Inspection Report Summary
Most inspections found no deficiencies, with several complaint investigations determined to be unsubstantiated. The facility’s most recent report from June 13, 2025, cited one deficiency related to the southside elevator going in and out of service over several years, which posed a potential safety and personal rights risk; the facility has a work order in place and is actively addressing the issue. Previous substantiated deficiencies involved understaffing causing delayed resident assistance and failure to report staff inappropriate behavior in a timely manner, but no fines or enforcement actions were listed in the available reports. The facility showed improvement with no deficiencies cited in the April and March 2025 inspections following earlier issues. Overall, the main concerns have involved environment/safety and staffing, with no severe or immediate jeopardy findings reported.
Deficiencies per Year
4
3
2
1
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 71
Capacity: 110
Deficiencies: 1
Jun 13, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the licensee does not maintain the facility in good repair.
Findings
The investigation substantiated the allegation that the southside elevator has been sporadically going out of service over the past few years, posing a potential safety and personal rights risk to residents. The facility has a work order out for repairs and is actively implementing solutions.
Complaint Details
The complaint was substantiated based on observations, interviews, and record reviews. The allegation was that the licensee does not maintain the facility in good repair, specifically regarding the southside elevator outages.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility shall be in good repair at all times for the safety and well-being of residents. This requirement is not met as evidenced by the southside elevator going in and out of service over the last few years. | Type B |
Report Facts
Capacity: 110
Census: 71
Plan of Correction Due Date: Jul 11, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alona Gomez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Yvonne Flores-Larios | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Lola Bullock | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 110
Deficiencies: 0
Apr 18, 2025
Visit Reason
The visit was conducted as a case management follow-up related to an unrelated complaint investigation concerning a resident (R1) who left the facility unassisted and attempted to roll into traffic, posing a safety risk.
Findings
The Executive Director disclosed that R1 has a history of suicidal ideations and elopement, was transferred to the hospital on a 5150 hold, and requires 1 on 1 supervision for return to the facility. The resident's family decided to move R1 to a higher level of care. No deficiencies were cited during the visit.
Complaint Details
The complaint involved R1 leaving the facility unassisted and attempting to roll into traffic. The complaint was substantiated with documentation of R1's history of depression, suicide, and elopement. The facility notified police and transferred R1 to the hospital on a 5150 hold.
Report Facts
Capacity: 110
Census: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lola Bullock | Executive Director | Met with Licensing Program Analyst and disclosed details about resident R1's incident |
| Alona Gomez | Licensing Program Analyst | Conducted the case management visit |
| Niare Dawn Feaster | Administrator/Director | Named as facility administrator/director |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 110
Deficiencies: 0
Apr 18, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations including improper eviction, unmet resident needs, staff leaving resident in soiled diaper, failure to provide charged services, short staffing, improper meals, resident isolation, and misuse of resident room.
Findings
After interviews, record reviews, and observations, the allegations were found to be unsubstantiated. There was no evidence of lapses in care, improper eviction, or misuse of resident space. The resident's care plan did not include diapering services, and meal concerns were related to resident's occasional forgetting to request meals. Staffing levels were adequate during visits.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included improper eviction, unmet resident needs, staff leaving resident in soiled diaper, failure to provide charged services, short staffing, improper meals, resident isolation, and misuse of resident room. Evidence did not support these claims.
Report Facts
Facility capacity: 110
Census: 73
Base monthly rate: 7413
Total amount billed: 46630.62
Notice to quit date: Feb 2, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Niare Dawn Feaster | Administrator | Administrator at time of investigation and interviewed regarding allegations |
| Lola Bullock | Executive Director | Met with Licensing Program Analyst during investigation |
| Alona Gomez | Licensing Program Analyst | Conducted complaint investigation visit and interviews |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 110
Deficiencies: 0
Mar 27, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that facility staff did not notify the responsible party of a change in condition and that facility staff served poor quality food.
Findings
The investigation included interviews, observations, and record reviews. The allegations were found to be unsubstantiated as there was no preponderance of evidence to prove the alleged violations occurred. Food quality was generally described as good or acceptable by staff and residents, and no change in resident condition was observed.
Complaint Details
The complaint involved allegations that facility staff failed to notify the responsible party of a resident's change in condition and served poor quality food. After interviews with staff and residents, observations of food service, and record review, the allegations were determined to be unsubstantiated.
Report Facts
Capacity: 110
Census: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alona Gomez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lola Bullock | Executive Director | Met with Licensing Program Analyst during investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Annual Inspection
Census: 78
Capacity: 110
Deficiencies: 0
Mar 20, 2025
Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The Licensing Program Analyst toured the facility and reviewed resident and staff records, medication storage, and safety measures. No deficiencies were cited during the visit.
Report Facts
Hot water temperature readings: Measured at 104.8, 112.6, 109.2, 108.4 degrees Fahrenheit in residents' shared bathrooms
Refrigerator temperature: 38
Freezer temperature: 0
Fire clearance capacity: 82
Fire clearance capacity: 28
Staff first aid training: 5
Residents records reviewed: 5
Staff records reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Niare Dawn Feaster | Executive Director | Met with Licensing Program Analyst during inspection and toured facility |
| Alona Gomez | Licensing Program Analyst | Conducted the inspection visit |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 110
Deficiencies: 0
Feb 7, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation of illegal eviction received on 2024-08-07.
