Inspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on April 23, 2025, which was clean with no issues noted. Earlier reports showed some deficiencies primarily related to incomplete resident records, delayed provision of records to authorized representatives, and staff lacking updated CPR and health screenings. A substantiated complaint in October 2023 involved a resident injury caused by staff neglect related to an accessible electric fireplace, while other complaint investigations were mostly unsubstantiated or involved minor issues such as missing personal property and medication concerns. Enforcement actions included termination of a staff member after a medication incident and reimbursement for lost resident items, but no fines or license actions were listed. The facility’s record shows improvement over time, with recent inspections consistently free of deficiencies.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 21
Capacity: 40
Deficiencies: 0
Apr 23, 2025
Visit Reason
An unannounced annual inspection was conducted to ensure compliance with Title 22 regulations at the care facility.
Findings
The inspection found the facility to be in compliance with all applicable regulations, with no deficiencies cited. Resident rooms, bathrooms, common areas, kitchen, and medication storage were all found to be properly maintained and sanitary.
Report Facts
Perishable food supply: 2
Non-perishable food supply: 7
Resident files reviewed: 5
Staff files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abigail Vue | Executive Director | Met with Licensing Program Analyst during inspection |
| Cassandra Mikkelson | Licensing Program Analyst | Conducted the annual inspection |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 18
Capacity: 40
Deficiencies: 0
Mar 11, 2025
Visit Reason
The visit was conducted as a case management incident investigation to review two incident reports sent to the Community Care Licensing Division (CCLD).
Findings
Licensing Program Analysts conducted interviews, toured the facility, and reviewed pertinent documents related to the incidents. No deficiencies were cited at this time, and further follow-up may occur if needed.
Complaint Details
The visit was triggered by two incident reports. No deficiencies were cited, and the Licensing Program Analysts will return if further follow-up is needed.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abigail Vue | Executive Director | Met with Licensing Program Analysts during the investigation. |
| Cassandra Mikkelson | Licensing Program Analyst | Conducted interviews and participated in the investigation. |
| Cheyenne Ratajczak | Licensing Program Analyst | Conducted interviews and participated in the investigation. |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 15
Capacity: 40
Deficiencies: 0
Aug 8, 2024
Visit Reason
The inspection visit was an unannounced case management visit to discuss recent COVID cases, review an incident report, and clear out the plan of correction from the annual inspection.
Findings
All COVID cases have been cleared and all residents are doing well. The incident report was discussed, and the administrator reported that the resident with a wound is receiving home health services. The plan of correction was reviewed and cleared with no deficiencies cited during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abigail Vue | Administrator | Met with Licensing Program Analyst during inspection and provided information on COVID cases and incident report. |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the unannounced case management visit and reviewed plan of correction. |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 12
Capacity: 40
Deficiencies: 3
Apr 18, 2024
Visit Reason
The inspection was an unannounced annual inspection conducted to ensure the health and safety of residents at the facility.
Findings
The inspection found no immediate health, safety, or personal rights violations in the areas toured. However, deficiencies were cited related to incomplete resident records, lack of updated CPR and first aid certificates for care staff, and missing health screenings for personnel.
Deficiencies (3)
| Description |
|---|
| Personnel did not have required health screenings as per CCR 87411(f). |
| Facility staff lacked updated CPR and first aid certificates as required by HSC 1569.618(c)(3). |
| Resident records were incomplete and not current as required by CCR 87506(a). |
Report Facts
Residents receiving hospice care: 2
Personnel non-compliance count: 2
Personnel non-compliance count: 5
Resident record non-compliance count: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abigail Vue | Administrator | Met with Licensing Program Analyst during inspection |
| Janelle Monique Douglas | Administrator/Director | Named as facility administrator/director |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the inspection and authored the report |
| Troy Ordonez | Licensing Program Manager/Supervisor | Supervisor of the inspection |
Inspection Report
Complaint Investigation
Census: 11
Capacity: 40
Deficiencies: 0
Nov 29, 2023
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report regarding missing medications during destruction of discontinued medications.
Findings
No deficiencies were cited during the inspection. The facility reported missing hydrocodone medications belonging to a past resident, conducted an internal investigation which was inconclusive, terminated the responsible staff member, and reported the incident to local police. The administrator agreed to submit any new medication destruction procedures to the licensing agency for review.
Complaint Details
The complaint involved missing medications (2 packs of hydrocodone) discovered during medication destruction. The investigation was inconclusive, the responsible staff member was terminated, and the incident was reported to the police.
Report Facts
Missing medications: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janelle Monique Douglas | Administrator | Met with Licensing Program Analyst during inspection and discussed incident |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the unannounced case management visit |
| Troy Ordonez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 14
Capacity: 40
Deficiencies: 2
Oct 3, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-02-10 alleging resident injury due to staff neglect and hazardous items accessible to residents.
