Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance. The most recent report from September 16, 2025, was clean with no deficiencies cited after investigating allegations about fee notices, assistance timeliness, and staffing. Past issues included isolated deficiencies related to resident safety, staffing shortages, emergency preparedness, and documentation, with some substantiated complaints about unlawful eviction and medication errors. The facility showed improvement over time, with recent annual inspections free of deficiencies and corrective actions taken for prior concerns. Minor or isolated issues remain, but no fines, license suspensions, or severe enforcement actions were listed in the available reports.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
62% occupied
Based on a September 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 112
Capacity: 180
Deficiencies: 0
Date: Sep 16, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-06-26 regarding failure to provide written notice prior to fee increases, untimely assistance to residents, and lack of contracted services due to staffing issues.
Complaint Details
The complaint was unsubstantiated. Allegations included failure to provide written notice prior to fee increases, failure to provide timely assistance, and failure to provide contracted services due to staffing shortages. Evidence did not support these claims.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews and record reviews showed that the resident frequently declined assistance but was capable of contacting emergency services, and the facility maintained sufficient staffing levels. No deficiencies were cited.
Report Facts
Capacity: 180
Census: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Priya Lal | Facility Designated Administrator | Met with Licensing Program Analyst during the complaint investigation |
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Rios | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 180
Deficiencies: 0
Date: Aug 7, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 2025-05-16 regarding facility cleanliness, medication management, incident reporting, pendant system functionality, timeliness of medical attention, and infection control practices.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included facility cleanliness, medication mismanagement, failure to report incidents, nonoperable pendant system, delayed medical attention, and infection control violations. All allegations were found to lack sufficient evidence to prove violations.
Findings
The investigation found no preponderance of evidence to substantiate any of the allegations. The facility was observed to be clean and sanitary, medication management was appropriate, incidents were reported as required, medical attention was timely, and infection control practices were followed. No deficiencies were cited.
Report Facts
Facility capacity: 180
Census: 113
Complaint control number: 27-AS-20250516094349
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Priya Lal | Facility Designated Administrator | Met with Licensing Program Analyst during investigation |
| Lisa Rios | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 180
Deficiencies: 1
Date: Aug 7, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted due to allegations that staff unlawfully evicted a resident.
Complaint Details
The complaint was substantiated based on observations, record reviews, and interviews, confirming that staff unlawfully evicted a resident by not providing the eviction notice to the department within the required timeframe.
Findings
The investigation substantiated that the facility staff unlawfully evicted a resident by failing to provide the eviction notice to the department within five days as required, posing potential health, safety, and personal rights risks to persons in care.
Deficiencies (1)
A written report of any eviction was not sent to the licensing agency within five days as required, and the licensee did not ensure they served a lawful eviction to the resident in care.
Report Facts
Capacity: 180
Census: 113
Deficiency due date: Aug 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Priya Lal | Facility Designated Administrator | Met during the investigation and involved in interview regarding eviction allegation |
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 109
Capacity: 180
Deficiencies: 0
Date: Jul 14, 2025
Visit Reason
The visit was an unannounced annual continuation inspection conducted to continue the annual visit from 04/29/2025 and to assess ongoing compliance with licensing requirements.
Findings
A comprehensive tour of the facility was conducted including resident rooms, common areas, kitchen, laundry, memory care unit, and exterior grounds. All safety measures, food storage, and resident accommodations were found to be adequate and in compliance. No deficiencies were observed or cited during this annual visit.
Report Facts
Licensed capacity: 180
Current census: 109
Hospice residents: 12
Fire extinguisher inspection date: Jul 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Priya Lal | Facility Designated Administrator | Met with Licensing Program Analyst during the inspection and participated in interviews |
| Arielle Pascua | Licensing Program Analyst | Conducted the inspection visit |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 112
Capacity: 180
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
The visit was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate the facility's compliance with licensing requirements.
Findings
No deficiencies were observed or cited during this annual visit. The Licensing Program Analyst reviewed facility records including resident and staff files, all of which were complete and up to date. Due to insufficient time, the inspection will be completed at a later date.
Report Facts
Licensed capacity: 180
Current census: 112
Non-ambulatory residents allowed: 137
Ambulatory residents allowed: 31
Bedridden residents allowed: 12
Hospice waiver: 15
Resident files reviewed: 3
Staff files reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arielle Pascua | Licensing Program Analyst | Conducted the annual inspection visit |
| Christina Goforth | Facility Designated Representative | Met with Licensing Program Analyst during inspection |
| Priya Lal | Administrator/Director | Named as facility administrator/director |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 114
Capacity: 180
Deficiencies: 0
Date: Oct 28, 2024
Visit Reason
The visit was an unannounced case management follow-up to review two Special Incident Reports received on 09/16/2024 and 10/24/2024 involving medication error and resident elopement incidents.
Findings
The inspection found that a medication technician administered a higher dose than prescribed to a resident and that a resident with dementia eloped from the memory care area but was safely redirected back. The facility had taken corrective actions including training and notification of family and hospice.
Report Facts
Incident dates: 2
Resident census: 114
Facility capacity: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arielle Pascua | Licensing Program Analyst | Conducted the case management visit and inspection |
| Christina Goforth | Facility Designated Representative | Met with Licensing Program Analyst during the visit |
| Lisa Rios | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 108
Capacity: 180
Deficiencies: 1
Date: Jul 22, 2024
Visit Reason
The visit was an unannounced case management follow-up on an incident report received on 07/15/2024 regarding a missing resident (elopement) from the facility.
Findings
The facility failed to follow its missing resident policy and did not conduct proper observation checks or a thorough search after a resident was found missing for nearly an hour. Staff did not conduct an initial head count or a full search of the memory care area, posing immediate health and safety risks.
Deficiencies (1)
Based on interviews and record review, the facility did not follow the missing persons policy and did not provide observation checks to prevent elopements. Resident R1 was able to leave the facility through the back door from 7:00pm to 8:55pm. Staff was notified but did not conduct a thorough check or head count, posing immediate health, safety, and personal rights risks.
Report Facts
Deficiency due date: Jul 23, 2024
Census: 108
Total Capacity: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arielle Pascua | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lisa Rios | Licensing Program Manager | Supervisor overseeing the inspection |
| Priya Lal | Facility Administrator | Facility Administrator involved in interviews and referenced in the report |
| Christina Goforth | Facility Designated Representative | Met with Licensing Program Analyst during the visit |
Inspection Report
Annual Inspection
Census: 109
Capacity: 180
Deficiencies: 1
Date: Jul 11, 2024
Visit Reason
The visit was an unannounced annual continuation inspection conducted to continue the annual visit started on 04/25/2024 and 05/09/2024, to assess compliance with licensing requirements.
