Inspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on August 20, 2025, which was clean with no issues noted. Earlier reports showed a few isolated deficiencies, mainly related to medication management and documentation from February 2024, where staff failed to administer prescribed medications properly and charged for services not provided; these were the most serious findings but did not result in fines or enforcement actions listed in the reports. Several complaint investigations were unsubstantiated, including allegations about resident care, safety, and staff conduct. A substantiated complaint in April 2021 involved a staff member vaping in the kitchen, which led to employee termination and a smoke-free environment violation, but no further similar issues appeared afterward. Overall, the facility’s record shows improvement over time with recent inspections consistently free of deficiencies.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 67
Capacity: 140
Deficiencies: 0
Aug 20, 2025
Visit Reason
The inspection was an unannounced required comprehensive annual inspection conducted to evaluate compliance with licensing requirements for the Residential Care Facility for the Elderly.
Findings
The facility was found to be operating within approved capacity and maintained in good condition with no obstructions, adequate furniture, and proper safety equipment. Records and medication audits showed no issues. No deficiencies or advisories were issued during this inspection.
Report Facts
Non-ambulatory residents capacity: 140
Hospice waivers approved: 10
Bedridden approved: 5
Resident files reviewed: 10
Staff files reviewed: 8
Medication records audited: 10
Water temperature: 106
Non-perishable food supply: 7
Perishable food supply: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Logan Harrison | Executive Director | Met with Licensing Program Analyst during inspection and named in exit interview |
| Raquel Hernandez | Licensing Program Analyst | Conducted the inspection visit |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 79
Capacity: 140
Deficiencies: 0
Jan 10, 2025
Visit Reason
Unannounced case management visit regarding a self-reported incident on the relocation of nineteen residents from Brookdale Ocean House due to mandatory evacuation orders from Fire Advisory.
Findings
During the visit, a health and safety check was conducted with no concerns observed. The facility has sufficient beds, hygiene supplies, food, staffing, and residents' medications and files were properly managed. Fire inspection and drills were verified as completed, and families were notified about the relocation.
Report Facts
Residents relocated: 19
Residents accounted for: 17
Residents en route: 2
Facility capacity: 140
Facility census: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa To | Executive Director | Met during visit and provided information on resident relocation and facility conditions |
| Bernadette Allen | Licensing Program Analyst | Conducted the unannounced case management visit and health and safety check |
| Marcos Ramos | Business Office Manager | Informed of the purpose of the visit and provided information on resident relocation |
| Helen Lee | Provided information on resident relocation | |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 140
Deficiencies: 0
Nov 5, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations including unlawful eviction, inaccurate medication dosage, restriction of visitors, and staff stealing money from residents.
Findings
The investigation included staff and resident interviews and a facility tour. All allegations were found to be unsubstantiated based on evidence gathered, with no deficiencies cited during the visit.
Complaint Details
The complaint investigation addressed allegations of unlawful eviction, staff not providing accurate medication dosages, staff not allowing residents to have visitors, and staff stealing money from residents. After interviews and record reviews, all allegations were deemed unsubstantiated.
Report Facts
Resident interviews: 5
Staff interviews: 4
Capacity: 140
Census: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raquel Hernandez | Licensing Program Analyst | Conducted the complaint investigation |
| Mary Rico | Licensing Program Analyst | Conducted the complaint investigation |
| Marcos Ramos | Business Office Manager | Met with LPAs during the investigation and received the report |
| Efren Malagon | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 140
Deficiencies: 0
Oct 25, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2024-06-12 regarding staff assistance with resident transfers and medication destruction practices.
Findings
Based on observations, interviews with staff and residents, and document review, the allegations were found to be unsubstantiated due to insufficient evidence to prove the alleged violations occurred.
Complaint Details
The complaint involved allegations that staff were not assisting residents with transfers from wheelchairs into transportation vehicles and were not properly destroying discontinued medications. The investigation found no preponderance of evidence to substantiate these allegations.
Report Facts
Capacity: 140
Census: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Magda Malcore | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Marco Ramos | Business Office Manager | Met with the Licensing Program Analyst during the investigation and received the report |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 140
Deficiencies: 0
Oct 25, 2024
Visit Reason
The inspection was a case management visit based on observations during complaint #56-AS-20240612081444.
Findings
The Licensing Program Analyst reviewed Staff #1's file and found that the staff member was currently being shadowed and training had started on October 2, 2024. The Business Office Manager was advised to cover training regarding the facility's policy on discontinued medications and destruction. A technical advisory on incidental and medical care was issued during the visit.
