Inspection Reports for
Brookdale Ocean House
2107 Ocean Ave, Santa Monica, CA 90405, United States, CA, 90405
Back to Facility ProfileDeficiencies (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
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
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
| Name | Title | Context |
|---|---|---|
| Helen Lee | Executive Director / Administrator | Met with Licensing Program Analyst during inspection and named in report. |
| Sandra Solarano | Resident Engagement Manager | Met with Licensing Program Analyst during inspection. |
| Ernand Dabuet | Licensing Program Analyst | Conducted the inspection visit. |
| Janae Hammond | Licensing Program Manager | Named 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
| Name | Title | Context |
|---|---|---|
| Helen Lee | Executive Director / Administrator | Met with Licensing Program Analyst during inspection and named in report. |
| Sandra Solarano | Resident Engagement Manager | Met with Licensing Program Analyst during inspection. |
| Ernand Dabuet | Licensing Program Analyst | Conducted the inspection visit. |
| Janae Hammond | Licensing Program Manager | Named 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
| Name | Title | Context |
|---|---|---|
| Helen Lee | Administrator | Met during the investigation and exit interview |
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation |
| Stephanie Cifuentes | Supervisor | Supervisor 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
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Helen Lee | Administrator | Facility administrator met during the investigation and named in the report |
| Stephanie Cifuentes | Licensing Program Manager | Named 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
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation |
| Helen Lee | Administrator | Facility administrator met during the investigation |
| Stephanie Cifuentes | Supervisor | Supervisor 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
| Name | Title | Context |
|---|---|---|
| Helen Lee | Administrator | Met during the investigation and informed of the visit purpose |
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Cifuentes | Licensing Program Manager | Named 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
| Name | Title | Context |
|---|---|---|
| Helen Lee | Executive Director | Met with Licensing Program Analysts during investigation and exit interview. |
| Regina Cloyd | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Jose Anguiano | Licensing Program Analyst | Assisted in conducting the complaint investigation. |
| Esmeralda Ornelas | Business Office Manager | Met with LPAs during investigation and provided information. |
| Pro Jenn O'Brien Chavez | Sales Manager | Met with LPAs during investigation and provided information. |
| Ulysses Coronel | Supervisor | Supervisor 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
| Name | Title | Context |
|---|---|---|
| Helen Lee | Executive Director | Met with Licensing Program Analysts during investigation and exit interview. |
| Esmeralda Ornelas | Business Office Manager | Met with Licensing Program Analysts during investigation. |
| Pro Jenn O'Brien Chavez | Sales Manager | Met with Licensing Program Analysts during investigation. |
| Regina Cloyd | Licensing Program Analyst | Conducted complaint investigation and delivered findings. |
| Ulysses Coronel | Licensing Program Manager | Oversaw 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
| Name | Title | Context |
|---|---|---|
| Helen Lee | Administrator | Met with Licensing Program Analyst during investigation and named in interview regarding call button response |
| Regina Cloyd | Licensing Program Analyst | Conducted 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
| Name | Title | Context |
|---|---|---|
| Helen Lee | Administrator | Met during investigation and provided information regarding call button response |
| Regina Cloyd | Licensing Program Analyst | Conducted the complaint investigation |
| Ulysses Coronel | Licensing Program Manager | Oversaw 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
| Name | Title | Context |
|---|---|---|
| Helen Lee | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Sparkle Day | Licensing Program Analyst | Conducted the unannounced inspection visit |
| Janae Hammond | Supervisor | Supervisor 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
| Name | Title | Context |
|---|---|---|
| Helen Lee | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Sparkle Day | Licensing Program Analyst | Conducted the unannounced inspection visit |
| Janae Hammond | Licensing Program Manager | Named 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
| Name | Title | Context |
|---|---|---|
| Mario Leon | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Helen Lee | Executive Director | Facility representative met during the investigation |
| Thomas Park | Administrator | Facility 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
| Name | Title | Context |
|---|---|---|
| Mario Leon | Licensing Program Analyst | Conducted the complaint investigation |
| Helen Lee | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Thomas Park | Administrator | Named as facility administrator |
| Ulysses Coronel | Licensing Program Manager | Oversaw 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
| Name | Title | Context |
|---|---|---|
| David Espana | Licensing Program Analyst | Conducted the complaint investigation visit |
| Thomas Park | Administrator | Facility administrator involved in interviews and investigation |
| Helen Lee | Administrator | Met with Licensing Program Analyst during visit |
| Ulysses Coronel | Supervisor | Supervisor 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
| Name | Title | Context |
|---|---|---|
| David Espana | Licensing Program Analyst | Conducted the complaint investigation visit |
| Ulysses Coronel | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Thomas Park | Administrator | Facility 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
| Name | Title | Context |
|---|---|---|
| David Espana | Licensing Program Analyst | Conducted the complaint investigation |
| Ulysses Coronel | Supervisor | Supervisor of the investigation |
| Thomas Park | Administrator | Facility administrator mentioned in report |
| Helen Lee | Met with Licensing Program Analyst during visit | |