Findings
The inspection found that 6 out of 14 resident files did not have a pre-appraisal assessment on file, which is required prior to admission. The facility was using a personal service assessment form that did not capture key assessment areas such as medication, service needs, ambulatory status, TB test, and social factors. A technical violation was cited under sections 87705(c)(5) and 87457(c).
Deficiencies (1)
6 out of 14 resident files reviewed did not have a Pre-Admission appraisal conducted in comparison with the admission criteria specified in Section 87455, posing potential health, safety, and personal rights risks to persons in care.
Report Facts
Resident files reviewed: 14
Resident files lacking pre-appraisal: 6
Census: 109
Total capacity: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Priya Lal | Facility Designated Administrator | Met with Licensing Program Analyst during inspection and interviewed |
| Arielle Pascua | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lisa Rios | Licensing Program Manager | Supervisor of the Licensing Program Analyst |
Inspection Report
Annual Inspection
Census: 102
Capacity: 180
Deficiencies: 0
Date: May 9, 2024
Visit Reason
The visit was an unannounced annual continuation inspection conducted to continue the annual visit from 04/25/2024.
Findings
During the visit, the Licensing Program Analyst toured the facility, reviewed 5 resident files, and found no deficiencies or citations.
Report Facts
Resident files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Priya Lal | Facility Designated Administrator | Met with Licensing Program Analyst during the inspection |
| Arielle Pascua | Licensing Program Analyst | Conducted the inspection visit |
| Lisa Rios | Licensing Program Manager | Named in the report header |
Inspection Report
Annual Inspection
Census: 106
Capacity: 180
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
The visit was an unannounced annual inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The inspection found no deficiencies or violations during the visit. The facility was observed to be in compliance with safety, medication management, and resident care standards, although a technical violation was noted for 8755(b)(26).
Report Facts
Residents on hospice: 11
Hospice waiver capacity: 15
Fire extinguisher inspection date: Jul 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Priya Lal | Facility Designated Administrator | Met with Licensing Program Analyst during the inspection and participated in interviews. |
| Arielle Pascua | Licensing Program Analyst | Conducted the inspection visit. |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 100
Capacity: 180
Deficiencies: 0
Date: Jan 25, 2024
Visit Reason
The visit was an unannounced case management follow-up to review multiple incident reports received by the department via fax on various dates between 12/20/2022 and 1/09/2024.
Findings
Based on interviews and records reviewed during the visit, no deficiencies were found.
Report Facts
Incident report dates: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Priya Lal | Facility Designated Administrator | Met with Licensing Program Analyst during the visit and interviewed |
| Arielle Pascua | Licensing Program Analyst | Conducted the case management visit and interviews |
| Lisa Rios | Licensing Program Manager | Named in report header |
Inspection Report
Plan of Correction
Census: 115
Capacity: 180
Deficiencies: 0
Date: Dec 4, 2023
Visit Reason
The visit was conducted as an unannounced Plan of Correction (POC) follow-up to verify that prior deficiencies and plan of corrections due on 11/17/2023 from a complaint visit on 11/09/2023 had been met.
Findings
The Plan of Correction was reviewed and found to be met and cleared. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Priya Lal | Facility Designated Administrator | Met with Licensing Program Analyst during the Plan of Correction visit. |
| Arielle Pascua | Licensing Program Analyst | Conducted the Plan of Correction visit. |
| Lisa Rios | Licensing Program Manager | Named in the report header. |
Inspection Report
Follow-Up
Census: 115
Capacity: 180
Deficiencies: 0
Date: Dec 4, 2023
Visit Reason
The visit was conducted as a follow-up on two incident reports received by the department on 11/02/2023 and 11/22/2023.
Findings
The facility conducted internal investigations on both incidents; one involving missing resident cash and the other involving delayed staff response to a resident's call for help. Additional staff training and corrective actions were implemented. No deficiencies were cited during this visit.
Report Facts
Incident report dates: Incident reports received on 11/02/2023 and 11/22/2023
Resident cash amount missing: 95
Staff response delay: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Priya Lal | Facility Designated Administrator | Met with Licensing Program Analyst during visit and involved in incident investigations |
| Arielle Pascua | Licensing Program Analyst | Conducted the case management visit and reviewed incident reports |
| Lisa Rios | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 180
Deficiencies: 1
Date: Nov 9, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted due to allegations that the facility did not follow its emergency plan during power outages, did not ensure residents' oxygen was operable, and had multiple power outages.
Complaint Details
The complaint investigation included three allegations: failure to follow emergency plan during power outages, failure to ensure residents' oxygen was operable, and multiple power outages. The first allegation was substantiated, the second was unsubstantiated, and the third was unfounded.
Findings
The investigation substantiated that the facility did not follow its emergency plan during power outages on 09/03/2023 and 09/04/2023, lacking emergency lighting, working elevators, and generator availability. The allegation that the facility did not ensure residents' oxygen was operable was unsubstantiated, and the allegation of multiple power outages was found unfounded. One deficiency was cited related to emergency preparedness.
Deficiencies (1)
The facility did not ensure that they followed the emergency plan outlined in their facility manual regarding emergency power and lighting during power outages.
Report Facts
Power outage duration: 1.75
Power outage duration: 2
Census: 102
Total capacity: 180
Plan of Correction due date: Nov 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lisa Rios | Licensing Program Manager | Oversaw the complaint investigation |
| Priya Lal | Facility Designated Administrator | Met with Licensing Program Analyst during investigation and provided information |
Inspection Report
Census: 121
Capacity: 180
Deficiencies: 0
Date: Oct 16, 2023
Visit Reason
The visit was a case management visit initiated by the licensee in response to a phone call received regarding resident R1.
Findings
No deficiencies were cited during this case management visit. An interview was conducted with the Facility Designated Administrator, and documentation regarding R1 will be obtained via email.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Priya Lal | Facility Designated Administrator | Met with Licensing Program Analyst during the visit and interviewed. |
| Arielle Pascua | Licensing Program Analyst | Conducted the case management visit. |
| Stephenie Doub | Licensing Program Manager | Named in the report header. |
Inspection Report
Follow-Up
Census: 121
Capacity: 180
Deficiencies: 1
Date: Oct 12, 2023
Visit Reason
The visit was conducted as a follow-up on an incident report received on 08/16/2023 regarding a medication count discrepancy involving resident R1's antibiotic medication.
Findings
The inspection found a technical violation related to medication administration where the Medication Administration Record was signed after administration but the medication count was incorrect. The responsible staff member was terminated after multiple incidents of unaccounted medication.
Deficiencies (1)
Technical Violation for 87465(c)(2) related to medication count discrepancy.
