Inspection Reports for
Brookdale Ocean House

2107 Ocean Ave, Santa Monica, CA 90405, United States, CA, 90405

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Deficiencies (last 5 years)

Deficiencies (over 5 years) 3.8 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

5% better than California average
California average: 4 deficiencies/year

Deficiencies per year

16 12 8 4 0
2021
2022
2023
2024
2025

Occupancy

Latest occupancy rate 75% occupied

Based on a September 2025 inspection.

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

Occupancy rate over time

20% 40% 60% 80% 100% May 2021 Aug 2022 Jun 2023 Sep 2023 Jan 2024 Mar 2025 Sep 2025

Inspection Report

Annual Inspection
Census: 112 Capacity: 150 Deficiencies: 0 Date: Sep 13, 2025

Visit Reason
The inspection was an unannounced annual required visit conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements for the facility.

Findings
The facility was found to be sanitary, appropriately furnished, and compliant with all applicable regulations. No deficiencies were identified during this inspection visit.

Report Facts
Residents on hospice care: 3 Apartment units: 116 Fire drills dates: Fire drills were completed on 05/31/25, 07/31/25, and 08/31/25.

Employees mentioned
NameTitleContext
Helen LeeExecutive Director / AdministratorMet with Licensing Program Analyst during inspection and named in report.
Sandra SolaranoResident Engagement ManagerMet with Licensing Program Analyst during inspection.
Ernand DabuetLicensing Program AnalystConducted the inspection visit.
Janae HammondLicensing Program ManagerNamed in report as Licensing Program Manager.

Inspection Report

Annual Inspection
Census: 112 Capacity: 150 Deficiencies: 0 Date: Sep 13, 2025

Visit Reason
The inspection was an unannounced annual required visit conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements.

Findings
The facility was found to be sanitary, appropriately furnished, and compliant with all applicable regulations. No deficiencies were identified during this inspection visit.

Report Facts
Residents on hospice care: 3 Hospice waiver capacity: 5 Apartment units: 116 Fire drills dates: 3

Employees mentioned
NameTitleContext
Helen LeeExecutive Director / AdministratorMet with Licensing Program Analyst during inspection and named in report.
Sandra SolaranoResident Engagement ManagerMet with Licensing Program Analyst during inspection.
Ernand DabuetLicensing Program AnalystConducted the inspection visit.
Janae HammondLicensing Program ManagerNamed as Licensing Program Manager on the report.

Inspection Report

Complaint Investigation
Census: 109 Capacity: 150 Deficiencies: 0 Date: Jul 3, 2025

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-05-12 regarding staffing adequacy, resident care, supervision of fall-risk residents, and response to call buttons.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included insufficient staffing, residents left soiled, inadequate supervision of fall-risk residents, and delayed response to call buttons. Evidence gathered did not support these claims.
Findings
The investigation found the allegations unsubstantiated based on interviews with residents and staff, observations, and record reviews. Staffing was deemed adequate, residents were not left soiled for extended periods, fall-risk residents were properly supervised, and call buttons were answered timely.

Report Facts
Residents interviewed: 12 Staff interviewed: 9 Residents reporting adequate staffing: 9 Residents reporting not left soiled: 9 Residents reporting proper supervision: 9 Residents reporting timely call button response: 9

Employees mentioned
NameTitleContext
Helen LeeAdministratorMet during the investigation and exit interview
Bernadette AllenLicensing Program AnalystConducted the complaint investigation
Stephanie CifuentesSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 109 Capacity: 150 Deficiencies: 0 Date: Jul 3, 2025

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-05-12 regarding staffing adequacy, resident care, supervision of fall-risk residents, and timely response to call buttons.

Complaint Details
The complaint included allegations that the licensee did not ensure enough staff to meet residents' needs, staff left residents soiled for extended periods, staff did not properly supervise fall-risk residents, and staff were not answering call buttons timely. The investigation found insufficient evidence to substantiate these allegations.
Findings
The investigation included interviews with residents and staff, observations, and record reviews. The evidence gathered indicated that the allegations were unsubstantiated, with adequate staffing, proper supervision, timely assistance, and routine resident checks observed.

Report Facts
Residents interviewed: 12 Staff interviewed: 9 Residents census: 109 Facility capacity: 150

Employees mentioned
NameTitleContext
Bernadette AllenLicensing Program AnalystConducted the complaint investigation and authored the report
Helen LeeAdministratorFacility administrator met during the investigation and named in the report
Stephanie CifuentesLicensing Program ManagerNamed as Licensing Program Manager overseeing the investigation

Inspection Report

Complaint Investigation
Census: 101 Capacity: 150 Deficiencies: 0 Date: May 21, 2025

Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 05/12/2025 regarding staffing adequacy, resident supervision, and timely response to call buttons at Brookdale Ocean House.

Complaint Details
The complaint included allegations that the licensee did not ensure enough staff to meet residents' needs, staff left residents soiled for extended periods, staff did not properly supervise residents at fall risk, and staff did not answer call buttons timely. The investigation found insufficient evidence to substantiate these allegations.
Findings
The investigation included interviews with residents and staff, observations, and record reviews. The allegations were found to be unsubstantiated as evidence showed adequate staffing, proper supervision of residents including those at fall risk, and timely response to call buttons.

Report Facts
Residents interviewed: 12 Staff interviewed: 9 Residents census: 101 Facility capacity: 150

Employees mentioned
NameTitleContext
Bernadette AllenLicensing Program AnalystConducted the complaint investigation
Helen LeeAdministratorFacility administrator met during the investigation
Stephanie CifuentesSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 101 Capacity: 150 Deficiencies: 0 Date: May 21, 2025

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2025-05-12 regarding staffing adequacy, resident supervision, and timely response to call buttons.

Complaint Details
The complaint included allegations that the licensee did not ensure enough staff to meet residents' needs, staff left residents soiled for extended periods, staff did not properly supervise residents at fall risk, and staff did not answer call buttons timely. The investigation found insufficient evidence to substantiate these allegations.
Findings
The investigation included interviews with residents and staff, observations, and record reviews. The evidence gathered indicated that the allegations were unsubstantiated, with staff providing adequate care, supervision, and timely assistance to residents.

Report Facts
Residents interviewed: 12 Staff interviewed: 9 Residents reporting adequate staffing: 9 Residents reporting not left soiled: 9 Residents reporting assistance with needs: 9 Residents reporting timely call button response: 9

Employees mentioned
NameTitleContext
Helen LeeAdministratorMet during the investigation and informed of the visit purpose
Bernadette AllenLicensing Program AnalystConducted the complaint investigation visit
Stephanie CifuentesLicensing Program ManagerNamed as Licensing Program Manager on the report

Inspection Report

Complaint Investigation
Census: 99 Capacity: 150 Deficiencies: 0 Date: Mar 27, 2025

Visit Reason
An unannounced complaint investigation was conducted in response to multiple allegations regarding unsanitary meal preparation, improper food storage, inadequate food service, and facility equipment disrepair at Brookdale Ocean House.

Complaint Details
The complaint investigation was triggered by allegations including unsanitary meal preparation, improper food storage, inadequate food service, and equipment disrepair. After thorough investigation including staff and resident interviews, kitchen and dining area tours, and record reviews, all allegations were found unsubstantiated.
Findings
The investigation found no preponderance of evidence to support any of the allegations. Interviews, observations, and record reviews indicated that food handling, storage, sanitation practices, food service adequacy, and equipment condition met regulatory standards. All allegations were unsubstantiated and no deficiencies were cited.