Findings
The complaint was substantiated for two allegations: a resident sustained a burn injury due to staff neglect related to an accessible electric fireplace, and staff left a hazardous item accessible to residents. Several other allegations regarding wound care, laundry, feeding, hygiene, and cleanliness were investigated and found unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations that a resident sustained an injury due to staff neglect and that staff left a hazardous item accessible to residents. The resident (R1) sustained second and third degree burns from an electric fireplace accessible in the common area. Other allegations regarding wound care, laundry, feeding, hygiene, and facility cleanliness were unsubstantiated.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Electric fireplace located in common area was accessible to residents in care causing injury, violating care requirements for persons with dementia. | Type A |
| Facility did not ensure electric fireplace was inaccessible to residents, violating personal rights of residents to safe, healthful, and comfortable accommodations. | Type A |
Report Facts
Civil penalty amount: 500
Capacity: 40
Census: 14
Plan of Correction Due Date: Oct 4, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Janella Douglas | Executive Director | Met with Licensing Program Analyst during inspection. |
| Morgan Greenwood Whinery | Executive Director | Met with Licensing Program Analyst during complaint investigation. |
Inspection Report
Annual Inspection
Census: 14
Capacity: 40
Deficiencies: 0
May 24, 2023
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted to ensure health and safety compliance at the facility.
Findings
The inspection found no deficiencies. The facility was observed to be clean, sanitary, and in good repair with proper food supplies, operable safety equipment, and locked medications. Resident files and staff records were reviewed and found compliant.
Report Facts
Resident files reviewed: 5
Staff records reviewed: 3
Hot water temperature: 118
Fire extinguisher last serviced: Apr 12, 2023
Fire drill last conducted: Apr 17, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerilyn Purol | Acting Executive Director | Met with Licensing Program Analyst during inspection |
| Sarena Keosavang | Licensing Program Analyst | Conducted the inspection |
| Anthony Perez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 40
Deficiencies: 1
Feb 22, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff did not provide all of a resident's records to the resident's authorized representative.
Findings
The investigation found the allegation substantiated. Records requested on 01/18/2023 were provided on 01/23/2023 but exceeded the required two business days for providing photocopies, violating Health and Safety Code 1569.269(a)(21).
Complaint Details
The complaint was substantiated based on evidence that the facility did not provide requested resident records within the required timeframe, violating residents' rights to prompt access and photocopies of their records.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide resident records within two business days as required by Health and Safety Code 1569.269(a)(21). | Type B |
Report Facts
Capacity: 40
Census: 24
Plan of Correction Due Date: Feb 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Executive Director | Interviewed during complaint investigation and exit interview |
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Perez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 17
Capacity: 40
Deficiencies: 1
Oct 4, 2022
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility did not answer communications promptly and appropriately to the resident's representatives.
Findings
The investigation found that the facility delayed providing requested resident records to the resident's responsible party by about a month, which was substantiated as a violation of residents' rights to prompt access to their records.
Complaint Details
The complaint was substantiated. The allegation was that the facility did not respond promptly to communications from the resident's representatives. The Executive Director left the facility without notice and did not complete or provide the authorization for release of records to the resident's responsible party in a timely manner.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide prompt access to resident records and photocopies within two business days as required, resulting in a delay of about one month. | Type B |
Report Facts
Capacity: 40
Census: 17
Plan of Correction Due Date: Oct 7, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chantal Salinas | Executive Director | Named in complaint findings related to failure to provide requested documents and leaving the facility without notice |
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
| Robyn Moore | Regional Nurse | Interviewed during investigation and involved in communication about records |
Inspection Report
Complaint Investigation
Census: 18
Capacity: 40
Deficiencies: 1
Sep 22, 2022
Visit Reason
An unannounced complaint investigation was conducted following a complaint that the facility did not answer communications promptly and appropriately to the resident's representatives.
Findings
The investigation found that the facility failed to provide resident R1's records to the responsible party in a timely manner, with records provided about a month late, constituting a violation of residents' rights. The allegation was substantiated.
Complaint Details
The complaint was substantiated. The allegation was that the facility did not answer communications promptly and appropriately to the resident's representatives. The responsible party's request for resident records was delayed due to a misplaced authorization form, resulting in records being provided about a month late.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide prompt access to resident records and photocopies within two business days as required, with records provided about a month late. | Type B |
Report Facts
Capacity: 40
Census: 18
Plan of Correction Due Date: Sep 29, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chantal Salinas | Executive Director | Met with Licensing Program Analyst during investigation and provided resident records |
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 17
Capacity: 40
Deficiencies: 0
May 12, 2022
Visit Reason
The visit was conducted as a follow-up on an unusual incident/injury report regarding allegations of physical and sexual abuse made by a memory care resident.
Findings
The facility conducted an internal investigation, notified appropriate parties, and no immediate health, safety, or personal rights violations were observed during the tour. No deficiencies were cited at this time.
Complaint Details
The complaint involved allegations of physical abuse by the resident's husband and a statement of sexual assault. The facility notified the resident's POA, Primary Care Physician, Ombudsman, and Police Department. Skin checks showed no bruises or new skin alterations. The facility is retraining staff on mandated reporting and updating the care plan to prevent male staff from personally caring for the resident.