Report Facts
Additional medication capsules found: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alex Chipponeri | Health and Wellness Director | Met with Licensing Program Analyst during the visit and interviewed regarding the medication incident. |
| Arielle Pascua | Licensing Program Analyst | Conducted the case management visit and inspection. |
| Stephenie Doub | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 180
Deficiencies: 0
Date: Oct 12, 2023
Visit Reason
The visit was conducted to follow up on an incident report received on 2023-09-13 regarding an allegation that resident R1 was hit by resident R2 a few days prior to notifying staff.
Complaint Details
The complaint involved an allegation that resident R1 was hit by resident R2. The allegation was investigated through interviews and observation, and no substantiated deficiencies were found.
Findings
Based on interviews and observations, no deficiencies were cited during this visit. Facility staff did not observe any redness or indications that R1 was hit, and R1 was unable to explain the injury at the time of interview.
Report Facts
Census: 121
Total Capacity: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alex Chipponeri | Health and Wellness Director | Met with Licensing Program Analyst during the visit and interviewed regarding the incident |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 180
Deficiencies: 0
Date: Oct 12, 2023
Visit Reason
The visit was a case management follow-up on an incident report received on 2023-09-22 regarding concerns about a resident's Power of Attorney and potential financial abuse.
Complaint Details
The complaint involved a resident notifying staff that they closed their account due to uncertainty about their Power of Attorney's handling of their money. The investigation found no substantiated financial abuse.
Findings
Based on interviews conducted during the visit, there were no concerns or evidence of financial abuse by the resident's Power of Attorney. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alex Chipponeri | Health and Wellness Director | Met during the visit and interviewed regarding the incident report. |
| Arielle Pascua | Licensing Program Analyst | Conducted the case management visit. |
| Stephenie Doub | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Follow-Up
Census: 120
Capacity: 180
Deficiencies: 1
Date: Aug 14, 2023
Visit Reason
The visit was an unannounced case management follow-up to an incident report received by the department regarding a resident expressing self-harm intentions.
Findings
The Licensing Program Analyst conducted interviews and reviewed relevant records, resulting in a Technical Violation issued for Section 87705(f)(1).
Deficiencies (1)
Technical Violation issued for Section 87705(f)(1)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Priya Lal | Facility Designated Administrator | Met with Licensing Program Analyst during the visit and involved in incident follow-up |
| Arielle Pascua | Licensing Program Analyst | Conducted the case management visit and issued the Technical Violation |
| Stephenie Doub | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 120
Capacity: 180
Deficiencies: 0
Date: Aug 14, 2023
Visit Reason
The visit was an unannounced case management follow-up on an incident report received by the department involving two residents in memory care.
Complaint Details
The visit was triggered by a special incident report received on 2023-05-26 regarding an incident where one resident pushed another into their wheelchair. The incident was investigated and found to have no resulting deficiencies.
Findings
Based on interviews and facility records reviewed during the visit, no deficiencies were cited. The Licensing Program Analyst will return if further follow-up is needed.
Report Facts
Census: 120
Total Capacity: 180
Incident Report Date: May 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katelyn Ledesma | Facility Designated Administrator | Met with Licensing Program Analyst during the visit and involved in the incident report follow-up |
| Arielle Pascua | Licensing Program Analyst | Conducted the unannounced case management visit and reviewed the incident |
Inspection Report
Follow-Up
Census: 120
Capacity: 180
Deficiencies: 0
Date: Aug 14, 2023
Visit Reason
The visit was an unannounced case management follow-up to an incident report received by the department regarding an incident between three residents in memory care.
Complaint Details
The visit was triggered by a special incident report received on 2023-05-16 involving an altercation between three residents. The complaint was investigated and found to have no deficiencies.
Findings
Based on interviews and facility records reviewed during the visit, no deficiencies were cited. The facility had appropriately monitored and managed the incident involving the residents.
Report Facts
Incident report date: May 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Priya Lal | Facility Designated Administrator | Met with Licensing Program Analyst during the visit and interviewed regarding the incident |
| Arielle Pascua | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
| Stephenie Doub | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 180
Deficiencies: 1
Date: Jun 13, 2023
Visit Reason
The visit was conducted as a case management follow-up on a facility-reported incident received by the department on 2023-05-25 involving staff misconduct.
Complaint Details
The complaint investigation was substantiated based on interviews and record review confirming staff misconduct. Staff member S1 was terminated on 2023-05-15 following the incident.
Findings
The investigation confirmed that staff member S1 smacked resident R1 during care, violating personal rights. S1 was removed from the staffing schedule pending investigation and subsequently terminated. The facility was cited for failure to ensure residents were treated with dignity and respect.
Deficiencies (1)
The facility did not ensure that resident R1 was treated with respect and dignity while in care of staff member S1, who was witnessed smacking R1. This posed an immediate health, safety, and personal rights risk.
Report Facts
Census: 120
Total Capacity: 180
Plan of Correction Due Date: Jul 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katelyn Ledesma | Facility Designated Administrator | Interviewed regarding the incident and investigation |
| Arielle Pascua | Licensing Program Analyst | Conducted the inspection and investigation |
| Stephenie Doub | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 127
Capacity: 180
Deficiencies: 0
Date: Mar 27, 2023
Visit Reason
The visit was an unannounced annual inspection conducted to evaluate the facility's compliance with licensing requirements and overall operation.
Findings
No deficiencies were observed or cited during this annual visit. The facility was found to have current resident and staff files, proper medication storage and administration, adequate safety measures, and sufficient furnishings and supplies.
Report Facts
Residents reviewed: 20
Staff files reviewed: 20
Non-ambulatory residents allowed: 31
Bedridden residents allowed: 12
Assisted living residents: 103
Memory care residents: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katelyn Ledesma | Facility Designated Administrator | Named in relation to the inspection and interview |
| Marites A. Rita | Licensed Vocational Nurse and Wellness Coordinator | Met during inspection |
| Christina Gorforth | Business Office Coordinator | Met during inspection |
| Arielle Pascua | Licensing Program Analyst | Conducted the inspection |
| Stephenie Doub | Licensing Program Manager | Named in report header/footer |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 180
Deficiencies: 0
Date: Oct 20, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-08-22 alleging the facility was unsanitary, odiferous, dirty, staff were not cleaning resident bedding or changing resident clothing, and that communication requests by resident representatives were not timely responded to.
Complaint Details
The complaint was unsubstantiated. Although allegations may have occurred, there was not a preponderance of evidence to prove the violations. No deficiencies were observed or cited.