Report Facts
Staff with food handler certifications: 15 Staff interviews: 6 Resident interviews: 8 Facility capacity: 150 Census: 99 Chipped plates observed: 3 Kitchen cleaning schedule dates: 6 Third-party inspection date: Mar 21, 2025

Employees mentioned
NameTitleContext
Helen LeeExecutive DirectorMet with Licensing Program Analysts during investigation and exit interview.
Regina CloydLicensing Program AnalystConducted the complaint investigation and delivered findings.
Jose AnguianoLicensing Program AnalystAssisted in conducting the complaint investigation.
Esmeralda OrnelasBusiness Office ManagerMet with LPAs during investigation and provided information.
Pro Jenn O'Brien ChavezSales ManagerMet with LPAs during investigation and provided information.
Ulysses CoronelSupervisorSupervisor overseeing the investigation.

Inspection Report

Complaint Investigation
Census: 99 Capacity: 150 Deficiencies: 0 Date: Mar 27, 2025

Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations received on 2025-03-07 regarding unsanitary meal preparation, improper food storage, inadequate food service, and equipment disrepair at the facility.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included unsanitary meal preparation, improper food and sanitation practices, improper food storage, inadequate food service, and equipment disrepair. After thorough investigation including staff and resident interviews, kitchen and dining area tours, and record reviews, no evidence was found to support the allegations.
Findings
Based on interviews, observations, and record reviews, the Department found no evidence to substantiate any of the allegations. All allegations including unsanitary meal preparation, improper food storage, inadequate food service, and equipment disrepair were determined to be unsubstantiated with no deficiencies cited.

Report Facts
Staff with food handler certifications: 15 Staff interviewed: 6 Resident interviews: 8 Chipped plates observed: 3 Facility capacity: 150 Facility census: 99

Employees mentioned
NameTitleContext
Helen LeeExecutive DirectorMet with Licensing Program Analysts during investigation and exit interview.
Esmeralda OrnelasBusiness Office ManagerMet with Licensing Program Analysts during investigation.
Pro Jenn O'Brien ChavezSales ManagerMet with Licensing Program Analysts during investigation.
Regina CloydLicensing Program AnalystConducted complaint investigation and delivered findings.
Ulysses CoronelLicensing Program ManagerOversaw complaint investigation.

Inspection Report

Complaint Investigation
Census: 83 Capacity: 150 Deficiencies: 0 Date: Dec 4, 2024

Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that facility staff did not dispense medications as prescribed and did not respond to a resident's call button.

Complaint Details
The complaint investigation was triggered by allegations that staff failed to dispense medications as prescribed and did not respond timely to a resident's call button. The investigation included record reviews, staff and resident interviews, and observations. The allegations were found unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found no preponderance of evidence to support the allegations regarding medication administration or response to call buttons. Both allegations were determined to be unsubstantiated and no deficiencies were cited.

Report Facts
Capacity: 150 Census: 83 Medication #1 missed doses: 3 Medication #2 missed doses: 13 Medication #3 administration: 1 Resident #1 call delays: 5 Call response time range: 32

Employees mentioned
NameTitleContext
Helen LeeAdministratorMet with Licensing Program Analyst during investigation and named in interview regarding call button response
Regina CloydLicensing Program AnalystConducted the complaint investigation

Inspection Report

Complaint Investigation
Census: 83 Capacity: 150 Deficiencies: 0 Date: Dec 4, 2024

Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2024-10-25 regarding allegations that facility staff did not dispense medications as prescribed and did not respond to a resident's call button.

Complaint Details
The complaint involved two allegations: 1) Facility staff did not dispense medications as prescribed, specifically medications #1, #2, and #3 for Resident #1. 2) Facility staff did not respond to Resident #1's call button, with reports of three unwitnessed falls and delayed response times ranging from 18 to 32 minutes. After review of records, interviews, and observations, both allegations were found unsubstantiated.
Findings
The investigation found no preponderance of evidence to support the allegations that medications were not dispensed as prescribed or that staff failed to respond to the resident's call button. Both allegations were determined to be unsubstantiated and no deficiencies were cited.

Report Facts
Medication administration exceptions: 1 Medication administration exceptions: 2 Medication administration exceptions: 2 Medication administration exceptions: 11 Medication administration: 1 Resident call response delay: 5 Call response time range (minutes): 18 Call response time range (minutes): 32 Resident falls: 3

Employees mentioned
NameTitleContext
Helen LeeAdministratorMet during investigation and provided information regarding call button response
Regina CloydLicensing Program AnalystConducted the complaint investigation
Ulysses CoronelLicensing Program ManagerOversaw the complaint investigation

Inspection Report

Annual Inspection
Census: 85 Capacity: 150 Deficiencies: 0 Date: Aug 28, 2024

Visit Reason
The visit was an unannounced one-year inspection conducted to evaluate compliance with licensing requirements for the facility.

Findings
The facility was found to be in compliance with all applicable regulations with no deficiencies observed. The environment was safe, clean, and properly maintained, and all required areas and equipment were checked and found to be in good condition.

Report Facts
Resident records reviewed: 8 Staff records reviewed: 8 Apartment units: 116 Hospice waiver capacity: 5

Employees mentioned
NameTitleContext
Helen LeeExecutive DirectorMet with Licensing Program Analyst during inspection and participated in exit interview
Sparkle DayLicensing Program AnalystConducted the unannounced inspection visit
Janae HammondSupervisorSupervisor overseeing the inspection

Inspection Report

Annual Inspection
Census: 85 Capacity: 150 Deficiencies: 0 Date: Aug 28, 2024

Visit Reason
The visit was an unannounced one-year inspection to evaluate compliance with licensing requirements for the facility.

Findings
The facility was found to be in full compliance with no deficiencies observed. All resident rooms, common areas, and safety equipment were inspected and found to be properly maintained and hazard-free.

Report Facts
Resident records reviewed: 8 Staff records reviewed: 8 Apartment units: 116 One-bedroom units: 16 Studio units: 92 Deluxe studio units: 7 Hospice waiver capacity: 5

Employees mentioned
NameTitleContext
Helen LeeExecutive DirectorMet with Licensing Program Analyst during inspection and participated in exit interview
Sparkle DayLicensing Program AnalystConducted the unannounced inspection visit
Janae HammondLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Complaint Investigation
Census: 82 Capacity: 150 Deficiencies: 0 Date: Jul 19, 2024

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-08-15 regarding staff mishandling medication, inadequate supervision, and delayed medical attention for a resident.

Complaint Details
The complaint involved three allegations: staff mishandling a resident's medication, inadequate supervision, and delayed medical attention. Interviews and record reviews did not support these allegations, resulting in an unsubstantiated finding.
Findings
The investigation found all allegations to be unsubstantiated based on interviews with staff and residents and review of medication administration records and staff training. No deficiencies were cited.

Report Facts
Capacity: 150 Census: 82 Estimated Days of Completion: 90 Number of residents interviewed: 8 Number of staff interviewed: 4

Employees mentioned
NameTitleContext
Mario LeonLicensing Program AnalystEvaluator who conducted the complaint investigation
Helen LeeExecutive DirectorFacility representative met during the investigation
Thomas ParkAdministratorFacility administrator named in the report

Inspection Report

Complaint Investigation
Census: 82 Capacity: 150 Deficiencies: 0 Date: Jul 19, 2024

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-08-15 alleging staff mishandled medication, failed to provide adequate supervision, and did not seek timely medical attention for a resident.

Complaint Details
The complaint involved allegations of staff mishandling a resident's medication, inadequate supervision, and delayed medical attention. Interviews and record reviews did not support these allegations, resulting in an unsubstantiated finding.
Findings
The investigation found all allegations to be unsubstantiated based on interviews with staff and residents and review of records. No deficiencies were cited during the investigation.