Complaint Details
Visit was triggered by complaint #56-AS-20240612081444. No substantiation status explicitly stated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marcos Ramos | Business Office Manager | Met during the visit and discussed the purpose of the visit; advised on training regarding discontinued medications. |
| Magda Malcore | Licensing Program Analyst | Conducted the case management visit and authored the report. |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 140
Deficiencies: 0
Oct 10, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that facility restroom lights on a timer were turned off, resulting in a fall to a resident.
Findings
The investigation included staff and resident interviews and a facility tour. All interviewed residents and staff reported no issues or falls related to the restroom lights or help pendants. The allegation was deemed unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint alleging that restroom lights on a timer were turned off causing a resident fall was investigated and found unsubstantiated based on interviews and observations.
Report Facts
Resident interviews conducted: 5
Staff interviews conducted: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa To | Executive Director | Met with Licensing Program Analysts during investigation |
| Raquel Hernandez | Licensing Program Analyst | Conducted complaint investigation |
| Mary Rico | Licensing Program Analyst | Assisted in complaint investigation |
| Efren Malagon | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 66
Capacity: 140
Deficiencies: 0
Feb 26, 2024
Visit Reason
The visit was an unannounced required comprehensive annual inspection conducted by Licensing Program Analyst Melody Brown.
Findings
The facility was found to be operating within the approved capacity with no deficiencies or advisories issued. Resident rooms, physical plant, food service, care and supervision, and record reviews were all satisfactory.
Report Facts
Rooms: 97
Bathrooms: 103
Direct care staff present: 5
Hospice waivers approved: 10
Bedridden approved: 5
Non-perishable food supply: 7
Perishable food supply: 2
Resident files reviewed: 4
Staff files reviewed: 4
Residents audited for medications: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa To | Executive Director | Met with Licensing Program Analyst during inspection and named in report |
| Melody Brown | Licensing Program Analyst | Conducted the inspection visit and authored the report |
| Marcos Ramos | Business Office Manager | Accompanied Licensing Program Analyst during the inspection |
| Efren Malagon | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 140
Deficiencies: 2
Feb 7, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 07/06/2023 regarding staff mismanaging residents' medication and charging residents for services not rendered.
Findings
The investigation substantiated that staff mismanaged residents' medication by failing to administer prescribed medications to Resident #1 and Resident #5 for multiple days. It was also substantiated that the facility charged Resident #1 for Escort/Mobility services not provided in April, May, and June 2023. Other allegations regarding staff forcing residents to remove bed rails, residents' room floors not being level, and staff refusing to take residents' blood pressure were found to be unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations that staff mismanaged residents' medication and charged residents for services not rendered. The allegations that staff forced residents to remove bed rails, residents' room floors were not level, and staff refused to take residents' blood pressure were unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to give Resident #1 and Resident #5 their medications as prescribed by their physician, posing immediate health, safety, and personal rights risks. | Type A |
| Charging Resident #1 for Escort and mobility services not rendered or provided in April, May, and June 2023, posing potential health, safety, and personal rights risks. | Type B |
Report Facts
Days medication not given: 3
Days medication not given: 5
Days medication not given: 8
Months charged for services not rendered: 3
Facility capacity: 140
Census: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melody Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Efren Malagon | Licensing Program Manager | Oversaw the complaint investigation. |
| Lisa To | Executive Director | Facility representative met during the investigation and exit interview. |
| Emelie R. Franco | Administrator | Facility administrator named in the report. |
Inspection Report
Census: 67
Capacity: 140
Deficiencies: 1
Feb 7, 2024
Visit Reason
The visit was an unannounced Case Management inspection conducted to evaluate compliance with licensing requirements and investigate potential deficiencies.
Findings
The inspection found that Residents #1 and #5 had half bed rails without a written physician's order indicating the need for postural support at the time they moved into the facility, posing a potential health and safety risk.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents #1 and #5 had half bed rails with no written physician order indicating the need for postural support upon admission. | Type B |
Report Facts
Capacity: 140
Census: 67
Plan of Correction Due Date: Feb 16, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa To | Executive Director | Met during inspection and informed of visit |
| Melody Brown | Licensing Program Analyst | Conducted the inspection and authored the report |
| Efren Malagon | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 140
Deficiencies: 0
Jun 27, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-06-05 regarding resident burn injury, failure to report unusual incidents to resident's POA, and lack of assistance with incontinence needs.
Findings
The investigation found no evidence to substantiate the allegations. Interviews with residents and staff indicated no resident sustained burn injuries, unusual incidents were properly reported to residents' POA, and staff assisted residents with incontinence needs as required.