Findings
After interviews with residents, staff, and family members, and review of housekeeping and laundry schedules, the investigation found insufficient evidence to substantiate the allegations. The facility was found to be clean and sanitary with routine cleaning and laundry services. Communication with resident representatives was generally timely. The allegations were determined to be unsubstantiated and no deficiencies were cited.
Report Facts
Capacity: 180
Census: 119
Staff interviewed: 6
Residents interviewed: 8
Family members interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation |
| Stephenie Doub | Licensing Program Manager | Oversaw the complaint investigation |
| Nori Dugan | Health Wellness Director | Received exit interview and report copy |
Inspection Report
Follow-Up
Capacity: 180
Deficiencies: 1
Date: Sep 7, 2022
Visit Reason
The visit was an unannounced case management follow-up to address the facility's lack of an active administrator after the previous administrator left on 07/29/2022.
Findings
The facility has not had an active administrator since 07/30/2022, which poses immediate health, safety, and personal rights risks to residents. Deficiencies were cited related to the absence of a qualified and currently certified administrator.
Deficiencies (1)
Failure to have a qualified and currently certified administrator on site since 07/30/2022, with no designated substitute to manage the facility.
Report Facts
Capacity: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chinny Takhar | Clinical Care Director | Met during the visit and involved in the follow-up regarding the administrator change |
| Arielle Pascua | Licensing Program Analyst | Conducted the unannounced case management facility visit |
| Stephenie Doub | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Capacity: 180
Deficiencies: 0
Date: Sep 7, 2022
Visit Reason
The visit was conducted to investigate a complaint received on 2022-07-08 alleging insufficient staffing to meet residents' needs and staff leaving residents unattended.
Complaint Details
The complaint was unsubstantiated. Although allegations may have happened or been valid, there was not a preponderance of evidence to prove the alleged violation occurred.
Findings
After interviews with eight residents, eight staff members, and two family members, the investigation found no sufficient evidence to substantiate the allegations. Residents and family members reported satisfaction with care and no issues with staff leaving residents unattended. No deficiencies were cited.
Report Facts
Capacity: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Chinny Takhar | Clinical Care Director | Facility representative met during investigation and recipient of report |
| Stephenie Doub | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 180
Deficiencies: 1
Date: Jun 16, 2022
Visit Reason
An unannounced Case Management - Deficiencies visit was conducted to investigate issues related to resident complaints and concerns about the facility's operations.
Complaint Details
The visit was complaint-related, triggered by previous interviews indicating that the Administrator told a resident that continued complaints could result in her losing her job, which could be interpreted as deterring residents from filing complaints with state licensing.
Findings
The inspection found that statements were made by facility staff that could deter residents from filing complaints, posing a potential threat to the health, safety, or personal rights of residents in care.
Deficiencies (1)
Statements were made that would deter residents from filing complaints, violating residents' personal rights under Title 22 regulations.
Report Facts
Residents at Resident Council Meeting: 20
Deficiency Type B count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Mackedsy | Administrator | Named in relation to statements deterring residents from filing complaints. |
| Sarah Hurt | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Stephenie Doub | Licensing Program Manager | Conducted the inspection and supervised the evaluation. |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 180
Deficiencies: 0
Date: Jun 16, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations including retaliation by the facility administrator against a resident, violation of Resident Council regulations, and violation of HIPPA laws.
Complaint Details
The complaint investigation was triggered by allegations that the facility administrator retaliated against a resident, violated Resident Council regulations, and violated HIPPA laws. The investigation found no evidence to substantiate these allegations.
Findings
All allegations were found to be unsubstantiated or unfounded after interviews and record reviews. No deficiencies were cited during the visit per Title 22 Regulations.
Report Facts
Capacity: 180
Census: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Mackedsy | Administrator | Named in allegations and participated in interviews during the complaint investigation |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephenie Doub | Licensing Program Manager | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 180
Deficiencies: 0
Date: Apr 29, 2022
Visit Reason
An unannounced complaint investigation was conducted to investigate allegations that the facility does not keep food hot during meal service.
Complaint Details
The complaint alleged that the facility does not keep food hot during meal service. The complaint was found to be unsubstantiated based on interviews and observations.
Findings
The investigation found that the facility kitchen staff is keeping the food hot during meal service. A resident reported past issues during a COVID outbreak when food was delivered to rooms, but stated the issue is no longer present. The kitchen manager addressed resident concerns and made improvements such as ordering black plates and heat lamps to keep food warm. The complaint was unsubstantiated and no deficiencies were cited.
Report Facts
Capacity: 180
Census: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation |
| Christina Goforth | Business Services Coordinator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 180
Deficiencies: 0
Date: Apr 29, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted to address multiple allegations including unsafe environment, unprofessional staff, malfunctioning pendants, short staffing, and food quality concerns at the facility.
Complaint Details
The complaint investigation addressed allegations that the facility does not provide a safe environment, staff are unprofessional, pendants do not work properly, the facility is short staffed, and food quality issues. All allegations were found to be unsubstantiated after interviews and record reviews.
Findings
The investigation found all allegations to be unsubstantiated based on interviews with staff, residents, and review of records including police calls and pendant testing documents. The facility was found to provide a safe environment, adequate staffing, professional staff, functioning pendants, and good quality food.
Report Facts
Capacity: 180
Census: 118
Police calls: 24
Staffing: 2
Staffing: 4
Staffing: 1
Staffing: 3
Response time: 5
Response time: 10
Bonus incentive: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation |
| Sara Mackedsy | Administrator | Facility administrator interviewed regarding safety, staffing, and other allegations |
| Christina GoForth | Business Office Coordinator | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Annual Inspection
Census: 117
Capacity: 180
Deficiencies: 0
Date: Apr 22, 2022
Visit Reason
An unannounced visit was conducted for the facility's annual inspection to evaluate compliance with regulations.
Findings
The inspection found the facility to be clean, well-maintained, and in compliance with all applicable regulations. No deficiencies were observed or cited during the inspection.
Report Facts
Residents on hospice: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Mackedsy | Administrator / Executive Director | Met with Licensing Program Analyst during the inspection |
| Sarah Hurt | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
| Stephenie Doub | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 180
Deficiencies: 1
Date: Mar 24, 2022
Visit Reason
Unannounced complaint investigation visit to investigate allegations including retaliation against a resident for filing a complaint, staff disrespect, charging for services not provided, and facility disrepair.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Sarah Hurt. Allegations included retaliation against a resident for filing a complaint, staff disrespect, charging for services not provided, and facility disrepair. The first three allegations were found unsubstantiated due to lack of preponderance of evidence, while the disrepair allegation was substantiated based on LPA observation.
Findings
The investigation found the allegations of retaliation, staff disrespect, and charging for services not provided to be unsubstantiated. However, the complaint regarding facility disrepair was substantiated due to the strong urine odor in the memory care carpeted hallway, posing a potential health and safety risk.