Report Facts
Estimated Days of Completion: 90 Staff interviewed: 6 Residents interviewed: 12

Employees mentioned
NameTitleContext
Mario LeonLicensing Program AnalystConducted the complaint investigation
Helen LeeExecutive DirectorMet with Licensing Program Analyst during investigation and exit interview
Thomas ParkAdministratorNamed as facility administrator
Ulysses CoronelLicensing Program ManagerOversaw the complaint investigation

Inspection Report

Complaint Investigation
Census: 75 Capacity: 150 Deficiencies: 0 Date: Jan 10, 2024

Visit Reason
The visit was an unannounced complaint investigation initiated due to allegations regarding elevator maintenance, staff response to call buttons, and timely meal provision for residents.

Complaint Details
The complaint investigation was triggered by allegations that the licensee does not keep facility elevators maintained in operating condition, staff do not respond to residents' call buttons in a timely manner, and staff do not provide residents with timely meals. After interviews with residents and staff, record reviews, and observations, all allegations were found unsubstantiated.
Findings
The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove any violations occurred. All three allegations—elevator maintenance, staff response to call buttons, and timely meal provision—were determined to be unsubstantiated.

Report Facts
Facility capacity: 150 Census: 75 Residents with oxygen: 1 Residents with dementia: 1 Residents with wheelchairs: 9 Residents with diapers: 2 Staff interviewed: 7 Residents interviewed: 8 Elevator modernization proposal amount: 592580 Elevator inspection dates: 2 Pagers in use: 4 Meal service staff: 3 Meal service cooks: 3

Employees mentioned
NameTitleContext
David EspanaLicensing Program AnalystConducted the complaint investigation visit
Thomas ParkAdministratorFacility administrator involved in interviews and investigation
Helen LeeAdministratorMet with Licensing Program Analyst during visit
Ulysses CoronelSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 75 Capacity: 150 Deficiencies: 0 Date: Jan 10, 2024

Visit Reason
The inspection was an unannounced complaint investigation visit initiated due to allegations regarding elevator maintenance, staff response to call buttons, and timely meal provision for residents.

Complaint Details
The complaint investigation was unsubstantiated for all three allegations: elevator maintenance, staff response to call buttons, and timely meal provision. The report states that although the allegations may have happened or be valid, there was insufficient evidence to prove violations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. The facility was addressing elevator maintenance with ongoing modernization efforts, staff responded timely to call buttons, and residents received meals in a timely manner according to interviews, records, and observations.

Report Facts
Residents with oxygen: 1 Residents with dementia: 1 Residents with wheelchairs: 9 Residents with diapers: 2 Staff interviewed: 7 Residents interviewed: 8 Elevator modernization proposal amount: 592580 Facility capacity: 150 Facility census: 75

Employees mentioned
NameTitleContext
David EspanaLicensing Program AnalystConducted the complaint investigation visit
Ulysses CoronelLicensing Program ManagerNamed as Licensing Program Manager overseeing the investigation
Thomas ParkAdministratorFacility Administrator involved in interviews and investigation

Inspection Report

Complaint Investigation
Census: 75 Capacity: 150 Deficiencies: 0 Date: Nov 15, 2023

Visit Reason
An unannounced complaint investigation visit was conducted on 11/15/2023 following a complaint received on 11/07/2023 regarding allegations of staff not treating residents with dignity and respect, inadequate food service, uncomfortable environment, failure to issue refunds, and not meeting residents' needs.

Complaint Details
The complaint investigation was initiated based on multiple allegations including staff not treating residents with dignity and respect, inadequate food service, uncomfortable environment, failure to issue refunds, and not meeting residents' needs. After interviews and evidence review, all allegations were determined to be unsubstantiated.
Findings
The investigation included interviews with residents, staff, and a witness, as well as facility observations and record reviews. All allegations were found to be unsubstantiated due to lack of preponderance of evidence to prove violations occurred.

Report Facts
Residents interviewed: 5 Staff interviewed: 5 Witness interviewed: 1 Facility capacity: 150 Facility census: 75

Employees mentioned
NameTitleContext
David EspanaLicensing Program AnalystConducted the complaint investigation
Ulysses CoronelSupervisorSupervisor of the investigation
Thomas ParkAdministratorFacility administrator mentioned in report
Helen LeeMet with Licensing Program Analyst during visit
S1Interviewed regarding refund allegation
R1Resident involved in refund allegation

Inspection Report

Complaint Investigation
Census: 75 Capacity: 150 Deficiencies: 0 Date: Nov 15, 2023

Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations including staff not treating residents with dignity and respect, inadequate food service, uncomfortable environment, failure to issue refunds, and not meeting residents' needs.

Complaint Details
The complaint investigation was initiated based on allegations received on 2023-11-07. Allegations included staff not treating residents with dignity and respect, inadequate food service, uncomfortable environment, failure to issue refunds, and not meeting residents' needs. After interviews and evidence review, all allegations were determined to be unsubstantiated.
Findings
The investigation included interviews with residents and staff, facility tours, and record reviews. All allegations were found to be unsubstantiated due to lack of preponderance of evidence to prove violations occurred.

Report Facts
Residents interviewed: 5 Staff interviewed: 5 Facility capacity: 150 Current census: 75

Employees mentioned
NameTitleContext
David EspanaLicensing Program AnalystConducted the complaint investigation visit
Thomas ParkAdministratorFacility administrator named in report
Helen LeeMet with Licensing Program Analyst during visit

Inspection Report

Complaint Investigation
Census: 73 Capacity: 150 Deficiencies: 0 Date: Nov 2, 2023

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-09-05 regarding staff not providing fluids when requested, not ensuring privacy, and not treating residents with dignity and respect.

Complaint Details
The complaint was unsubstantiated. Allegations included staff not providing fluids when requested, not ensuring privacy, and not treating residents with dignity and respect. Interviews with residents and staff, observations, and records did not support these allegations.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Interviews with residents and staff, observations, and record reviews indicated that staff provided fluids when requested, ensured privacy, and treated residents with dignity and respect. No deficiencies were cited.

Report Facts
Residents interviewed: 8 Staff interviewed: 7

Employees mentioned
NameTitleContext
Lourdes MontoyaLicensing Program AnalystConducted the complaint investigation visit
Helen LeeExecutive Director/AdministratorMet with Licensing Program Analyst during the visit
Stephanie CifuentesSupervisorSupervisor overseeing the investigation
Thomas ParkAdministratorFacility administrator named in the report

Inspection Report

Complaint Investigation
Census: 73 Capacity: 150 Deficiencies: 0 Date: Nov 2, 2023

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-09-05 regarding staff not providing fluids when requested, not ensuring privacy, and not treating residents with dignity and respect.

Complaint Details
The complaint involved allegations that staff did not provide fluids when requested, did not ensure privacy, and did not treat residents with dignity and respect. Interviews with residents and staff, observations, and record reviews did not support these allegations. The complaint was deemed unsubstantiated.
Findings
The investigation included interviews with residents and staff, observations, and record reviews. The allegations were found to be unsubstantiated due to insufficient evidence to prove the alleged violations occurred. No deficiencies were cited.