Complaint Details
The complaint involved three allegations: 1) Resident sustained burn injury while in care, 2) Staff did not report unusual incident to resident's POA, and 3) Staff do not assist resident with incontinence needs. All allegations were found unsubstantiated based on interviews and records review.
Report Facts
Capacity: 140
Census: 70
Allegations: 3
Staff checks per day: 3.5
Staff checks frequency hours: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melody Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Luis Rodriguez | District Director of Operations | Met with Licensing Program Analyst during investigation and exit interview |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 140
Deficiencies: 0
Jun 20, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2022-08-02 regarding staff performance, facility charges, resident needs evaluation, electrical wiring, visitor entry, medication assistance, incontinence care, bathing assistance, call button response, and room cleanliness.
Findings
The investigation found no evidence to substantiate any of the ten allegations. Interviews with residents and staff, observations, and records review indicated that services were provided as specified, no extra charges were made, resident needs were evaluated pre-admission, electrical wiring was in good repair, visitors were not denied entry, medication assistance was provided, residents received incontinence and bathing care, call buttons were responded to timely, and resident rooms were kept clean.
Complaint Details
The complaint investigation was unsubstantiated for all ten allegations, meaning there was insufficient evidence to prove the alleged violations occurred.
Report Facts
Capacity: 140
Census: 70
Number of allegations: 10
Call button response time (minutes): 10
Call button response time (minutes): 15
Shower schedule (per week): 2
Room cleaning frequency (per week): 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melody Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Efren Malagon | Licensing Program Manager | Oversaw the complaint investigation |
| Lisa To | Executive Director | Facility representative met during investigation and exit interview |
Inspection Report
Annual Inspection
Census: 73
Capacity: 140
Deficiencies: 0
Nov 7, 2022
Visit Reason
An unannounced required annual inspection was conducted with an emphasis on infection control due to the COVID-19 pandemic.
Findings
The facility was found to be in compliance with no deficiencies cited. Infection control measures were in place and effective, with no current COVID-19 cases. The facility was clean, well-maintained, and operational requirements were met.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the inspection and identified herself to the Wellness Coordinator. |
| Emelie Franco | Wellness Coordinator | Interviewed regarding infection control measures and received the inspection report. |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 140
Deficiencies: 0
Sep 2, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not emptying residents' urinals and not making residents' beds.
Findings
The investigation found insufficient evidence to substantiate the allegations. Resident #1 stated that staff do empty the portable urinal and make the bed, and that these services are performed when requested. Therefore, the allegations were deemed unsubstantiated.
Complaint Details
The complaint was unsubstantiated based on interviews and evidence gathered during the investigation. Although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur.
Report Facts
Capacity: 140
Census: 88
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa To | Administrator | Facility administrator involved in the investigation |
| Marco Ramos | Business Manager | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 69
Capacity: 140
Deficiencies: 0
Aug 23, 2021
Visit Reason
The visit was an unannounced required annual inspection with an emphasis on infection control due to the COVID-19 pandemic.
Findings
No health and safety concerns were observed during the inspection. The facility had sufficient infection control supplies, PPE, and a designated infection control lead. No deficiencies were cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elecia Weathersby | Licensing Program Analyst | Conducted the inspection and made observations regarding infection control. |
| Mechelle Alona | Sales Manager | Greeted the Licensing Program Analyst and was present during the inspection. |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 140
Deficiencies: 2
Apr 26, 2021
Visit Reason
The visit was conducted to investigate complaints received on 2020-04-14 regarding staff vaping in the facility kitchen and ineffective pest control.
Findings
The complaint that staff were vaping in the kitchen was substantiated based on video evidence and resulted in termination of the employee involved. The complaint regarding ineffective pest control was found to be unfounded as the facility had addressed prior pest issues with a professional service.
Complaint Details
The complaint investigation was substantiated for the allegation of staff vaping in the kitchen, with evidence including video footage and employee termination. The pest control complaint was unsubstantiated based on review of pest control contracts and service reports.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Plan of Operation: Facility staff did not maintain a current, written definitive plan of operation as evidenced by S1 violating facility policy by vaping in the kitchen. | Type B |
| Smoke-Free environment violation when video evidence revealed vaping in the kitchen, posing a risk to health and safety of others. | Type B |
Report Facts
Capacity: 140
Census: 58
Plan of Correction Due Date: Apr 26, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa To | Executive Director | Met with during investigation and named as facility administrator |
| Amy Goldenberg | Licensing Program Analyst | Conducted the complaint investigation |
| S1 | Employee | Employee found vaping in the kitchen and terminated |
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