Deficiencies (1)
Facility carpets smelling of urine posing a potential health, safety, risk to residents in care.
Report Facts
Facility capacity: 180
Census: 116
Fee amount: 539
Plan of Correction due date: Mar 30, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Mary Margaret Chappell | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Sara Mackedsy | Administrator | Facility administrator named in the report |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 180
Deficiencies: 0
Date: Mar 24, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 02/24/2022 regarding bed bugs in the facility, the character of the administrator, and the facility's procedures for handling insect reports.
Complaint Details
The complaint investigation was unsubstantiated for all allegations: bed bugs presence, administrator character, and procedural compliance regarding insect reports. Evidence did not prove violations occurred.
Findings
The investigation found all allegations to be unsubstantiated. The administrator was found to be of good character based on staff and resident interviews. The facility had recently treated a room for bed bugs and took appropriate containment actions. The facility followed procedures adequately when insect reports were received, and no deficiencies were cited.
Report Facts
Capacity: 180
Census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Mackedsy | Administrator | Named in the complaint and investigation findings regarding character and facility management |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation |
| Mary Margaret Chappell | Executive Director | Met with the Licensing Program Analyst during the investigation |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 180
Deficiencies: 0
Date: Jan 10, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that the facility did not have sufficient staff to serve breakfast in a timely manner.
Complaint Details
The complaint was unsubstantiated as there was not a preponderance of evidence to prove the alleged violation occurred. The allegation was that the facility did not have sufficient staff to serve breakfast in a timely manner.
Findings
The investigation found that the facility had sufficient staff to serve breakfast timely based on staff schedules and resident interviews. The allegation was deemed unsubstantiated and no deficiencies were cited during the visit.
Report Facts
Capacity: 180
Census: 113
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sara Mackedsy | Executive Director | Met with Licensing Program Analyst during the investigation |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 180
Deficiencies: 0
Date: Dec 28, 2021
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2021-11-04 regarding the allegation that the facility failed to allow resident council members to be interviewed during the inspection process.
Complaint Details
The complaint alleged that the facility failed to allow resident council members to be interviewed during the inspection process. The allegation was found to be unsubstantiated based on interviews and record reviews.
Findings
The investigation found that the allegation was unsubstantiated. Records and interviews confirmed that resident council members were allowed to be interviewed during past inspections and the facility provided a private meeting space for such interviews.
Report Facts
Facility capacity: 180
Census: 119
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arlene D Garcia | Licensing Program Analyst | Conducted the complaint investigation and made the unannounced visit |
| Pamela Bradley | Administrator | Facility administrator named in the report |
| Marites Rita | Nurse | Met with the Licensing Program Analyst during the inspection |
| Sara Mackedsky | Executive Director | Met with Licensing Program Analyst via telephone during the inspection |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager in the report |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 180
Deficiencies: 0
Date: Dec 28, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by multiple allegations including failure to provide separate activities for different communities, reduced mealtime hours, lack of transportation for residents, and unmet needs of residents in hospice care.
Complaint Details
The complaint investigation was unsubstantiated based on interviews, observations, and record reviews. There was no preponderance of evidence to prove the allegations occurred as reported.
Findings
All allegations were found to be unsubstantiated. The facility provided separate activities for different communities, maintained appropriate mealtime hours within regulations, offered multiple transportation options for residents, and adequately met the needs of residents in hospice care as confirmed by interviews, observations, and record reviews.
Report Facts
Capacity: 180
Census: 119
Dining room hours: 7
Dining room closing time discussed: 18.5
Residents dining after 6:30pm: 2
Memory Care staff: 3
Residents in hospice interviewed: 5
Staff interviewed regarding hospice care: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arlene D Garcia | Licensing Program Analyst | Conducted the complaint investigation and made observations |
| Pamela Bradley | Administrator | Provided information regarding dining hours and transportation |
| Marites Rita | Nurse | Met with Licensing Program Analyst during visit |
| Nis Cisneros | Authorized Driver | Driver for facility transportation |
| Lisette Morera | Resident Coordinator | Driver for facility transportation |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Plan of Correction
Census: 44
Capacity: 180
Deficiencies: 0
Date: Dec 17, 2021
Visit Reason
The visit was conducted to deliver an Amended Report and clear a citation, as part of a Plan of Correction (POC) unannounced visit.
Findings
The Licensing Program Analyst observed the Resident President meeting with the Executive Director to confirm receipt of the response letter regarding resolution meeting requests. The Resident Council agreed to the meeting and confirmed the time with the Executive Director. The Executive Director provided a written response to past resident council concerns as required by the POC.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Bradley | Administrator | Facility Administrator named in the report header. |
| Sarah Mackedsky | Executive Director | Met with Licensing Program Analyst during the visit and involved in the Plan of Correction activities. |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager in the report. |
| Arlene D Garcia | Licensing Program Analyst | Conducted the visit and delivered the Amended Report. |
Inspection Report
Annual Inspection
Census: 114
Capacity: 180
Deficiencies: 0
Date: Dec 1, 2021
Visit Reason
The inspection was an unannounced required one-year visit to evaluate compliance with regulations and deliver findings related to allegations.
Findings
The Licensing Program Analyst inspected various facility areas including physical plant, Memory Care, and Assisted Living communities, reviewed staff and resident vaccination records, and observed compliance with safety and health protocols. No deficiencies were cited in violation of California Code of Regulations.
Report Facts
Staff vaccinated: 56
Resident vaccinated: 108
Fire Drill Log date: Fire Drill Log conducted on 2021-11-29
Ansel system service date: Ansel system serviced on 2021-06-25
Fire extinguisher service date: Fire extinguishers serviced on 2020-12-05
Elevator service date: Elevator serviced on 2020-12-17
Ecolab monthly service reports: Monthly reports dated from 2021-01-21 to 2021-11-18
Water temperature Memory Care: 110.8
Water temperature Assisted Living: 108.8
Staff files reviewed: 8
Resident files reviewed: 8
Last Omnicare Audit date: Last Omnicare Audit report dated 2021-10-30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Bradley | Administrator | Facility Administrator named in report header |
| Sara Mackedsky | Executive Director | Met with Licensing Program Analyst via telephone during visit |
| Arlene Garcia | Licensing Program Analyst | Conducted the inspection and authored the report |
| Marites Rita | Nurse | Greeted Licensing Program Analyst upon arrival |
| Stephenie Doub | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 180
Deficiencies: 2
Date: Dec 1, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including failure to allow resident council members to be interviewed, improper rate increase notice, and failure to respond to Resident Council written requests.