Report Facts
Residents interviewed: 8 Staff interviewed: 7 Complaint received date: Sep 5, 2023

Employees mentioned
NameTitleContext
Lourdes MontoyaLicensing Program AnalystConducted the complaint investigation and visit
Stephanie CifuentesLicensing Program ManagerOversaw the complaint investigation
Helen LeeExecutive Director/AdministratorFacility representative met during the investigation
Thomas ParkAdministratorFacility administrator named in report header

Inspection Report

Complaint Investigation
Census: 78 Capacity: 150 Deficiencies: 1 Date: Sep 29, 2023

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff financially abused a resident by stealing money from the resident's bank accounts.

Complaint Details
The complaint was substantiated. The allegation was that staff financially abused a resident by stealing money. Interviews with witnesses, the victim, staff, and residents supported the claim. The preponderance of evidence standard was met confirming the allegation.
Findings
The investigation substantiated the allegation that staff person #1 misappropriated $10,000 from a resident's personal bank accounts. Interviews and records review confirmed the theft and partial return of funds via a cashier's check. The facility was found to be operational and in good repair with no signs of resident distress.

Deficiencies (1)
Failure to ensure resident's personal rights due to staff person #1 misappropriating resident's money from Resident V1 personal bank account.
Report Facts
Amount stolen: 10000 Amount returned: 8000 Deficiency Type: Type B Capacity: 150 Census: 78

Employees mentioned
NameTitleContext
Jeremiah RandleLicensing Program AnalystConducted the complaint investigation visit and delivered findings
Wendy GibbsLicensing Program AnalystConducted an unannounced visit to amend the report
Heidy BendanaInvestigatorConducted interviews related to the complaint investigation
Jayden BettencourtAssociate Executive DirectorFacility representative met during investigation and exit interview
Matan BurstynExecutive DirectorMet investigator during initial visit and provided information
Thomas ParkAdministratorFacility administrator named in report header

Inspection Report

Complaint Investigation
Census: 78 Capacity: 150 Deficiencies: 2 Date: Sep 29, 2023

Visit Reason
A case management visit was conducted in conjunction with a complaint investigation visit triggered by a complaint regarding staff criminal record clearance and failure to timely report an incident of financial abuse.

Complaint Details
The complaint investigation identified that staff Trevor Weiss did not have a criminal record clearance associated with the facility and that the administrator or designated staff did not timely report an incident of financial abuse to CDSS CCLD.
Findings
The licensee was found to have deficiencies including failure to ensure staff Trevor Weiss had a valid criminal record clearance and failure to timely report an incident of financial abuse to CDSS CCLD. Citations were issued and civil penalties assessed.

Deficiencies (2)
Failure to ensure staff Trevor Weiss was cleared or associated to the facility with a criminal record clearance as required.
Failure to timely report an incident of financial abuse to CDSS CCLD as required.
Report Facts
Capacity: 150 Census: 78

Employees mentioned
NameTitleContext
Trevor WeissNamed in deficiency for lacking criminal record clearance
Matan BurstynAdministratorNamed in deficiency for failure to timely report financial abuse incident
Jayden BettencourtAssociate Executive DirectorMet with Licensing Program Analyst during visit
Jeremiah RandleLicensing Program AnalystConducted the case management and complaint investigation visit
Janae HammondLicensing Program ManagerSupervisor overseeing the inspection

Inspection Report

Complaint Investigation
Census: 78 Capacity: 150 Deficiencies: 1 Date: Sep 29, 2023

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff financially abused a resident by misappropriating the resident's money.

Complaint Details
The complaint was substantiated. The allegation was that staff financially abused a resident by stealing $10,000 from the resident's bank accounts. Interviews with witnesses, the victim, staff, and residents, along with document reviews, supported the allegation. Staff person #1 admitted to cashing checks and returning only part of the money. The preponderance of evidence standard was met.
Findings
The investigation substantiated the allegation that staff person #1 misappropriated $10,000 from a resident's personal bank accounts. Interviews and document reviews confirmed the financial abuse, and the facility was found operational and in good repair with no signs of resident distress.

Deficiencies (1)
Failure to ensure resident's personal rights due to staff person #1 misappropriating resident's money from Resident V1 personal bank account, violating CCR 87468.1 Personal Rights of Residents.
Report Facts
Census: 78 Total Capacity: 150 Amount stolen: 10000 Amount returned: 8000 Plan of Correction Due Date: Sep 29, 2023

Employees mentioned
NameTitleContext
Thomas ParkAdministratorNamed as facility administrator
Jayden BettencourtAssociate Executive DirectorMet with Licensing Program Analyst during investigation and received exit interview
Jeremiah RandleLicensing Program AnalystConducted the complaint investigation visit
Wendy GibbsLicensing Program AnalystConducted an unannounced visit to amend the report
Heidy BendanaInvestigatorConducted interviews related to the complaint investigation
Matan BurstynExecutive DirectorInterviewed during investigation
Janae HammondLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Complaint Investigation
Census: 78 Capacity: 150 Deficiencies: 2 Date: Sep 29, 2023

Visit Reason
The visit was a case management and complaint investigation conducted on 09/29/2023 in conjunction with a complaint visit on 06/28/2023 to address deficiencies related to staff criminal record clearance and timely reporting of financial abuse incidents.

Complaint Details
The complaint investigation visit on 06/28/2023 (control # 11-AS-20230627152651) identified deficiencies related to staff criminal record clearance and failure to report financial abuse incidents. Civil penalties were assessed.
Findings
The licensee failed to ensure that staff Trevor Weiss had a valid criminal record clearance associated with the facility and failed to timely report an incident of financial abuse to CDSS CCLD. Citations were issued and civil penalties assessed.

Deficiencies (2)
Staff Trevor Weiss did not have a Criminal Record Clearance associated with the facility as required by Health and Safety Code Section 1569.17(b).
Administrator or designated staff did not timely report an incident of Financial Abuse to CDSS CCLD as required by Title 22 Regulations 82711.
Report Facts
Capacity: 150 Census: 78

Employees mentioned
NameTitleContext
Trevor WeissStaff member without criminal record clearance
Matan BurstynAdministratorFailed to timely report incident of financial abuse
Jayden BettencourtAssociate Executive DirectorMet with Licensing Program Analyst during visit
Jeremiah RandleLicensing Program AnalystConducted the case management and complaint investigation visit

Inspection Report

Complaint Investigation
Census: 77 Capacity: 150 Deficiencies: 1 Date: Sep 18, 2023

Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 10/28/2022 alleging that facility staff did not provide timely assistance to a resident who had fallen and failed to follow reporting requirements.

Complaint Details
The complaint alleged that facility staff did not provide resident assistance for an extended period after a fall and failed to follow reporting requirements. The allegation of delayed assistance was unsubstantiated, but the failure to report the incident was substantiated.
Findings
The investigation found that the resident fell on 10/05/2022 around 11:00 P.M. but did not call for assistance until the following morning at breakfast time. Staff were unaware of the fall until then and provided immediate assistance. However, the facility failed to report the incident to the licensing agency within the required timeframe, constituting a violation of reporting requirements. The allegation of delayed assistance was unsubstantiated.

Deficiencies (1)
Staff did not report a special incident report that resident 1 had fallen on 10/05/2022 within seven days as required by CCR 87211(a)(1).
Report Facts
Capacity: 150 Census: 77 Deficiencies cited: 1 POC due date: Sep 25, 2023

Employees mentioned
NameTitleContext
Pamela BunkerLicensing Program AnalystConducted the complaint investigation and authored the report
Matan BurstynExecutive DirectorMet with Licensing Program Analyst during the investigation
Thomas ParkAdministratorFacility administrator named in the report

Inspection Report

Complaint Investigation
Census: 77 Capacity: 150 Deficiencies: 1 Date: Sep 18, 2023

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff did not provide resident assistance for an extended period of time after a resident fell and failed to follow reporting requirements.

