Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. The most recent report from September 25, 2025, included two complaint investigations with no deficiencies cited. However, there have been some isolated deficiencies over time, primarily related to medication management, including improper medication administration and disposal, and one instance of failure to conduct safety checks after a resident fall. These issues were addressed with staff terminations and additional training, and there is no indication of ongoing severe problems or enforcement actions such as fines or license suspensions. The facility’s record shows improvement in recent years, with the latest inspections free of deficiencies and complaints mostly unsubstantiated.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
1.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
66% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Capacity: 376
Deficiencies: 0
Sep 25, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2025-06-10 regarding resident hygiene needs and billing for services not rendered.
Findings
The investigation found insufficient evidence to substantiate the allegation that staff did not ensure residents' hygiene needs were met, and the billing complaint was found to be unfounded as the additional service was removed from billing per resident and responsible party request. No deficiencies were issued during the complaint visits.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Melinda Medina. The hygiene allegation was unsubstantiated due to lack of preponderance of evidence. The billing allegation was unfounded based on record review and interviews. No deficiencies were cited.
Report Facts
Facility capacity: 376
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visits |
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during complaint visits |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 248
Capacity: 376
Deficiencies: 0
Sep 25, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2025-07-25 regarding staff not providing resident records to the resident's authorized representative and a questionable death.
Findings
The investigation found insufficient evidence to substantiate the allegation regarding resident records, resulting in an unsubstantiated finding. The allegation of questionable death was found to be unfounded based on medical records, and no deficiencies were issued during the complaint visit.
Complaint Details
The complaint investigation was unsubstantiated for the allegation that staff did not provide resident records to the resident's authorized representative. The allegation of questionable death was found to be unfounded, meaning it was false or without reasonable basis.
Report Facts
Capacity: 376
Census: 248
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the complaint visit |
Inspection Report
Complaint Investigation
Census: 248
Capacity: 376
Deficiencies: 2
Sep 10, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that facility staff did not properly dispose of resident medications upon termination of services and did not dispense medications as prescribed.
Findings
The investigation found that resident R1 was administered medication belonging to residents R2 and R3, and that medication for R3, who had left the facility, was still on site. The allegations were substantiated and deficiencies were cited related to medication disposal and administration.
Complaint Details
The complaint was substantiated based on evidence that medications were not properly disposed of upon termination of services and medications were not dispensed as prescribed. Staff involved in the incident were terminated and additional training was provided.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. | Type B |
| Basic services shall at a minimum include care and supervision including assistance with taking medications. This was not met as evidenced by R1 being administered medication belonging to both R2 and R3. | Type B |
Report Facts
Capacity: 376
Census: 248
Deficiencies cited: 2
Plan of Correction Due Date: Sep 26, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during complaint investigation |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 253
Capacity: 376
Deficiencies: 0
May 21, 2025
Visit Reason
The inspection was an unannounced Case Management Annual Continuation visit conducted to complete items from a previous visit on 2025-05-14, including staff file review, resident records review, and completion of the care tool.
Findings
No deficiencies were cited during this visit. The visit was completed with an exit interview and the facility report was signed by the Administrator.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the inspection visit. |
| Melinda Medina | Licensing Program Analyst | Conducted the unannounced Case Management Annual Continuation visit. |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 253
Capacity: 376
Deficiencies: 0
May 21, 2025
Visit Reason
The visit was a Case Management visit conducted following receipt of a Death Report for a resident. The purpose was to conduct case management information review and follow-up after the death report.
Findings
No deficiencies were observed or cited during the visit. The Licensing Program Analyst reviewed the resident's last physician report and facility progress note, and noted the presence of residents on hospice and receiving home health services.
Report Facts
Residents on hospice: 21
Residents receiving home health services: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the visit |
| Sarah Archuelta-Weaver | Met with Licensing Program Analyst during the visit | |
| Melinda Medina | Licensing Program Analyst | Conducted the Case Management visit |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 253
Capacity: 376
Deficiencies: 0
May 14, 2025
Visit Reason
An unannounced annual inspection was conducted by Licensing Program Analyst M. Medina to evaluate the facility's compliance with licensing requirements.