Complaint Details
The complaint investigation was triggered by allegations that the facility failed to allow resident council members to be interviewed during the inspection process, increased rates without proper notice, and failed to respond to Resident Council written requests. The first allegation was unsubstantiated, while the latter two were substantiated.
Findings
The allegation that the facility failed to allow resident council members to be interviewed was unsubstantiated. However, the allegation that the facility failed to respond in writing to Resident Council written requests within 14 calendar days was substantiated. Additionally, the facility increased rates without proper notice as the reasons provided did not meet regulatory requirements.
Deficiencies (2)
Facility failed to respond in writing to Resident Council written concerns or recommendations within 14 calendar days.
Facility did not provide a proper description of additional costs related to the rate increase notice.
Report Facts
Capacity: 180
Census: 114
Deficiencies cited: 2
Plan of Correction Due Dates: 12
Plan of Correction Due Dates: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arlene D Garcia | Licensing Program Analyst | Conducted the complaint investigation and made the unannounced visit |
| Sara Mackedsky | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Pamela Bradley | Administrator | Facility administrator mentioned in the report header |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 180
Deficiencies: 2
Date: Dec 1, 2021
Visit Reason
The inspection was an unannounced Case Management Visit regarding a reported AWOL incident involving a resident that occurred on 2021-11-07.
Complaint Details
The complaint investigation was substantiated based on interviews and record review regarding the AWOL incident of resident R-1 on 2021-11-07.
Findings
The investigation substantiated the allegation that the resident left the facility unassisted, which posed an immediate health and safety risk. Deficiencies were cited related to personnel sufficiency and timely incident reporting.
Deficiencies (2)
Based on observation and record review, resident R-1 AWOL'd from the facility despite a LIC 602 stating the resident was not allowed to leave unassisted, posing an immediate health and safety risk.
Administrator failed to submit the elopement incident report within the required seven days, submitting it 9 days late, posing an immediate health and safety risk.
Report Facts
Deficiencies cited: 2
Incident date: 7
Incident report submission delay: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arlene D Garcia | Licensing Program Analyst | Conducted the unannounced visit and investigation |
| Sara Mackedsky | Executive Director | Met with Licensing Program Analyst via telephone during the visit |
| Pamela Bradley | Administrator | Named in relation to failure to timely submit incident report |
| Stephenie Doub | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Census: 117
Capacity: 180
Deficiencies: 2
Date: Nov 9, 2021
Visit Reason
Licensing Program Analyst Arlene Garcia conducted a case management visit to investigate bed bug infestation reported by the facility.
Findings
Bed bugs were substantiated in multiple rooms, confirmed by pest control services. The facility failed to report the infestation to the licensing agency as required, posing a potential health risk to residents.
Deficiencies (2)
Facility was not clean, safe, sanitary and in good repair due to bed bugs discovered in multiple rooms, posing a potential health risk to residents.
Licensee failed to report the infestation of bed bugs to the department within required timeframes.
Report Facts
Capacity: 180
Census: 117
Plan of Correction Due Date: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Mackedsy | Executive Director | Interviewed during visit and involved in discussion of bed bug infestation |
| Arlene D Garcia | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Stephenie Doub | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 117
Capacity: 180
Deficiencies: 0
Date: Aug 23, 2021
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the licensee failed to have sufficient staff to meet the needs of the residents.
Complaint Details
The complaint alleged insufficient staffing to meet residents' needs, specifically noting residents having to wait over an hour for meal service. The allegation was found to be unsubstantiated.
Findings
The investigation included interviews, observations, and record reviews. It was found that there was sufficient staff to meet residents' needs during meal service, and residents interviewed did not report concerns about staffing shortages. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Residents observed during lunch: 18
Residents interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arlene D Garcia | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Sara Mackedsy | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 117
Capacity: 180
Deficiencies: 0
Date: Aug 23, 2021
Visit Reason
An unannounced case management visit was conducted to follow up on an incident that occurred on 08/10/2021 involving residents R1 and R2.
Findings
No deficiencies were observed or cited during the case management inspection. The department closed the case management with no further investigation required after reviewing resident files, observing activities, and confirming proactive measures were in place.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Mackedsy | Executive Director | Met with Licensing Program Analyst during the inspection and provided information about resident evaluations and staff training. |
| Arlene D Garcia | Licensing Program Analyst | Conducted the unannounced case management visit and inspection. |
| Stephenie Doub | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Census: 28
Capacity: 180
Deficiencies: 0
Date: Aug 19, 2021
Visit Reason
An informal conference was conducted to discuss the high volume of deficiencies, complaints, and inability to remain in substantial compliance with regulations over the last 2 years.
Findings
No deficiencies were cited during this visit. The facility is undergoing management transition and recovery efforts including staff training and operational improvements. Various concerns such as staffing, care, supervision, security, and maintenance were discussed with plans for ongoing improvements.
Report Facts
Type A violations cited since licensure: 16
Licensed capacity: 180
Fire clearance capacity: 137
Fire clearance capacity: 31
Fire clearance capacity: 12
Hospice waiver capacity: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Bradley | Administrator / Interim Operational Manager | Facility management transition and operational recovery |
| Sara Mackedsy | Executive Director | Met during visit and involved in leadership and training efforts |
| Sarah Archuleta Weaver | Interim LVN | Brought in during management transition |
| Stephenie Doub | Licensing Program Manager | Present at informal conference |
| Arlene Garcia | Licensing Program Analyst | Present at informal conference |
| Zachary Butcher | District Director of Operations | Present at informal conference and discussed facility issues |
| Kadijatu Barrie | District Nurse | Present at informal conference |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 180
Deficiencies: 2
Date: Jul 28, 2021
Visit Reason
An unannounced complaint investigation visit was conducted following allegations that residents do not feel safe and that facility food is not being handled in a safe manner.
Complaint Details
The complaint investigation was substantiated, meaning there was a preponderance of evidence to prove the allegations true as reported.
Findings
The investigation found substantiated evidence that residents did not feel safe due to increased altercations in memory care, and that food prepared for dinner service was not properly covered, violating food safety regulations.
Deficiencies (2)
Facility personnel were insufficient in numbers and competence to meet resident needs, evidenced by residents having altercations indicating possible staffing issues.
Food prepared for dinner service was not covered properly, including meat for main course, strawberry dessert, and side dishes.
Report Facts
Capacity: 180
Census: 123
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arlene D Garcia | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Stephenie Doub | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Pamela Bradley | Operations Specialist | Met with the Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 124
Capacity: 180
Deficiencies: 1
Date: Jul 19, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff were not associated with the facility, the administrator was not designated to the facility, and the acting administrator was not qualified to manage the facility.