Findings
The investigation found that the resident (R1) was not allowed to return to the facility due to a stage 3 wound, consistent with facility policy and Title 22 regulations. No official eviction letter was issued and relatives removed the resident's belongings. The allegation of illegal eviction was unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged illegal eviction. The investigation was unsubstantiated as there was no evidence that an illegal eviction occurred.
Report Facts
Capacity: 110
Census: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Niare Feaster | Executive Director | Met during investigation and provided statements regarding resident's wound and return to facility |
| Alona Gomez | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 110
Deficiencies: 1
Feb 7, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-08-14 regarding the facility not responding to residents' needs in a timely manner and other allegations including illegal eviction and failure to provide transportation assistance.
Findings
The allegation that the facility was not responding to residents' needs in a timely manner was substantiated due to understaffing leading to longer response times. The allegations of illegal eviction and failure to provide or assist in transportation were found to be unsubstantiated based on interviews and documentation review.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility did not respond to residents' needs in a timely manner due to understaffing. The allegations of illegal eviction and failure to provide or assist in transportation were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary of adequate services. This requirement is not met as evidenced by the facility not providing adequate services to residents requesting assistance which posed a potential personal rights violation. | Type B |
Report Facts
Capacity: 110
Census: 80
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Niare Feaster | Executive Director | Met with Licensing Program Analyst during investigation and acknowledged staffing issues |
| Alona Gomez | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 110
Deficiencies: 0
Aug 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations received on 2024-03-13 regarding staff making residents move rooms, threatening residents with eviction, and not meeting residents' needs.
Findings
The investigation included interviews with residents and staff and review of files. The allegations were found to be unsubstantiated due to lack of preponderance of evidence proving the violations occurred.
Complaint Details
The complaint involved allegations that staff made residents move rooms, threatened residents with eviction, and failed to meet residents' needs. Interviews revealed residents moved voluntarily, eviction threats were not substantiated, and residents' needs were generally met except for one resident's personal caregiver issue. The allegations were unsubstantiated.
Report Facts
Capacity: 110
Census: 78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Niare Dawn Feaster | Executive Director | Met with Licensing Program Analyst during investigation and involved in interview regarding eviction allegation |
| Alona Gomez | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 75
Capacity: 110
Deficiencies: 0
Aug 9, 2024
Visit Reason
The visit was an unannounced case management inspection conducted due to receiving an Unusual Incident Report (UIR) regarding a resident's attempted suicide.
Findings
The Licensing Program Analyst found no deficiencies during the visit. The resident involved was on a 5150 hold and had self-inflicted cuts. The facility was found to be within regulation standards.
Report Facts
Cuts on resident: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Niare Dawn Feaster | Executive Director | Met with Licensing Program Analyst and involved in incident management |
| Alona Gomez | Licensing Program Analyst | Conducted the inspection visit |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Capacity: 110
Deficiencies: 0
Jun 6, 2024
Visit Reason
The visit was conducted as a case management visit due to receiving an Unusual Incident Report (UIR) regarding a resident who committed suicide.
Findings
During the visit, the Licensing Program Analyst interviewed staff, reviewed the resident's file, and toured the resident's room. No deficiencies were cited during the visit.
Complaint Details
The investigation was triggered by an Unusual Incident Report of a resident found deceased from an apparent suicide. The resident was independent and had no documented suicidal ideations prior to the incident.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Clark | Licensing Program Analyst | Conducted the case management visit and investigation. |
| Jennifer Gordon-Alvarez | Health and Wellness Director | Met with the Licensing Program Analyst during the visit and provided information. |
| Niare Dawn Feaster | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 110
Deficiencies: 1
Apr 25, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to a complaint received on 07/31/2023 regarding staff not following proper reporting requirements and other allegations.
Findings
The investigation substantiated that the facility failed to report a resident's concerns regarding staff inappropriate behavior within the required timeframe, posing a potential risk to resident safety. Other allegations including improper mobility and bathing assistance, infrequent bedding changes, inappropriate staff interactions, and lack of a proper emergency disaster plan were investigated with some found unsubstantiated.
Complaint Details
The complaint investigation was substantiated for failure to follow proper reporting requirements. Other allegations related to mobility assistance, bathing assistance, bedding changes, inappropriate staff interactions, and emergency disaster plan were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to report resident's concerns regarding staff inappropriate behavior to the licensing agency within 7 days of occurrence, posing a potential risk to resident health and safety. | Type B |
Report Facts
Capacity: 110
Census: 72
Plan of Correction Due Date: Apr 30, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luisa Fontanilla | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Jennifer Gordon-Alvarez | Facility representative met during the investigation and exit interview | |
| Akindele A Omole | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Capacity: 110
Deficiencies: 1
Feb 23, 2024
Visit Reason
The visit was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing regulations.