Findings
The facility was observed to be clean, odor free, and comfortable with residents participating in activities. No deficiencies were observed during the inspection.
Report Facts
Food supply duration: 2
Perishable food supply: 2
Non-perishable food supply: 7
Water temperature range (Fahrenheit): 108
Water temperature range (Fahrenheit): 114
Fire extinguisher service date: Jan 2, 2025
Last fire drill date: Apr 29, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Toomer | Executive Director | Met with Licensing Program Analyst during facility tour |
| Sarah Archuleta-Weaver | Health and Wellness Director | Accompanied Licensing Program Analyst during facility tour |
| Melinda Medina | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 253
Capacity: 376
Deficiencies: 0
May 14, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-02-24 alleging that staff left residents soiled for extended periods and other concerns including unqualified staff checking glucose and administering insulin and pest control issues.
Findings
The investigation found insufficient evidence to substantiate the allegations of residents being left soiled, unqualified staff administering insulin, and pest control issues. The allegations were determined to be unsubstantiated or unfounded, and no deficiencies were issued during the complaint visits.
Complaint Details
The complaint investigation was unsubstantiated for the allegation that staff left residents soiled for extended periods. Another complaint regarding unqualified staff checking glucose and administering insulin and pest control was found unfounded. No deficiencies were cited.
Report Facts
Capacity: 376
Census: 253
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during complaint investigation |
| Sarah Archuelta-Weaver | Health and Wellness Director | Met with Licensing Program Analyst during complaint investigation |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 253
Capacity: 376
Deficiencies: 0
May 14, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint alleging that facility staff do not follow infection control requirements.
Findings
The investigation determined that infection control practices are in place and proper procedures are followed to protect the health and safety of residents. The allegations were found to be unfounded and the complaint was dismissed.
Complaint Details
The complaint alleged that facility staff do not follow infection control requirements. The investigation found these allegations to be unfounded, meaning they were false, could not have happened, and/or were without reasonable basis.
Report Facts
Complaint Control Number: 24
Complaint Control Number Full: 24-AS-20250225145623
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the visit |
Inspection Report
Monitoring
Census: 255
Capacity: 376
Deficiencies: 0
Apr 29, 2025
Visit Reason
The visit was an unannounced Case Management visit to verify that a specific staff member (S1) is not on the property, as S1 is excluded and not permitted on the grounds.
Findings
No deficiencies were cited during the visit. The Executive Director confirmed there is no record of the excluded staff member employed at the facility.
Report Facts
Capacity: 376
Census: 255
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the visit and confirmed no record of excluded staff member employed |
| Melinda Medina | Licensing Program Analyst | Conducted the unannounced Case Management visit |
Inspection Report
Complaint Investigation
Census: 247
Capacity: 376
Deficiencies: 0
Apr 7, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2025-01-21 regarding concerns about resident safety, cleanliness of resident rooms, and facility odors.
Findings
The investigation found insufficient evidence to substantiate the allegations. No deficiencies were issued during this complaint visit, and the allegations were determined to be unsubstantiated.
Complaint Details
The complaint involved allegations that staff did not ensure a safe environment for residents, did not adequately clean resident rooms, and did not maintain the facility free from odors. The investigation concluded these allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 376
Census: 247
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the investigation and exit interview |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sarah Aruchelta-Weaver | Health & Wellness Director | Participated in subsequent facility tour during investigation |
Inspection Report
Census: 242
Capacity: 376
Deficiencies: 0
Feb 7, 2025
Visit Reason
The visit was an unannounced Case Management visit to verify that Staff (S1) is not on the property, as S1 is excluded and not permitted to be on the grounds at any time.
Findings
The Executive Director confirmed that Staff (S1) has not been employed at the facility since 04/18/2020 and was disassociated from the facility on 05/04/2021. No citations were issued during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during visit and provided information about excluded staff. |
| Melinda Medina | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 205
Capacity: 376
Deficiencies: 0
Nov 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2024-08-19 regarding staff behavior, timely response to resident alerts, adequate care and supervision, and staff training.
Findings
The investigation found insufficient evidence to substantiate the allegations, resulting in the complaints being unsubstantiated or unfounded. No deficiencies were issued during the visit.