Complaint Details
The complaint was substantiated regarding staff not being associated with the facility. The allegations about the administrator designation and qualifications of the acting administrator were unsubstantiated.
Findings
The allegation that staff were not associated with the facility was substantiated based on interviews and records reviewed. The allegation that the administrator was not designated and the acting administrator was not qualified was found to be unsubstantiated.
Deficiencies (1)
The Licensee did not ensure the staff was fingerprint cleared and associated to the facility prior to working, posing an immediate health and safety risk to residents in care.
Report Facts
Capacity: 180
Census: 124
Deficiencies cited: 1
Plan of Correction Due Date: Jul 20, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arlene D Garcia | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephenie Doub | Licensing Program Manager | Oversaw the complaint investigation |
| Pamela Bradley | Operations Specialist | Met with the Licensing Program Analyst during the investigation |
| Odette Colondres | Administrator | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Census: 124
Capacity: 180
Deficiencies: 2
Date: Jul 19, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-06-09 regarding kitchen equipment disrepair and inadequate supervision of residents, as well as allegations of rough handling of residents and retaliation against complainants.
Complaint Details
The complaint investigation was substantiated for kitchen equipment disrepair and inadequate supervision, with a preponderance of evidence supporting these allegations. The allegations of rough handling of residents and retaliation against complainants were unsubstantiated due to lack of evidence and inability to interview relevant parties.
Findings
The investigation substantiated the allegations that kitchen equipment was in disrepair and staff were not providing appropriate supervision of residents, citing deficiencies related to staffing and facility maintenance. The allegations that staff handled residents roughly and that the facility retaliated against complainants were found to be unsubstantiated.
Deficiencies (2)
Licensees who accept and retain residents with dementia shall ensure adequate direct care staff to support residents' needs; evidence showed insufficient staffing leading to resident altercations.
Facility buildings and grounds were not kept clean, sanitary, and in good repair; observed broken sanitizer, leaking buffet station, and missing thermometers.
Report Facts
Capacity: 180
Census: 124
Deficiencies cited: 2
Plan of Correction Due Dates: Jul 19, 2021
Plan of Correction Due Dates: Jul 29, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arlene D Garcia | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Stephenie Doub | Licensing Program Manager | Oversaw the complaint investigation |
| Pamela Bradley | Operations Specialist | Met with Licensing Program Analyst during inspection and exit interview |
Inspection Report
Complaint Investigation
Census: 124
Capacity: 180
Deficiencies: 2
Date: Jul 19, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including insufficient staff to meet residents' needs, residents feeling unsafe, improper food handling, failure to follow the menu, lack of incontinent care, and staff misconduct.
Complaint Details
The complaint investigation was substantiated for allegations of insufficient staffing, resident safety concerns, unsafe food handling, and failure to follow menus. The allegation of staff not providing incontinent care and lack of supplies was unsubstantiated. The allegation that staff forced a resident to eat on the floor and poor facility management was unfounded.
Findings
The investigation substantiated allegations that staff was insufficient to meet residents' needs, residents did not feel safe due to altercations, food was not handled safely, and menus were not properly followed. The allegation regarding lack of incontinent care was unsubstantiated, and the allegation of staff forcing a resident to eat on the floor and poor management by the administrator was unfounded.
Deficiencies (2)
Responsibility for providing care and supervision. The licensee did not ensure enough staff to support residents requiring additional supervision and timely meal service, posing immediate risk.
Food service requirements not met: menus not posted or updated, food left uncovered.
Report Facts
Capacity: 180
Census: 124
Deficiencies cited: 2
Plan of Correction Due Dates: Jul 19, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arlene D Garcia | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Stephenie Doub | Licensing Program Manager | Oversaw the complaint investigation |
| Pamela Bradley | Operations Specialist | Met with Licensing Program Analyst during inspection |
| Odette Colondres | Administrator | Facility administrator mentioned in report |
Inspection Report
Plan of Correction
Census: 123
Capacity: 180
Deficiencies: 2
Date: Jul 1, 2021
Visit Reason
Unannounced plan of correction (POC) visit to verify correction of citations issued during the case management visit conducted on 2021-06-16.
Findings
The deficiency related to fire safety cited on 2021-06-16 was cleared, but civil penalties are still pending. An unlocked cleaning cart was observed unattended and could not be locked, and dirty carpets and cobwebs were noted throughout the facility. Deficiencies were cited and civil penalties assessed for repeat violations.
Deficiencies (2)
Unlocked cleaning cart in the main hallway on the second floor unattended, posing an immediate health and safety risk to residents.
Facility grounds not maintained; dirty carpets in stairway and cobwebs on windows posing a potential safety risk to residents.
Report Facts
Capacity: 180
Census: 123
Deficiency due date: Jul 2, 2021
Deficiency due date: Jul 9, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the unannounced POC visit and authored the report |
| Stephenie Doub | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 180
Deficiencies: 2
Date: Jul 1, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including facility staff not providing resident showers, residents' meals not served due to lack of staffing/scheduling, and staff not responding to residents calling for assistance.
Complaint Details
The complaint investigation was initiated based on allegations received on 06/01/2021. The allegation that facility staff were not providing resident showers was unsubstantiated. The allegations that residents' meals were not served due to lack of staffing/scheduling and that staff were not responding to residents calling for assistance were substantiated. The Nurse Call System was found to be malfunctioning, contributing to delayed responses.
Findings
The allegation that facility staff were not providing resident showers was found to be unsubstantiated after review of shower schedules and interviews. However, the allegations that residents' meals were not served timely due to staffing issues and that staff were not responding promptly to residents' calls for assistance were substantiated. Deficiencies related to personnel requirements and call system functionality were cited.
Deficiencies (2)
87468(a)(2) Personal Rights. Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
87411(a) Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
Report Facts
Census: 123
Total Capacity: 180
Residents observed during dining service: 20
Staff observed during dining service: 4
Meal wait time: 15
Meal wait time: 25
Call system response time: 5
Call system response time: 16
Plan of Correction Due Date: Jul 11, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arlene D Garcia | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Albert Johnson | Licensing Program Analyst | Conducted the complaint investigation |
| Sarah Archuleta-Weaver | Clinical Director | Met with LPAs during investigation and exit interview |
| Odette Colondres | Administrator | Facility administrator mentioned in report header |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 180
Deficiencies: 1
Date: Jun 16, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that residents were engaging in multiple physical altercations and that the facility was understaffed.
Complaint Details
The complaint investigation was substantiated based on interviews, record reviews, staff schedules, and timesheets. Multiple resident altercations were confirmed, including incidents on 5/30/21, 5/16/21, and 4/26/21. The facility was found to be understaffed, placing residents at risk for further injury or hospitalization.