Complaint Details
The complaint alleged that facility staff did not provide timely assistance to a resident who had fallen and did not follow reporting requirements. The allegation of delayed assistance was found unsubstantiated due to lack of evidence that staff delayed assistance. The allegation of failure to report the incident was substantiated.
Findings
The investigation found that the resident fell on 10/05/2022 around 11:00 PM but did not call for assistance and staff were unaware of the fall until the following morning at breakfast time. Staff provided immediate assistance once aware. The facility failed to submit a special incident report within seven days as required by regulations. The allegation of delayed assistance was unsubstantiated, but the failure to report was substantiated.

Deficiencies (1)
Staff did not report a special incident report that resident 1 had fallen on 10/05/2022 within seven days as required by Title 22 regulations.
Report Facts
Capacity: 150 Census: 77 Deficiencies cited: 1 Plan of Correction Due Date: Sep 25, 2023

Employees mentioned
NameTitleContext
Pamela BunkerLicensing Program AnalystConducted the complaint investigation visit and interviews
Matan BurstynExecutive DirectorMet with the Licensing Program Analyst during the visit
Olga KirkseyStaff interviewed regarding the incident and reporting
Amanda MonroyNurseChecked the resident's pendant prior to the fall date

Inspection Report

Annual Inspection
Census: 77 Capacity: 150 Deficiencies: 0 Date: Sep 2, 2023

Visit Reason
The visit was an unannounced Required - 1 Year Annual inspection conducted using the new CARE Inspection Tools to evaluate compliance with licensing regulations.

Findings
The facility was found to be in full compliance with no deficiencies observed. Resident apartments and common areas were clean, well furnished, and free from hazards. Safety features such as smoke alarms, emergency call systems, and fire extinguishers were all in working order.

Report Facts
Number of resident apartments inspected: 8 Fire/emergency drill date: Aug 28, 2023 Hot water temperature range (Fahrenheit): 108.5-110.4

Employees mentioned
NameTitleContext
Antonine RichardLicensing Program AnalystConducted the inspection and evaluation
Matan BurstynExecutive DirectorFacility representative who accompanied inspection and received report
Jesus CorreaStaff member who toured the facility with LPA

Inspection Report

Annual Inspection
Census: 77 Capacity: 150 Deficiencies: 0 Date: Sep 2, 2023

Visit Reason
The inspection was an unannounced Required - 1 Year Annual visit to evaluate the facility's compliance using the new CARE Inspection Tools.

Findings
The facility was found to be clean, well-maintained, and in compliance with Title 22 regulations. No deficiencies or citations were observed or issued during the inspection.

Report Facts
Apartments inspected for hot water temperature: 9 Facility capacity: 150 Resident census: 77 Apartment units: 116 Fire/emergency drill date: Aug 28, 2023 Floors in building: 10 Resident apartments inspected: 8

Employees mentioned
NameTitleContext
Antonine RichardLicensing Program AnalystConducted the inspection and toured the facility.
Matan BurstynExecutive DirectorMet with the Licensing Program Analyst and participated in the inspection.
Jesus CorreaStaff member met during the inspection tour.

Inspection Report

Complaint Investigation
Census: 76 Capacity: 150 Deficiencies: 1 Date: Aug 25, 2023

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-06-14 regarding failure of facility staff to respond timely to residents' call buttons and failure to provide meal service to residents in their rooms.

Complaint Details
The complaint investigation was substantiated for the allegation that facility staff did not respond to residents' call buttons in a timely manner, with evidence including resident and staff interviews and direct observation of delayed response times. The allegation that staff failed to provide meal service to residents in their rooms was unsubstantiated due to lack of sufficient evidence.
Findings
The investigation substantiated that facility staff did not respond to residents' call buttons in a timely manner, with delays ranging from 15 to over 60 minutes, posing a potential health and safety risk. The allegation regarding failure to provide meal service to residents in their rooms was unsubstantiated as residents reported receiving meals and snacks, although sometimes delayed due to staff being busy.

Deficiencies (1)
Failure to ensure residents' call buttons were answered within a timely manner, posing a potential health and safety risk.
Report Facts
Census: 76 Total Capacity: 150 Plan of Correction Due Date: Sep 1, 2023 Call button response delay: 30 Call button response delay observed: 23

Employees mentioned
NameTitleContext
Wendy GibbsLicensing Program AnalystConducted the complaint investigation and authored the report
Eva M AlvarezLicensing Program ManagerOversaw the complaint investigation
Thomas ParkAdministratorFacility administrator involved in interviews and findings
Matan BurstynMet with Licensing Program Analyst during inspection visit

Inspection Report

Complaint Investigation
Census: 76 Capacity: 150 Deficiencies: 1 Date: Aug 25, 2023

Visit Reason
The inspection was an unannounced complaint investigation visit conducted to address allegations received on 2023-06-14 regarding staff response times to residents' call buttons and meal service delivery.

Complaint Details
The complaint investigation was triggered by allegations that facility staff failed to respond promptly to residents' call buttons and failed to provide meal service to residents in their rooms. The call button response allegation was substantiated based on interviews and observations, while the meal service allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation substantiated that facility staff did not respond to residents' call buttons in a timely manner, posing a potential health and safety risk. Another allegation regarding failure to provide meal service to residents in their rooms was unsubstantiated.

Deficiencies (1)
Licensee did not ensure residents' call buttons were answered within a timely manner, posing a potential health and safety risk.
Report Facts
Residents not receiving meals: 3 Call button wait time: 30 Call button response time observed: 23

Employees mentioned
NameTitleContext
Wendy GibbsLicensing Program AnalystConducted the complaint investigation and authored the report.
Thomas ParkAdministratorFacility administrator met with Licensing Program Analyst during the investigation.
Eva M AlvarezSupervisorSupervisor overseeing the complaint investigation.
Matan BurstynMet with Licensing Program Analyst during the investigation.

Inspection Report

Complaint Investigation
Census: 76 Capacity: 150 Deficiencies: 1 Date: Jul 27, 2023

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-11-23 alleging that the facility is in disrepair.

Complaint Details
The complaint investigation was substantiated based on evidence gathered, interviews, and records reviewed. The allegation of physical plant disrepair was confirmed.
Findings
The investigation substantiated the allegation that the facility was in disrepair, specifically noting a hole in the bathroom ceiling above the shower that had not been repaired and was covered with a board due to a damaged water pipeline, and a torn and worn carpet in Resident #1's Room #704 that posed a safety hazard. A citation was issued for failure to maintain the facility in good repair.

Deficiencies (1)
A hole in the bathroom ceiling (above the shower) had not been repaired and covered with a board due to a damaged water pipeline. The carpet was torn and worn out and a safety hazard.
Report Facts
Capacity: 150 Census: 76 Plan of Correction Due Date: Aug 3, 2023

Employees mentioned
NameTitleContext
Elizabeth CenicerosLicensing Program AnalystConducted the complaint investigation and authored the report
Matan BurstynExecutive DirectorNew Administrator interviewed during the investigation and recipient of the exit interview
Chris KingMaintenance DirectorInterviewed during the investigation regarding repairs
Amanda MonroyWellness DirectorInterviewed during initial 10-day visit related to the complaint
Olga KirskeyExecutive DirectorAdministrator during initial 10-day visit
Janae HammondLicensing Program ManagerOversaw the licensing program and signed the report

Inspection Report

Complaint Investigation
Census: 76 Capacity: 150 Deficiencies: 1 Date: Jul 27, 2023

Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation received on 11/23/2022 that the facility is in disrepair.