Complaint Details
The complaint investigation addressed allegations including staff behavior posing risks to residents, failure to address resident alerts timely, inadequate care and supervision, and improper staff training. The findings concluded the allegations were unsubstantiated or unfounded due to lack of preponderance of evidence.
Report Facts
Capacity: 376
Census: 205
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the complaint investigation visit |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 205
Capacity: 376
Deficiencies: 0
Nov 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-08-21 regarding staff not meeting residents' toileting needs and staff not maintaining accurate resident records.
Findings
The investigation found insufficient evidence to substantiate the allegations regarding residents' toileting needs, and the allegation about inaccurate resident records was found to be unfounded. No deficiencies were issued during the complaint visit.
Complaint Details
The complaint was unsubstantiated for the allegation that staff were not meeting residents' toileting needs. The allegation that staff did not maintain accurate records for a resident was found to be unfounded and dismissed.
Report Facts
Capacity: 376
Census: 205
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the complaint investigation visit |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 238
Capacity: 376
Deficiencies: 0
Jul 8, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2024-06-28 alleging that the facility was in disrepair.
Findings
The investigation found the allegation of the facility being in disrepair to be unfounded. Observations showed thermostats were within regulation and only a few parking lights needed repair. No deficiencies were cited and the complaint was dismissed.
Complaint Details
The complaint alleging the facility was in disrepair was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
Report Facts
Parking lights needing repair: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Toomer | Executive Director | Met with Licensing Program Analyst during the complaint investigation. |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 210
Capacity: 376
Deficiencies: 0
May 29, 2024
Visit Reason
The inspection was an unannounced annual inspection conducted by Licensing Program Analysts to evaluate compliance with licensing requirements.
Findings
The inspection found that staff and resident files contained the required documentation and staff trainings, and the Emergency Disaster plan was up to date. No deficiencies were cited during this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Toomer | Executive Director | Met with Licensing Program Analysts during the inspection and conducted the facility tour. |
Inspection Report
Annual Inspection
Census: 210
Capacity: 376
Deficiencies: 0
May 29, 2024
Visit Reason
An unannounced annual inspection was conducted by Licensing Program Analysts to evaluate the facility's compliance with licensing requirements.
Findings
The facility was observed to be clean, odor free, and well maintained with adequate seating and lighting. Safety features such as grab bars, nonskid mats, fire extinguishers, and carbon monoxide detectors were in place and operational. No deficiencies were observed during the inspection.
Report Facts
Water temperature range: 111
Water temperature range: 117
Fire extinguisher service date: Jan 8, 2024
Last fire drill date: Apr 18, 2024
Food supply duration: 2
Food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Toomer | Executive Director | Met with Licensing Program Analysts during the inspection and participated in facility tour |
| Melinda Medina | Licensing Program Analyst | Conducted facility tour and inspection |
| L. Salazar | Licensing Program Analyst | Conducted file review for residents and staff |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 236
Capacity: 376
Deficiencies: 0
Oct 11, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to a complaint received on 2023-09-21 alleging staff did not prevent residents from falling, did not meet residents' hygiene needs, and did not adequately supervise residents resulting in wandering.
Findings
The investigation included a facility tour, interviews, and record reviews. Staffing was found adequate, exits were secure, shower schedules and refusals were documented. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were issued.
Complaint Details
The complaint was unsubstantiated. Allegations included failure to prevent falls, inadequate hygiene care, and insufficient supervision leading to residents wandering. The investigation found no evidence to prove the alleged violations occurred.
Report Facts
Complaint control number: 24-AS-20230921081034
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during investigation |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melinda Hoffmann | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 233
Capacity: 376
Deficiencies: 1
Jul 27, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations including a questionable death and failure of staff to conduct safety checks on a resident after a fall.
Findings
The complaint regarding questionable death was unsubstantiated as the cause of death was due to medical conditions. The complaint that staff did not conduct safety checks after a resident's fall was substantiated, resulting in a cited deficiency for violation of Title 22, Section 87468.2(a)(4).