| S1 | Interviewed regarding refund allegation | |
| R1 | Resident 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
| Name | Title | Context |
|---|---|---|
| David Espana | Licensing Program Analyst | Conducted the complaint investigation visit |
| Thomas Park | Administrator | Facility administrator named in report |
| Helen Lee | Met 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
| Name | Title | Context |
|---|---|---|
| Lourdes Montoya | Licensing Program Analyst | Conducted the complaint investigation visit |
| Helen Lee | Executive Director/Administrator | Met with Licensing Program Analyst during the visit |
| Stephanie Cifuentes | Supervisor | Supervisor overseeing the investigation |
| Thomas Park | Administrator | Facility 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
| Name | Title | Context |
|---|---|---|
| Lourdes Montoya | Licensing Program Analyst | Conducted the complaint investigation and visit |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw the complaint investigation |
| Helen Lee | Executive Director/Administrator | Facility representative met during the investigation |
| Thomas Park | Administrator | Facility 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
| Name | Title | Context |
|---|---|---|
| Jeremiah Randle | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Wendy Gibbs | Licensing Program Analyst | Conducted an unannounced visit to amend the report |
| Heidy Bendana | Investigator | Conducted interviews related to the complaint investigation |
| Jayden Bettencourt | Associate Executive Director | Facility representative met during investigation and exit interview |
| Matan Burstyn | Executive Director | Met investigator during initial visit and provided information |
| Thomas Park | Administrator | Facility 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
| Name | Title | Context |
|---|---|---|
| Trevor Weiss | Named in deficiency for lacking criminal record clearance | |
| Matan Burstyn | Administrator | Named in deficiency for failure to timely report financial abuse incident |
| Jayden Bettencourt | Associate Executive Director | Met with Licensing Program Analyst during visit |
| Jeremiah Randle | Licensing Program Analyst | Conducted the case management and complaint investigation visit |
| Janae Hammond | Licensing Program Manager | Supervisor 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
| Name | Title | Context |
|---|---|---|
| Thomas Park | Administrator | Named as facility administrator |
| Jayden Bettencourt | Associate Executive Director | Met with Licensing Program Analyst during investigation and received exit interview |
| Jeremiah Randle | Licensing Program Analyst | Conducted the complaint investigation visit |
| Wendy Gibbs | Licensing Program Analyst | Conducted an unannounced visit to amend the report |
| Heidy Bendana | Investigator | Conducted interviews related to the complaint investigation |
| Matan Burstyn | Executive Director | Interviewed during investigation |
| Janae Hammond | Licensing Program Manager | Named 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
| Name | Title | Context |
|---|---|---|
| Trevor Weiss | Staff member without criminal record clearance | |
| Matan Burstyn | Administrator | Failed to timely report incident of financial abuse |
| Jayden Bettencourt | Associate Executive Director | Met with Licensing Program Analyst during visit |
| Jeremiah Randle | Licensing Program Analyst | Conducted 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
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Matan Burstyn | Executive Director | Met with Licensing Program Analyst during the investigation |
| Thomas Park | Administrator | Facility 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
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Matan Burstyn | Executive Director | Met with the Licensing Program Analyst during the visit |
| Olga Kirksey | Staff interviewed regarding the incident and reporting | |
| Amanda Monroy | Nurse | Checked 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
| Name | Title | Context |
|---|---|---|
| Antonine Richard | Licensing Program Analyst | Conducted the inspection and evaluation |
| Matan Burstyn | Executive Director | Facility representative who accompanied inspection and received report |
| Jesus Correa | Staff 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
| Name | Title | Context |
|---|---|---|
| Antonine Richard | Licensing Program Analyst | Conducted the inspection and toured the facility. |
| Matan Burstyn | Executive Director | Met with the Licensing Program Analyst and participated in the inspection. |
| Jesus Correa | Staff 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
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Thomas Park | Administrator | Facility administrator involved in interviews and findings |
| Matan Burstyn | Met 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
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Thomas Park | Administrator | Facility administrator met with Licensing Program Analyst during the investigation. |
| Eva M Alvarez | Supervisor | Supervisor overseeing the complaint investigation. |
| Matan Burstyn | Met 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
| Name | Title | Context |
|---|---|---|
| Elizabeth Ceniceros | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Matan Burstyn | Executive Director | New Administrator interviewed during the investigation and recipient of the exit interview |
| Chris King | Maintenance Director | Interviewed during the investigation regarding repairs |
| Amanda Monroy | Wellness Director | Interviewed during initial 10-day visit related to the complaint |
| Olga Kirskey | Executive Director | Administrator during initial 10-day visit |
| Janae Hammond | Licensing Program Manager | Oversaw 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
| Name | Title | Context |
|---|---|---|
| Elizabeth Ceniceros | Licensing Program Analyst / Retired Annuitant | Evaluator who conducted the complaint investigation and observed deficiencies |
| Matan Burstyn | Executive Director | New Administrator interviewed during the investigation and recipient of the exit interview |
| Chris King | Maintenance Director | Interviewed during the subsequent visit and observed repairs |
| Amanda Monroy | Wellness Director | Staff interviewed during initial 10-day visit |