Report Facts
Capacity: 40
Census: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juan Ramirez | Resident Care Coordinator | Met with Licensing Program Analyst during the visit |
| Robyn Moore | Regional Nurse | Interviewed regarding the incident report and toured the facility |
| Sarena Keosavang | Licensing Program Analyst | Conducted the inspection visit |
| Anthony Perez | Licensing Program Manager | Named in the report header |
Inspection Report
Annual Inspection
Census: 17
Capacity: 40
Deficiencies: 0
Apr 7, 2022
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure compliance with health and safety regulations.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Report Facts
Capacity: 40
Census: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juan Ramirez | Resident Care Coordinator | Met with Licensing Program Analyst during inspection |
| Sarena Keosavang | Licensing Program Analyst | Conducted the inspection |
| Robyn Moore | Regional Nurse | Participated in infection control domain evaluation |
| Anthony Perez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 20
Capacity: 40
Deficiencies: 1
Nov 16, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that the facility did not safeguard a resident's personal property and did not reimburse the resident for lost property, and concerns about inadequate record keeping.
Findings
The complaint regarding missing personal property was substantiated, with the facility reimbursing the resident $54.80 for lost items. The allegation of inadequate record keeping was found to be unsubstantiated after review of records and interviews. The facility agreed to review relevant regulations and submit documentation.
Complaint Details
The complaint was substantiated regarding the facility's failure to safeguard a resident's personal property and failure to reimburse for lost items. The allegation about inadequate record keeping was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to safeguard resident's cash, personal property, and valuables as evidenced by missing hearing aid, fitted sheets, and clothing posing a potential health and safety risk. | Type B |
Report Facts
Reimbursement amount: 54.8
Facility capacity: 40
Resident census: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation |
| Sherrie Kuar | Executive Director | Met with Licensing Program Analyst during investigation and involved in findings |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 17
Capacity: 40
Deficiencies: 0
Jun 3, 2021
Visit Reason
The inspection was a required unannounced 1-Year Inspection focusing on the infection control domain, conducted to ensure health and safety compliance at the facility.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sherrie Kuar | Executive Director | Mentioned as the Executive Director who was in a meeting during the inspection. |
| Kenneth Chewey | Maintenance Supervisor | Met with Licensing Program Analyst during the inspection and assisted with the facility tour. |
| Jacob Williams | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 21
Capacity: 40
Deficiencies: 0
May 13, 2021
Visit Reason
Unannounced complaint investigation visit conducted in response to a complaint received on 08/17/2020 alleging sexual abuse, physical abuse, failure to notify resident's authorized representative, improper treatment for lice, and unsafe room conditions.
Findings
All allegations were investigated and found to be unsubstantiated due to conflicting information and lack of preponderance of evidence. The facility followed appropriate procedures for lice treatment and safety measures were observed during the visit.
Complaint Details
The complaint included allegations of sexual abuse, physical abuse, failure to notify the resident's authorized representative, improper treatment for lice, and unsafe room conditions. All allegations were found to be unsubstantiated after investigation, including interviews with staff, review of medical and incident reports, and facility observations.
Report Facts
Facility capacity: 40
Resident census: 21
Number of facility staff interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sherrie Kuar | Executive Director | Named in relation to notification and investigation of allegations |
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 21
Capacity: 40
Deficiencies: 0
Mar 25, 2021
Visit Reason
The visit was an unannounced Case Management - Incident conducted via telephone to follow up on an Unusual Incident Report submitted regarding an incident on 03/16/2021 involving inappropriate touching between two memory care residents.
Findings
The Licensing Program Analyst interviewed the Executive Director who reported that law enforcement was called, a police report was made, and no injuries were noted after a skin check. The residents' physicians were informed and new medication orders were provided. No deficiencies were cited at this time.
Complaint Details
The complaint involved a memory care resident reporting another resident entering their room and touching them inappropriately. The incident was substantiated by law enforcement involvement and follow-up actions including notification of responsible parties and physician updates.
Report Facts
Capacity: 40
Census: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sherrie Kuar | Executive Director | Interviewed regarding the incident report |
| Sarena Keosavang | Licensing Program Analyst | Conducted the telephone case management incident visit |
| Anthony Perez | Licensing Program Manager | Named in report header |
Inspection Report
Census: 21
Capacity: 40
Deficiencies: 0
Oct 30, 2020
Visit Reason
The visit was an unannounced Case Management telephone visit conducted to follow up on an Unusual Incident/Injury Report regarding a resident who had shortness of breath and was unresponsive, requiring transfer to the emergency room.
Findings
The Licensing Program Analyst interviewed the administrator and found that the resident was in the process of hospice initiation with declining health. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sherrie Kuar | Administrator | Interviewed regarding the unusual incident report and resident's health status. |
| Sarena Keosavang | Licensing Program Analyst | Conducted the unannounced Case Management visit and interview. |
Loading inspection reports...