Complaint Details
The complaint investigation was triggered by allegations of questionable death and failure of staff to conduct safety checks after a fall. The questionable death allegation was unsubstantiated. The allegation regarding safety checks was substantiated with a deficiency cited.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff did not conduct safety checks following a resident's fall on 1/14/23, which is required procedure. | Type A |
Report Facts
Capacity: 376
Census: 233
Deficiencies cited: 1
Plan of Correction due date: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 233
Capacity: 376
Deficiencies: 0
Jul 27, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint alleging that staff did not ensure the facility was free from bed bugs.
Findings
The investigation found that although there was a report of bed bugs, the facility had the problem professionally treated prior to the complaint being received. The allegation was determined to be unsubstantiated and no deficiencies were issued.
Complaint Details
The complaint alleged that staff did not ensure the facility was free from bed bugs. The allegation was unsubstantiated based on interviews and record review.
Report Facts
Capacity: 376
Census: 233
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during the investigation |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melinda Hoffmann | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 233
Capacity: 376
Deficiencies: 0
Jul 27, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that a resident had access to a knife and that the facility was not kept free of pests.
Findings
The investigation found the allegations unsubstantiated. The resident's apartment was treated for pests prior to the complaint, and there was no evidence that the resident had access to a knife. No deficiencies were cited.
Complaint Details
The complaint was unsubstantiated based on interviews, record reviews, and a facility tour. Allegations included resident access to a knife and pest infestation, both found unsubstantiated.
Report Facts
Complaint Control Number: 24-AS-20230613152947
Capacity: 376
Census: 233
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jeffrey Toomer | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 233
Capacity: 376
Deficiencies: 0
Jul 20, 2023
Visit Reason
An unannounced Annual Inspection was conducted as a required 1-year visit to evaluate the facility's compliance with regulations.
Findings
The facility was observed to be clean, odor free, and well maintained with adequate accommodations and safety measures. No deficiencies were observed during the inspection.
Report Facts
Food supply duration: 2
Food supply duration: 7
Fire extinguisher service date: Jan 18, 2023
Last fire drill date: Jul 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the unannounced Annual Inspection |
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during inspection |
| Daniel Devine | Administrator | Facility Administrator |
Inspection Report
Complaint Investigation
Census: 207
Capacity: 376
Deficiencies: 0
Jun 23, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint alleging staff neglect resulting in resident hospitalization.
Findings
The investigation found the complaint to be unfounded, meaning the allegation was false, could not have happened, and/or was without a reasonable basis. No deficiencies were issued during the inspection.
Complaint Details
The complaint alleged that staff neglect resulted in resident hospitalization. The investigation concluded the complaint was unfounded.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during the complaint investigation. |
| Sarah Weaver | Health and Wellness Director | Met with Licensing Program Analyst during the complaint investigation. |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 207
Capacity: 376
Deficiencies: 0
Jun 23, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-04-03 alleging that a resident sustained a fall while in care, staff failed to report an incident to the resident's authorized representative, and staff do not answer phone calls.
Findings
The investigation found that the complaint was unfounded, meaning the allegations were false, could not have happened, or were without a reasonable basis. The resident in question had not been a resident since 2022-04-18.
Complaint Details
The complaint was investigated and found to be unfounded.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation. |
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 195
Capacity: 376
Deficiencies: 0
Feb 23, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that facility staff were not allowing a resident to have visitors.
Findings
The investigation found the complaint to be unfounded, meaning the allegation was false or without reasonable basis. No deficiencies were issued during the inspection.
Complaint Details
The complaint alleged that facility staff were not allowing a resident to have visitors. Upon review, a court order of no contact was found on file, supporting the finding that the complaint was unfounded.
Report Facts
Capacity: 376
Census: 195
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation |
| Sarah Weaver | Health and Wellness Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Capacity: 376
Deficiencies: 1
Jan 25, 2023
Visit Reason
An unannounced Case Management visit was conducted regarding a self-reported medication error received by the Fresno Regional Office on 12/02/22 involving resident R1.
Findings
The facility reported that on 11/26/22, resident R1 received an incorrect dosage of Lorazepam (.5 mg instead of the ordered .25 mg every 2 hours as needed). The Health & Wellness Director contacted the physician, hospice agency, and responsible party. Staff received additional medication training on 11/29/22. A deficiency was cited related to this medication error.