Findings
The inspection found incomplete resident files missing emergency ID, emergency medical consent, and personal rights documents for residents R1 and R3. Updated copies of several administrative and emergency documents were requested for submission by 03/01/2024.
Deficiencies (1)
| Description |
|---|
| Resident files were incomplete, missing emergency ID, emergency medical consent, and personal rights for residents R1 and R3. |
Report Facts
Capacity: 110
Fire clearance capacity: 110
POC due date: Mar 1, 2024
Resident records reviewed: 5
Staff records reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Niare Dawn Feaster | Executive Director | Met with Licensing Program Analyst during inspection and agreed to plan of correction |
| Alona Gomez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Yvonne Flores-Larios | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 110
Deficiencies: 1
Aug 2, 2023
Visit Reason
The inspection was conducted as a 10-day investigation related to complaint #15-AS-20230731144026 regarding failure to notify the Community Care Licensing (CCL) about a change in the facility's Administrator.
Findings
A Type B deficiency was cited for failure to notify the Department in writing within 30 days of hiring a new administrator, as required by Title 22 California Code of Regulations. The Executive Director had been working since 01/15/2022 but did not notify CCL, posing a potential risk to client health and safety.
Complaint Details
The visit was triggered by complaint #15-AS-20230731144026. The deficiency was substantiated as the facility failed to notify CCL about the change in Administrator.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify the Department in writing within 30 days of hiring a new administrator, including required documentation. | Type B |
Report Facts
Deficiency count: 1
Plan of Correction Due Date: Aug 3, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Akindele A Omole | Administrator | Facility Administrator who failed to notify CCL of change |
| Niare Feaster | Executive Director | Met during inspection and involved in exit interview |
| Yvonne Flores-Larios | Licensing Program Manager / Supervisor | Named as Licensing Program Manager and Supervisor overseeing the inspection |
| Luisa Fontanilla | Licensing Program Analyst / Evaluator | Conducted the inspection and signed the report |
Inspection Report
Routine
Census: 45
Capacity: 110
Deficiencies: 0
Aug 10, 2022
Visit Reason
Unannounced Infection Control Inspection conducted as a required 1-year visit.
Findings
The facility was toured including multiple areas and infection control measures were observed such as screening stations, hand washing stations, and PPE supplies. Staff records showed compliance with TB testing. No deficiencies were cited during the visit.
Report Facts
Staff records reviewed: 5
Staff with TB test on file: 5
Food supply duration: 2
Food supply duration: 7
PPE supply duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Akindele Omole | Executive Director | Met with Licensing Program Analysts during inspection and involved in facility tour |
| Carolyn Appeal | Wellness Director | Participated in facility tour and exit interview |
| Lizette Francisco | Licensing Program Analyst | Conducted inspection |
| Harpreet Humpal | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 110
Deficiencies: 1
Oct 7, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations including staff not intervening in a verbal altercation between residents and failure to assess a resident prior to admission.
Findings
The investigation substantiated that staff member S6 did not intervene during a verbal altercation between two residents, posing a potential health and safety concern. Another allegation regarding failure to assess a resident prior to admission was found to be unfounded.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not intervene in a verbal altercation between residents. The allegation that the facility did not assess a resident prior to admission was found to be unfounded.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents were not accorded safe, healthful and comfortable accommodations, furnishings and equipment as staff did not intervene during a verbal altercation between two residents. | Type B |
Report Facts
Capacity: 110
Census: 43
Deficiencies cited: 1
Plan of Correction Due Date: Oct 22, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Akindele Omole | Executive Director | Met with Licensing Program Analysts during complaint investigation |
| Lizette Francisco | Licensing Program Analyst | Conducted complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 110
Deficiencies: 0
Oct 7, 2021
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2021-03-12 regarding allegations that a resident left the facility unsupervised and that a resident was not accorded dignity in their relationship with staff.
Findings
The investigation included interviews with staff and residents and review of documents. There was no preponderance of evidence to substantiate the allegations; staff and residents denied the incidents, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint involved allegations that a resident left the facility unsupervised and that a resident was not accorded dignity in their relationship with staff. After investigation, including interviews with 7 staff and 5 residents, the allegations were found to be unsubstantiated due to lack of evidence.
Report Facts
Complaint Control Number: 15-AS-20210312105400
Number of staff interviewed: 7
Number of residents interviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Akindele Omole | Executive Director | Met with during investigation and mentioned in findings |
| Lizette Francisco | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 110
Deficiencies: 0
Oct 7, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 2021-01-27 regarding residents' rooms not being cleaned properly and staff making inappropriate comments towards residents.
Findings
The investigation found that residents' rooms were not being cleaned properly based on information obtained, but all interviewed residents expressed satisfaction with housekeeping. Allegations of staff making inappropriate comments were not substantiated as residents denied witnessing such behavior.
Complaint Details
The complaint investigation was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.
Report Facts
Number of residents interviewed: 5
Number of staff interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Akindele Omole | Executive Director | Met with Licensing Program Analysts during the investigation |
| Lizette Francisco | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
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