Complaint Details
The complaint investigation was substantiated. The allegation of the facility being in disrepair was confirmed based on observations, interviews, and document reviews. The preponderance of evidence standard was met.
Findings
The investigation substantiated the allegation that the facility was in disrepair, specifically noting a hole in the bathroom ceiling above the shower and torn, worn-out carpet in Resident #1's room, which posed a safety hazard. A citation was issued for failure to maintain the facility in a clean, safe, sanitary, and good repair condition.

Deficiencies (1)
87303(a) Maintenance and Operation: The facility was not clean, safe, sanitary, and in good repair as evidenced by a hole in the bathroom ceiling above the shower and torn, worn-out carpet posing a safety hazard.
Report Facts
Capacity: 150 Census: 76 Plan of Correction Due Date: Aug 3, 2023

Employees mentioned
NameTitleContext
Elizabeth CenicerosLicensing Program Analyst / Retired AnnuitantEvaluator who conducted the complaint investigation and observed deficiencies
Matan BurstynExecutive DirectorNew Administrator interviewed during the investigation and recipient of the exit interview
Chris KingMaintenance DirectorInterviewed during the subsequent visit and observed repairs
Amanda MonroyWellness DirectorStaff interviewed during initial 10-day visit
Olga KirskeyExecutive DirectorAdministrator during initial 10-day visit
Janae HammondSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 67 Capacity: 150 Deficiencies: 1 Date: Jun 22, 2023

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the licensee does not ensure the facility is adequately staffed to meet residents’ needs.

Complaint Details
The complaint alleged that the licensee does not ensure the facility is adequately staffed to meet residents’ needs. The allegation was substantiated based on interviews, observations, and record reviews.
Findings
The investigation found that staffing levels were insufficient to meet the daily needs of residents, with caregivers assisting multiple residents with showers, dressing, grooming, toileting, and meal escorting, resulting in staff not always being able to assist residents when needed. The allegation was substantiated and citations were issued.

Deficiencies (1)
Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by insufficient number of competent staff during 8-hour shifts, posing potential health and safety risks.
Report Facts
Capacity: 150 Census: 67 Deficiency Type: 1 Plan of Correction Due Date: Jun 30, 2023

Employees mentioned
NameTitleContext
Wendy GibbsLicensing Program AnalystConducted the complaint investigation and authored the report
Matan BurstynExecutive DirectorMet with Licensing Program Analyst during the investigation and provided information on staffing
Thomas ParkAdministratorFacility Administrator named in the report
Eva M AlvarezSupervisorSupervisor overseeing the licensing evaluation

Inspection Report

Complaint Investigation
Census: 67 Capacity: 150 Deficiencies: 1 Date: Jun 22, 2023

Visit Reason
The visit was an unannounced complaint investigation initiated due to an allegation that the licensee does not ensure the facility is adequately staffed to meet residents' needs.

Complaint Details
The complaint was substantiated. The allegation was that the licensee did not ensure adequate staffing to meet residents' needs. The investigation included interviews with caregivers, staff, residents, and review of staffing schedules, confirming insufficient staffing.
Findings
The investigation found that staffing levels were insufficient to meet the needs of residents, with caregivers unable to assist all residents requiring help with daily activities during an 8-hour shift. The allegation was substantiated and citations were issued.

Deficiencies (1)
Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by insufficient competent staff during an 8-hour shift, posing potential health and safety risks.
Report Facts
Census: 67 Total Capacity: 150 Deficiency Count: 1 Plan of Correction Due Date: Jun 30, 2023

Employees mentioned
NameTitleContext
Wendy GibbsLicensing Program AnalystConducted the complaint investigation and authored the report
Eva M AlvarezLicensing Program ManagerOversaw the complaint investigation
Matan BurstynExecutive DirectorFacility representative interviewed during investigation
Thomas ParkAdministratorFacility administrator named in report

Inspection Report

Complaint Investigation
Census: 72 Capacity: 150 Deficiencies: 1 Date: Mar 29, 2023

Visit Reason
The inspection was an unannounced complaint investigation conducted to address the allegation that facility equipment is in disrepair.

Complaint Details
The complaint was substantiated. The allegation was that facility equipment is in disrepair, specifically one elevator being out of service for months and washing machines frequently needing repair. Residents and staff confirmed the issues, and documentation showed ongoing maintenance and repair efforts with delays due to parts availability.
Findings
The investigation found that one elevator has been out of service for months due to parts being on back order, and washing machines were frequently out of service. Residents and staff confirmed these issues, and records showed frequent service calls. Plans are in place to replace both elevators with construction starting April 1, 2023.

Deficiencies (1)
Facility shall be clean, safe, sanitary and in good repair at all times; maintenance shall include provision of maintenance services and procedures for safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by elevator and washing machine disrepair.
Report Facts
Facility capacity: 150 Census: 72 Plan of Correction due date: Apr 7, 2023 Elevator modernization start date: Apr 1, 2023 Elevator modernization completion date: Apr 1, 2025

Employees mentioned
NameTitleContext
Perry ScottLicensing Program AnalystConducted the complaint investigation and authored the report
Holly RiceAssociate Executive DirectorInterviewed during investigation and recipient of report
Thomas ParkAdministratorFacility administrator listed in report
Janae HammondLicensing Program ManagerOversaw the complaint investigation
Matan BurstynExecutive Director (incoming)New Executive Director starting 03/30/23, planning elevator replacement announcement

Inspection Report

Complaint Investigation
Census: 79 Capacity: 150 Deficiencies: 0 Date: Oct 3, 2022

Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility did not safeguard a resident's personal belongings.

Complaint Details
The complaint alleged that the facility did not safeguard a resident's personal belongings. Interviews with staff and residents indicated that personal belongings were generally safeguarded. The resident who reported missing items had no proof of who took them, and the caregiver suspected was no longer employed. The facility provided a personal property document which did not list the missing items. The allegation was deemed unsubstantiated.
Findings
The investigation included interviews with staff and residents and a review of evidence. The allegation was found to be unsubstantiated due to insufficient evidence to prove the claim, although the resident believed personal items were missing from her room over two years ago during COVID-19.

Report Facts
Capacity: 150 Census: 79

Employees mentioned
NameTitleContext
Pamela BunkerLicensing Program AnalystConducted the complaint investigation visit
Joshua CastilloAssociate Executive DirectorInterviewed during the investigation regarding resident belongings
Olga KirkseyExecutive DirectorInterviewed during the investigation
Stephanie CifuentesSupervisorSupervisor overseeing the complaint investigation

Inspection Report

Complaint Investigation
Census: 79 Capacity: 150 Deficiencies: 0 Date: Oct 3, 2022

Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility did not safeguard a resident's personal belongings.

Complaint Details
The complaint alleged that the facility did not safeguard a resident's personal belongings, specifically missing silver flatware sets reported by one resident. Interviews and observations revealed no proof of theft and no corroborating evidence. The allegation was deemed unsubstantiated.
Findings
The investigation included interviews with staff and residents and a review of evidence. The allegation was found to be unsubstantiated due to insufficient evidence to prove the alleged violation occurred. No deficiencies were cited.