Complaint Details
The visit was complaint-related due to a self-reported medication error involving resident R1. The complaint was substantiated by the cited deficiency.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Incidental Medical and Dental Care: Medication was not given according to physician's directions as evidenced by a medication error reported on 11/26/22 for resident R1. | Type A |
Report Facts
Facility capacity: 376
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martha Fernandez de Hoban | Health and Wellness Director | Met with Licensing Program Analyst during visit and involved in medication error incident |
| Melinda Medina | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Melinda Hoffmann | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 285
Capacity: 376
Deficiencies: 0
Dec 14, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-09-19 regarding allegations of staff inappropriately discarding resident's medication, not responding timely to resident's call button, not administering resident's medication, and not providing an air mattress in a timely manner.
Findings
The investigation found no evidence to substantiate the allegations. The complaint about discarding medication was unsubstantiated as records showed no medications destroyed. The allegation of delayed response to call button could not be confirmed. The medication administration allegation was unsubstantiated due to lack of preponderance of evidence. The allegation regarding the air mattress was forwarded to the appropriate agency and found unfounded.
Complaint Details
The complaint was unsubstantiated. Allegations included inappropriate medication disposal, delayed response to call button, failure to administer medication, and failure to provide an air mattress timely. The agency found no evidence to support these claims and dismissed the complaint. The air mattress allegation was referred to the California Department of Public Health as it involved a Skilled Nursing Facility outside Community Care Licensing jurisdiction.
Report Facts
Capacity: 376
Census: 285
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation and follow-up visit |
| Reg Webster | Administrator | Facility administrator met during investigation |
| Serigy Pidgirny | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 376
Deficiencies: 3
Oct 24, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 06/17/2022 regarding bed bugs in a resident's room, poor quality of food provided to residents, and improper food storage.
Findings
The investigation substantiated the allegations that the facility had bed bugs in multiple rooms and that food was uncovered, undated, stored improperly, and served in rusted/unclean trays, posing potential health, safety, and personal rights risks to residents.
Complaint Details
The complaint investigation was substantiated based on interviews, observations, and record reviews including pest control receipts and maintenance logs confirming bed bugs, and observations of food quality and storage issues. The complaint control number is 24-AS-20220617090359.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility had bed bugs in rooms 239, 240, 242, and 249, violating residents' rights to safe, healthful, and comfortable accommodations. | Type B |
| Food was uncovered, undated, stored improperly, and served in rusted/unclean trays, violating general food service requirements for good quality food. | Type B |
| Readily perishable foods or beverages were stored uncovered and undated in the refrigerator and on countertops, posing risk of food infections or intoxications. | Type B |
Report Facts
Facility capacity: 376
Deficiencies cited: 3
Plan of Correction due date: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Garza | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Reginald Webster | Director | Facility Director met with Licensing Program Analyst during inspection and exit interview |
| See Moua | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 240
Capacity: 376
Deficiencies: 0
Sep 23, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not providing residents with activities while in care.
Findings
The Licensing Program Analyst conducted interviews and observations, finding that residents receive monthly activity calendars and daily reminders, and participate in various activities. The complaint was determined to be unfounded and dismissed.
Complaint Details
The complaint alleged that staff were not providing residents with activities. After investigation including interviews with residents and staff and facility tour, the complaint was found to be unfounded.
Report Facts
Capacity: 376
Census: 240
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Reg Webster | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 194
Capacity: 376
Deficiencies: 1
Jul 21, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2022-04-08 regarding medical attention delays, dehydration, neglect, and illegal eviction at the facility.
Findings
The investigation substantiated that medical attention was not sought in a timely manner for a resident experiencing an emergency change in condition, citing a violation of CCR 87465(g). The allegation of severe dehydration was unsubstantiated due to insufficient evidence. The allegations of neglect resulting in pressure injuries and illegal eviction were found to be unfounded and dismissed.