| Olga Kirskey | Executive Director | Administrator during initial 10-day visit |
| Janae Hammond | Supervisor | Supervisor 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
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Matan Burstyn | Executive Director | Met with Licensing Program Analyst during the investigation and provided information on staffing |
| Thomas Park | Administrator | Facility Administrator named in the report |
| Eva M Alvarez | Supervisor | Supervisor 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
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Matan Burstyn | Executive Director | Facility representative interviewed during investigation |
| Thomas Park | Administrator | Facility 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
| Name | Title | Context |
|---|---|---|
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Holly Rice | Associate Executive Director | Interviewed during investigation and recipient of report |
| Thomas Park | Administrator | Facility administrator listed in report |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
| Matan Burstyn | Executive 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
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation visit |
| Joshua Castillo | Associate Executive Director | Interviewed during the investigation regarding resident belongings |
| Olga Kirksey | Executive Director | Interviewed during the investigation |
| Stephanie Cifuentes | Supervisor | Supervisor 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
| Name | Title | Context |
|---|---|---|
| Joshua Castillo | Associate Executive Director | Interviewed during the investigation and provided information about the allegation |
| Olga Kirksey | Executive Director | Met with the Licensing Program Analyst during the investigation |
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Cifuentes | Licensing Program Manager | Named 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
| Name | Title | Context |
|---|---|---|
| Don Senaha | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joshua Castillo | Associate Executive Director | Participated 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
| Name | Title | Context |
|---|---|---|
| Joshua Castillo | Associate Executive Director | Met during investigation and exit interview |
| Amanda Monroy | LVN | Met during investigation |
| Don Senaha | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw 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
| Name | Title | Context |
|---|---|---|
| Joshua Castillo | Associate Executive Director | Met with Licensing Program Analyst during investigation and provided information |
| Troy Agard | Licensing Program Analyst | Conducted 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
| Name | Title | Context |
|---|---|---|
| Troy Agard | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ulysses Coronel | Licensing Program Manager | Oversaw the complaint investigation |
| Joshua Castillo | Associate Executive Director | Facility representative interviewed during investigation |
| Thomas Park | Administrator | Facility 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
| Name | Title | Context |
|---|---|---|
| Jey Cardenas | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Joshua Castillo | Associate Executive Director | Interviewed during investigation |
| Thomas Rekowski | Former Executive Director | Interviewed 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
| Name | Title | Context |
|---|---|---|
| Jey Cardenas | Licensing Program Analyst | Conducted the complaint investigation |
| Thomas Park | Administrator | Facility administrator involved in the investigation |
| Joshua Castillo | Associate Executive Director | Interviewed during the investigation |
| Thomas Rekowski | Former Executive Director | Interviewed 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
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the inspection and evaluation |
| Thomas Park | Administrator | Facility administrator named in report header |
| Tom Rekowski | Executive Director | Provided information during inspection and participated in tour |
| Rose Linesch | Lead Receptionist | Spoke with Licensing Program Analyst during risk assessment |
| Angela J Kendrick | Supervisor | Supervisor 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
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Thomas Park | Administrator | Facility administrator mentioned in the report header. |
| Tom Rekowski | Executive Director | Facility representative who provided information during the inspection. |
| Rose Linesch | Lead Receptionist | Spoke 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
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Robert Kujawa | IB Investigator | Conducted interviews and record reviews related to the complaint |
| Thomas Rekowski | Executive Director | Met 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
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Robert Kujawa | IB Investigator | Conducted interviews and record reviews related to the complaint investigation |
| Thomas Rekowski | Executive Director | Met with Licensing Program Analyst during the investigation |
| Eva M Alvarez | Supervisor | Supervisor 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
| Name | Title | Context |
|---|---|---|
| Tom Rekowski | Executive Director | Interviewed during the complaint investigation regarding records request |
| Stephanie Cifuentes | Licensing Program Analyst | Conducted 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
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
| Tom Rekowski | Executive Director | Interviewed 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
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Tom Rekowski | Executive Director | Interviewed during the investigation and provided information on staffing and training |
| Eva M Alvarez | Supervisor | Supervisor overseeing the complaint investigation |
| Thomas Park | Administrator | Facility 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
| Name | Title | Context |
|---|---|---|
| Tom Rekowski | Executive Director | Interviewed during investigation and involved in scheduling staff training |
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation report |
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