Report Facts
Capacity: 150 Census: 79

Employees mentioned
NameTitleContext
Joshua CastilloAssociate Executive DirectorInterviewed during the investigation and provided information about the allegation
Olga KirkseyExecutive DirectorMet with the Licensing Program Analyst during the investigation
Pamela BunkerLicensing Program AnalystConducted the complaint investigation visit
Stephanie CifuentesLicensing Program ManagerNamed as Licensing Program Manager on the report

Inspection Report

Complaint Investigation
Census: 79 Capacity: 150 Deficiencies: 0 Date: Aug 11, 2022

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2022-07-11 regarding the facility's adherence to the Admission Agreement, residents' hygiene needs, and staff meeting residents' needs while in care.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to adhere to the Admission Agreement, unmet resident hygiene needs, and staff not meeting resident needs. The Licensing Program Analyst conducted interviews with residents (R1-R9) and staff (S1-S4), reviewed service documents and Personal Service Plans, and conducted a plant inspection. No evidence was found to support the allegations.
Findings
The investigation found no evidence or witnesses supporting the allegations. Interviews with residents and staff, document reviews, and a plant inspection revealed that the facility adhered to the Admission Agreement, residents' hygiene needs were met, and staff met residents' needs. All allegations were determined to be unsubstantiated and no deficiencies were found.

Report Facts
Capacity: 150 Census: 79

Employees mentioned
NameTitleContext
Don SenahaLicensing Program AnalystConducted the complaint investigation and authored the report
Joshua CastilloAssociate Executive DirectorParticipated in the investigation and exit interview

Inspection Report

Complaint Investigation
Census: 79 Capacity: 150 Deficiencies: 0 Date: Aug 11, 2022

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2022-07-11 regarding the facility's adherence to the Admission Agreement, resident hygiene needs, and staff meeting resident needs.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to adhere to the Admission Agreement, unmet resident hygiene needs, and staff not meeting resident needs. The preponderance of evidence standard was not met for any allegation.
Findings
The investigation found no evidence or witnesses supporting the allegations. Interviews with residents and staff, document reviews, and a plant inspection revealed that the allegations were unsubstantiated. No deficiencies were found at the time of the visit.

Report Facts
Capacity: 150 Census: 79

Employees mentioned
NameTitleContext
Joshua CastilloAssociate Executive DirectorMet during investigation and exit interview
Amanda MonroyLVNMet during investigation
Don SenahaLicensing Program AnalystConducted the complaint investigation
Eva M AlvarezLicensing Program ManagerOversaw the complaint investigation

Inspection Report

Complaint Investigation
Census: 79 Capacity: 150 Deficiencies: 1 Date: Aug 9, 2022

Visit Reason
The inspection was an unannounced complaint investigation conducted to address the allegation that the facility elevator(s) are not maintained in operating condition.

Complaint Details
The complaint was substantiated. The allegation was that the facility elevators are not maintained in operating condition. Interviews with residents and staff confirmed the elevators have been broken for about 3 months, causing safety and accessibility concerns. Repair records showed frequent service calls and breakdowns. The preponderance of evidence standard was met.
Findings
The investigation found the allegation substantiated based on interviews with 8 residents and 5 staff who all confirmed the elevators have been broken for about 3 months, observations of elevator out of service signage, and review of repair records showing frequent breakdowns and repairs. The facility is cited for failure to maintain elevators in operating condition.

Deficiencies (1)
87303 Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by interviews, record review, and observation of elevator malfunction.
Report Facts
Residents interviewed: 8 Staff interviewed: 5 Elevator repairs: 6 Elevator callbacks: 6 Facility capacity: 150 Current census: 79

Employees mentioned
NameTitleContext
Joshua CastilloAssociate Executive DirectorMet with Licensing Program Analyst during investigation and provided information
Troy AgardLicensing Program AnalystConducted the complaint investigation and authored the report

Inspection Report

Complaint Investigation
Census: 79 Capacity: 150 Deficiencies: 1 Date: Aug 9, 2022

Visit Reason
The inspection was an unannounced complaint investigation conducted to address the allegation that the facility elevator(s) are not maintained in operating condition.

Complaint Details
The complaint was substantiated. Interviews with 8 residents and 5 staff confirmed the elevators have been broken for approximately three months. Records showed multiple repair attempts and callbacks. The elevators had been out of service on multiple occasions, including a prior incident where residents were trapped inside.
Findings
The investigation found the allegation substantiated based on interviews with 8 residents and 5 staff who all confirmed the elevators have been broken down for about three months, causing safety and accessibility concerns. Record review showed frequent elevator repairs and observed signage indicating one elevator was out of service.

Deficiencies (1)
Facility failed to maintain elevator(s) in operating condition, violating CCR 87303(a) requiring the facility to be clean, safe, sanitary and in good repair at all times.
Report Facts
Residents interviewed: 8 Staff interviewed: 5 Elevator repairs recorded: 6 Elevator callbacks recorded: 7 Facility capacity: 150 Current census: 79

Employees mentioned
NameTitleContext
Troy AgardLicensing Program AnalystConducted the complaint investigation and authored the report
Ulysses CoronelLicensing Program ManagerOversaw the complaint investigation
Joshua CastilloAssociate Executive DirectorFacility representative interviewed during investigation
Thomas ParkAdministratorFacility administrator named in report header

Inspection Report

Complaint Investigation
Census: 85 Capacity: 150 Deficiencies: 0 Date: May 18, 2022

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident was charged for services not received.

Complaint Details
The complaint alleged that a resident was charged for services not received. The investigation included interviews with facility staff and review of resident records. The allegation was found to be unsubstantiated.
Findings
The investigation found that although the resident was charged for services starting from the admission agreement date, the allegation was unsubstantiated due to lack of preponderance of evidence. The facility does not conduct income verifications and relies on resident self-attestation for payment ability. No deficiencies were cited.

Report Facts
Census: 85 Total Capacity: 150

Employees mentioned
NameTitleContext
Jey CardenasLicensing Program AnalystConducted the complaint investigation visit and interviews
Joshua CastilloAssociate Executive DirectorInterviewed during investigation
Thomas RekowskiFormer Executive DirectorInterviewed via telephone during investigation

Inspection Report

Complaint Investigation
Census: 85 Capacity: 150 Deficiencies: 0 Date: May 18, 2022

Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that a resident was charged for services not received.

Complaint Details
The complaint alleged that a resident was charged for services not received. The investigation included interviews with facility staff and review of resident records. It was found that the resident was considered a community member as of the admission agreement date and charges started accruing then. The resident's insurance claim was denied, and the resident was responsible for repayment. The allegation was unsubstantiated.
Findings
The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violation occurred. The allegation was determined to be unsubstantiated and no deficiencies were cited.

Report Facts
Capacity: 150 Census: 85

Employees mentioned
NameTitleContext
Jey CardenasLicensing Program AnalystConducted the complaint investigation
Thomas ParkAdministratorFacility administrator involved in the investigation
Joshua CastilloAssociate Executive DirectorInterviewed during the investigation
Thomas RekowskiFormer Executive DirectorInterviewed via telephone during the investigation

Inspection Report

Annual Inspection
Census: 91 Capacity: 150 Deficiencies: 0 Date: Aug 25, 2021

Visit Reason
An unannounced Required - 1 Year Annual visit was conducted focusing primarily on Infection Control measures using the CARE Inspection Tools.

Findings
The facility was found to be in compliance with all Title 22 regulated areas, including safety, sanitation, infection control, and emergency preparedness. No deficiencies were cited during the inspection.

Report Facts
Facility capacity: 150 Census: 91 Fire/emergency drill date: Aug 16, 2021 Apartment units: 116 Apartment types: 16 Apartment types: 92 Apartment types: 8 Hot water temperature range: 112.5 Hot water temperature range: 113

Employees mentioned
NameTitleContext
Pamela BunkerLicensing Program AnalystConducted the inspection and evaluation
Thomas ParkAdministratorFacility administrator named in report header
Tom RekowskiExecutive DirectorProvided information during inspection and participated in tour
Rose LineschLead ReceptionistSpoke with Licensing Program Analyst during risk assessment
Angela J KendrickSupervisorSupervisor overseeing the licensing evaluation

Inspection Report

Annual Inspection
Census: 91 Capacity: 150 Deficiencies: 0 Date: Aug 25, 2021

Visit Reason
An unannounced Required - 1 Year Annual visit focusing primarily on Infection Control measures using the new CARE Inspection Tools.