Complaint Details
The complaint investigation addressed multiple allegations: 1) Medical attention was not sought timely for a resident; 2) Resident became severely dehydrated; 3) Neglect/lack of supervision resulted in pressure injuries; 4) Illegal eviction. The medical attention allegation was substantiated, dehydration allegation was unsubstantiated, and neglect and eviction allegations were unfounded.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee did not immediately telephone 9-1-1 when a resident had an emergency change in condition posing an imminent threat to health and safety. | Type A |
Report Facts
Capacity: 376
Census: 194
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawna Doucette | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Reg Webster | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Sergiy Pidgirny | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Routine
Census: 220
Capacity: 376
Deficiencies: 0
Jun 14, 2022
Visit Reason
The visit was an unannounced required Infection Control Inspection conducted to assess compliance with infection control practices.
Findings
The facility was found to be in compliance with required infection control practices. No deficiencies were observed during the inspection.
Report Facts
PPE supply duration: 30
Fire extinguisher service date: Jan 26, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the infection control inspection |
| Reg Webster | Administrator | Facility administrator involved in the inspection and interview |
Inspection Report
Follow-Up
Census: 210
Capacity: 376
Deficiencies: 0
Jun 3, 2022
Visit Reason
The visit was a Case Management follow-up to an incident report that occurred on 2022-05-23.
Findings
The Licensing Program Analyst conducted interviews and obtained relevant files related to the incident. An exit interview was conducted with the facility administrator and a copy of the report was provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Reg Webster | Administrator | Responded to assist with the case management and participated in the exit interview. |
| Karen Lomax | Staff member met by Licensing Program Analyst to discuss the purpose of the visit. | |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Shawna Doucette | Licensing Program Analyst | Conducted the case management visit and signed the report. |
Inspection Report
Complaint Investigation
Census: 175
Capacity: 376
Deficiencies: 0
May 16, 2022
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 2022-01-19 alleging the facility was unsanitary.
Findings
The investigation found the area in wing of building B to be clean and in good repair with no detectable stains or odors from pets. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleging the facility was unsanitary was investigated and found to be unsubstantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly J. McClurg | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Reg Webster | Executive Director IV | Met with Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Capacity: 376
Deficiencies: 0
May 12, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including lack of care and supervision resulting in resident death, failure to provide access to a call button, and inadequate care.
Findings
The investigation found that the resident had a terminal medical condition resulting in death, had access to a call button, was not left soiled, and the facility was providing adequate care and supervision. The allegations were unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included lack of care and supervision resulting in resident death, failure to provide access to a call button, resident left soiled, and inadequate care and supervision. After review of records and interviews, there was insufficient evidence to prove violations occurred.
Report Facts
Facility capacity: 376
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawna Doucette | Licensing Program Analyst | Conducted the complaint investigation |
| Reg Webster | Administrator | Facility administrator involved in the investigation |
| Sergiy Pidgirny | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 205
Capacity: 376
Deficiencies: 0
Feb 24, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not properly maintain resident records and were not following the admission agreement.
Findings
The investigation found no evidence to support the allegations; staff maintained resident records properly and followed the admission agreement. The complaint was determined to be unfounded.
Complaint Details
The complaint was unsubstantiated and unfounded after investigation.
Report Facts
Capacity: 376
Census: 205
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Reg Webster | Administrator | Met with Licensing Program Analyst during the complaint investigation |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melinda Hoffmann | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 203
Capacity: 376
Deficiencies: 1
Dec 20, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including a questionable death and staff mismanagement of residents' medication.
Findings
The allegation regarding a questionable death was found to be unsubstantiated due to lack of preponderance of evidence. The allegation of staff mismanaging residents' medication was substantiated, citing failure to consult a physician before releasing medication to a resident, posing an immediate health and safety risk. A plan of correction was implemented and cleared.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Darius Williams. The allegation of questionable death was unsubstantiated. The allegation of medication mismanagement was substantiated. Civil penalties are pending review.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff contacted a physician prior to releasing medication to Resident 1, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 376
Census: 203
Staff trained: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Reg Webster | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Serigy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 203
Capacity: 376
Deficiencies: 0
Dec 20, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations including resident neglect, improper medication administration, unmet resident needs, and insufficient staffing.
