Queen Ayers | Administrator | Facility administrator involved in interviews and exit interview |
| Joel Esquivel | Licensing Program Manager | Oversaw licensing program and signed report |
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