Findings
The investigation substantiated the allegations of multiple physical altercations among residents and understaffing. Several altercations were documented with one resident requiring emergency room care. The facility was found to have an inadequate number of direct care staff, posing an immediate risk to resident health and safety.
Deficiencies (1)
Licensees who accept and retain residents with dementia shall ensure an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidenced by the number of altercations reported, posing an immediate risk to residents.
Report Facts
Census: 120
Total Capacity: 180
Deficiency Count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arlene D Garcia | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Stephenie Doub | Licensing Program Manager | Named in relation to the deficiency citation and report oversight |
| Pamela Bradley | Interim Executive Director | Met with investigators during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 180
Deficiencies: 2
Date: Jun 16, 2021
Visit Reason
The inspection was an unannounced complaint investigation initiated by Licensing Program Analysts Albert Johnson and Arlene Garica to assess compliance with regulations.
Complaint Details
The visit was triggered by a complaint investigation. Deficiencies were substantiated and civil penalties were assessed.
Findings
Deficiencies were observed including an outdated fixed Ansul fire safety system in the kitchen last serviced on 09/02/2019, and an unlocked cleaning chart in the main hallway posing an immediate health and safety risk. Civil penalties were assessed.
Deficiencies (2)
Fixed Ansul fire safety system in the kitchen was outdated and not maintained per semi-annual schedule; last service was on 09/02/2019.
Unlocked cleaning chart in the main hallway unattended, posing an immediate health and safety risk to residents.
Report Facts
Capacity: 180
Census: 120
Plan of Correction Due Date: Jun 17, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted complaint investigation and cited deficiencies |
| Arlene Garica | Licensing Program Analyst | Conducted complaint investigation |
| Pamela Bradley | Operational Specialist | Met with LPAs during inspection |
| Stephenie Doub | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 180
Deficiencies: 1
Date: May 7, 2021
Visit Reason
This was an unannounced complaint investigation visit triggered by a complaint received on 2021-04-14 alleging that staff were not meeting residents' needs.
Complaint Details
The complaint alleging staff not meeting residents' needs was substantiated based on interviews and records reviewed. The investigation included interviews with the Executive Director, Nurse, and RS, and found staff lacked knowledge in oxygen equipment operation.
Findings
The investigation substantiated the allegation that staff were not meeting residents' needs. A deficiency was cited for failure to ensure staff were knowledgeable and trained in the operation of oxygen equipment, posing a potential risk to residents.
Deficiencies (1)
Failure to ensure that staff were knowledgeable and trained in the operation of oxygen equipment, posing a potential risk to residents.
Report Facts
Capacity: 180
Census: 120
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arlene D Garcia | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Odette Colondres | Executive Director | Facility representative interviewed during investigation |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 180
Deficiencies: 1
Date: Apr 12, 2021
Visit Reason
The visit occurred to deliver findings related to a complaint dated 03/23/2021 regarding facility safety concerns.
Complaint Details
The visit was complaint-related, triggered by a complaint dated 03/23/2021. The complaint was substantiated by the observation of unlocked toxins posing immediate health risks.
Findings
During the inspection, Licensing Program Analysts observed unlocked toxins accessible to residents in both common areas and resident rooms, posing an immediate health risk. The administrator secured and locked the toxins during the tour.
Deficiencies (1)
Unlocked toxins accessible to residents in multiple rooms and common areas, violating storage requirements for poisons and dangerous items.
Report Facts
Census: 120
Total Capacity: 180
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arlene D Garcia | Licensing Program Analyst | Conducted inspection and delivered findings |
| Albert Johnson | Licensing Program Analyst | Conducted inspection and delivered findings |
| Odette Colondres | Administrator | Facility administrator who secured toxins during the tour and participated in exit interview |
| Stephenie Doub | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 180
Deficiencies: 2
Date: Feb 23, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on 12/09/2020 regarding residents' food quality, quantity, and timeliness of service.
Complaint Details
The complaint was substantiated based on interviews with residents, staff, and witnesses, and review of facility records. The allegations involved poor food quality, insufficient quantity, and late meal service due to staffing issues.
Findings
The investigation substantiated the complaints that residents' food was not of good quality or sufficient quantity and that food was served late due to staffing and scheduling issues. These deficiencies posed potential health and safety risks.
Deficiencies (2)
Food was not of good quality; commercial foods were not properly approved and food in damaged containers was used or retained.
Insufficient food service personnel employed, trained, and scheduled to meet residents' needs, resulting in late, cold, and unappetizing meal deliveries.
Report Facts
Capacity: 180
Census: 111
Deficiencies cited: 2
Plan of Correction Due Date: Mar 23, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bruce Jacobs | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Yvette Colondres | Executive Director | Facility representative interviewed during investigation |
| Liza King | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 180
Deficiencies: 0
Date: Nov 5, 2020
Visit Reason
Unannounced investigation of a complaint alleging that a resident sustained unexplained injuries due to abuse or neglect.
Complaint Details
Allegation that Resident (R-1) sustained unexplained injuries while in care as a result of abuse or neglect. The allegation was unsubstantiated after investigation.
Findings
The investigation found the allegations to be unsubstantiated based on interviews with staff and witnesses. No deficiencies were noted or cited.
Report Facts
Facility capacity: 180
Census: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bruce Jacobs | Licensing Evaluator | Conducted the complaint investigation and tele-visit |
| Adaline Kiehn | Executive Director | Met with Licensing Evaluator during investigation and exit interview |
| Czarrina A Camilon-Lee | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 180
Deficiencies: 1
Date: Nov 5, 2020
Visit Reason
The visit was a Case Management phone call to discuss deficiencies observed during a complaint investigation related to the facility's failure to document bruises and discolorations on a resident's arms.
Complaint Details
The deficiency was observed during a complaint investigation. Hospice staff first observed bruising on 06/26/2020, and the facility executive director was unaware of the marks until 06/29/2020. Direct care staff did not document or report the bruising. The deficiency was cited per California Code of Regulations, Title 22 chapter 8.
Findings
The facility failed to document significant bruising and skin tears on Resident R-1's hands and arms, which were first observed by hospice staff on 06/26/2020 but not reported to the physician or responsible party for about 10 days, posing a potential safety risk.
Deficiencies (1)
Failure to regularly observe and document changes in physical health condition, specifically bruising and skin tears on Resident R-1 not reported timely.
Report Facts
Plan of Correction due date: Nov 16, 2020
Plan of Correction completion timeframe: 30
Delay in reporting bruising: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adaline Kiehn | Facility Administrator | Spoke with Licensing Program Analyst during case management call |
| Bruce Jacobs | Licensing Program Analyst | Conducted case management phone call and complaint investigation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
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