Findings
The investigation included interviews, record reviews, and observations. The allegations were found to be unsubstantiated due to lack of preponderance of evidence. Observations showed the resident had a call pendant, was assisted with feeding, and medication administration records confirmed medications were provided.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included neglect, medication errors, unmet needs, and staffing issues. Evidence did not prove violations occurred.
Report Facts
Capacity: 376
Census: 203
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Reg Webster | Administrator | Facility administrator met during the investigation |
| Serigy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Capacity: 376
Deficiencies: 0
Dec 7, 2021
Visit Reason
The visit was an unannounced case management health check conducted in response to a death report received from the facility on 12/6/2021.
Findings
The facility was observed to be clean, odor-free, and in good repair with staff wearing masks. Residents were engaged in activities and meals. Chemicals and medications were securely stored. No deficiencies were observed during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the unannounced visit and authored the report. |
| Reg Webster | Administrator | Met with Licensing Program Analyst during the visit. |
| Serigy Pidgirny | Licensing Program Manager | Named in the report header. |
Inspection Report
Census: 160
Capacity: 376
Deficiencies: 0
Sep 7, 2021
Visit Reason
An unannounced Health and Safety check visit was conducted as part of Case Management - Health Checks.
Findings
The facility was observed to be free of obstructions, insects, and odors. Staff were wearing masks and appropriate PPE was available. Residents were observed in dining and resting areas. No deficiencies were observed at this time.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the unannounced Health and Safety check visit. |
| Silvia Martinez | Health and Wellness Director | Met with Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 180
Capacity: 376
Deficiencies: 0
Jun 23, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that a resident was being financially abused while in care.
Findings
The investigation found that the complaint was unfounded. Interviews and verification with the resident, bank representatives, and investigators showed no suspicious activity and that the resident had authorized the transactions.
Complaint Details
The complaint alleged financial abuse of a resident. The investigation determined the allegation was false, could not have happened, and/or was without reasonable basis, resulting in dismissal of the complaint.
Report Facts
Capacity: 376
Census: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Reg Webster | Executive Director | Met with Licensing Program Analyst during the investigation |
| Serigy Pidgirny | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 180
Capacity: 376
Deficiencies: 0
Jun 23, 2021
Visit Reason
The inspection was an unannounced annual visit conducted to evaluate the facility's compliance with regulatory requirements.
Findings
No deficiencies were observed during the inspection. The facility demonstrated compliance with COVID-19 mitigation measures, including visitor screening, staff mask usage, and availability of personal protective equipment.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the unannounced annual visit and observed compliance with regulations. |
| Reg Webster | Executive Director | Met with Licensing Program Analyst during the inspection and participated in the facility tour. |
Inspection Report
Complaint Investigation
Census: 192
Capacity: 376
Deficiencies: 1
Mar 3, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not meeting supervision needs of residents and other related complaints.
Findings
The allegation that staff were not meeting supervision needs of residents was substantiated based on interviews and document review showing delayed response times to residents' pendant system. Other allegations regarding medication assistance, meal provision, staff qualifications, and resident retention were unsubstantiated.
Complaint Details
The complaint investigation was substantiated for the allegation that staff were not meeting supervision needs of residents due to delayed response times exceeding ten minutes. Other allegations were unsubstantiated. The investigation was conducted by Licensing Program Analyst Darius Williams with interviews of staff and residents and document review.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel were not sufficient in numbers and competent to provide services necessary to meet resident needs, evidenced by staff not responding to residents in a timely manner. | Type B |
Report Facts
Census: 192
Total Capacity: 376
Plan of Correction Due Date: Mar 12, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Reg Webster | Administrator | Facility administrator met with Licensing Program Analyst and was involved in the exit interview and plan of correction discussions |
Inspection Report
Census: 193
Capacity: 376
Deficiencies: 0
Dec 15, 2020
Visit Reason
The visit was a Case Management - Incident conducted as a health and safety check due to pre-cautionary Covid-19 measures.
Findings
No deficiencies were noted during the inspection. The Licensing Program Analyst observed two storage rooms stocked with appropriate Personal Protective Equipment.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the Case Management visit and observed PPE storage. |
| Reg Webster | Administrator | Met with Licensing Program Analyst during the Case Management visit. |
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