Findings
The facility was found to be in compliance with all Title 22 regulated areas, including safety, sanitation, medication storage, and emergency preparedness. No deficiencies were cited during the inspection.

Report Facts
Apartment units: 116 Fire/emergency drill date: Aug 16, 2021 Hot water temperature range: 112.5

Employees mentioned
NameTitleContext
Pamela BunkerLicensing Program AnalystConducted the inspection and authored the report.
Thomas ParkAdministratorFacility administrator mentioned in the report header.
Tom RekowskiExecutive DirectorFacility representative who provided information during the inspection.
Rose LineschLead ReceptionistSpoke with Licensing Program Analyst during risk assessment.

Inspection Report

Complaint Investigation
Capacity: 150 Deficiencies: 0 Date: Aug 24, 2021

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 03/15/2021 regarding resident death, room maintenance, resident assistance, and mistreatment.

Complaint Details
The complaint investigation involved allegations that a resident sustained a death while in care, staff did not properly maintain resident rooms, staff were not properly assisting residents, and residents were being mistreated. After interviews, record reviews, and observations, the allegations were found unsubstantiated.
Findings
The investigation found no sufficient evidence to support any of the allegations including resident death while in care, improper room maintenance, inadequate resident assistance, or mistreatment. The allegations were determined to be unsubstantiated.

Report Facts
Facility capacity: 150

Employees mentioned
NameTitleContext
Stephanie CifuentesLicensing Program AnalystConducted the complaint investigation and interviews
Robert KujawaIB InvestigatorConducted interviews and record reviews related to the complaint
Thomas RekowskiExecutive DirectorMet with Licensing Program Analyst during the investigation

Inspection Report

Complaint Investigation
Capacity: 150 Deficiencies: 0 Date: Aug 24, 2021

Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations including resident death while in care, improper maintenance of resident rooms, inadequate assistance to residents, and resident mistreatment.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included resident death due to neglect, improper room maintenance, inadequate assistance, and mistreatment. Interviews with residents, staff, and review of records found no evidence to support these allegations.
Findings
The investigation found no sufficient evidence to support any of the allegations. The resident death was due to COVID-19 related pneumonia after being out of facility care. Residents' rooms were properly maintained, staff properly assisted residents, and no mistreatment was found.

Report Facts
Facility capacity: 150

Employees mentioned
NameTitleContext
Stephanie CifuentesLicensing Program AnalystConducted the complaint investigation visit and interviews
Robert KujawaIB InvestigatorConducted interviews and record reviews related to the complaint investigation
Thomas RekowskiExecutive DirectorMet with Licensing Program Analyst during the investigation
Eva M AlvarezSupervisorSupervisor overseeing the complaint investigation

Inspection Report

Complaint Investigation
Census: 83 Capacity: 150 Deficiencies: 0 Date: Jun 9, 2021

Visit Reason
The inspection was an unannounced complaint investigation conducted to investigate the allegation that the facility did not release a resident's records to the resident's representative.

Complaint Details
The allegation was that the facility did not release resident's records to the resident representative. The investigation found that the facility received a records request from an authorized legal representative, responded by providing the records in parts, and residents confirmed access to their records. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation included interviews with staff, residents, and the Executive Director, as well as a review of records. The evidence did not substantiate the allegation, as records were provided to the authorized representative after a request, and residents confirmed access to their records.

Report Facts
Capacity: 150 Census: 83

Employees mentioned
NameTitleContext
Tom RekowskiExecutive DirectorInterviewed during the complaint investigation regarding records request
Stephanie CifuentesLicensing Program AnalystConducted the complaint investigation

Inspection Report

Complaint Investigation
Census: 83 Capacity: 150 Deficiencies: 0 Date: Jun 9, 2021

Visit Reason
An unannounced complaint investigation was conducted to investigate the allegation that the facility did not release a resident's records to the resident representative.

Complaint Details
The complaint alleged that the facility did not release resident's records to the resident representative. The investigation found that the facility responded to the records request appropriately and the allegation was unsubstantiated.
Findings
The investigation included interviews with staff, residents, and review of records. It was found that the facility had received a records request from an authorized legal representative and had provided the records in a timely manner. Six out of seven residents interviewed had not requested their records, and one resident received their requested file promptly. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

Report Facts
Capacity: 150 Census: 83

Employees mentioned
NameTitleContext
Stephanie CifuentesLicensing Program AnalystConducted the complaint investigation
Tom RekowskiExecutive DirectorInterviewed during investigation and involved in records request process

Inspection Report

Complaint Investigation
Census: 79 Capacity: 150 Deficiencies: 1 Date: May 7, 2021

Visit Reason
The inspection was an unannounced complaint investigation conducted due to allegations of insufficient staffing to meet residents' needs and untrained staff at the facility.

Complaint Details
The complaint investigation was initiated based on allegations of insufficient staffing and untrained staff. The untrained staff allegation was substantiated, while the insufficient staffing allegation was unsubstantiated.
Findings
The allegation of untrained staff was substantiated based on interviews, observations, and records review, revealing staff had been scheduled for tasks without proper training. The allegation of insufficient staffing was unsubstantiated as evidence showed staffing levels were adequate for the current resident census and needs.

Deficiencies (1)
Failure to ensure all personnel were given on the job training or had related experience for their assigned tasks.
Report Facts
Staff trained: 7 Residents interviewed: 8 Staff interviewed: 6 Caregivers on duty: 3 Caregivers on duty: 2 Caregivers on duty: 1 Facility capacity percentage: 68

Employees mentioned
NameTitleContext
Stephanie CifuentesLicensing Program AnalystConducted the complaint investigation and authored the report
Tom RekowskiExecutive DirectorInterviewed during the investigation and provided information on staffing and training
Eva M AlvarezSupervisorSupervisor overseeing the complaint investigation
Thomas ParkAdministratorFacility administrator named in the report

Inspection Report

Complaint Investigation
Census: 79 Capacity: 150 Deficiencies: 1 Date: May 7, 2021

Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations of insufficient staffing to meet residents' needs and untrained staff at the facility.

Complaint Details
The complaint investigation was initiated based on allegations of insufficient staffing and untrained staff. The untrained staff allegation was substantiated, while the insufficient staffing allegation was unsubstantiated. The investigation included interviews with staff, residents, and the Executive Director, as well as review of training records and staff schedules.
Findings
The investigation substantiated the allegation of untrained staff due to staff being scheduled for tasks without proper training, posing a potential health and safety risk. The allegation of insufficient staffing was unsubstantiated based on interviews, observations, and records showing staffing levels appropriate for the current resident census and needs.

Deficiencies (1)
Facility failed to ensure staff had sufficient training, posing a potential health and safety risk to clients in care.
Report Facts
Capacity: 150 Census: 79 Staff trained: 7 Staff interviewed: 6 Residents interviewed: 8

Employees mentioned
NameTitleContext
Tom RekowskiExecutive DirectorInterviewed during investigation and involved in scheduling staff training
Stephanie CifuentesLicensing Program AnalystConducted the complaint investigation
Eva M AlvarezLicensing Program ManagerOversaw the complaint investigation report

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