Inspection Report Summary
Most inspections found no deficiencies, with several complaint investigations deemed unsubstantiated. The facility’s most recent report from September 9, 2025, had no deficiencies and involved a follow-up on a resident’s unintentional skin tear. Earlier reports showed some medication management issues, including missed doses and improper glucose testing by unskilled staff, which posed health risks but were addressed through plans of correction. There was also a substantiated staffing deficiency in early 2023 and an incident of staff theft in 2024 that led to termination and police involvement. Overall, the facility appears to have improved over time, with the latest inspections showing compliance and no new deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
1.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
36% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 58
Capacity: 160
Deficiencies: 0
Sep 9, 2025
Visit Reason
An unannounced case management visit was conducted to follow up on an SOC 341 received by the department regarding a reported incident involving a caregiver causing a skin tear on a resident's arm.
Findings
The Licensing Program Analyst observed no health or safety concerns during the visit. The resident reported the injury was unintentional and caregivers were attempting to assist. The facility has scheduled a care plan meeting and conducted an in-service on transfers in response to the resident's decline.
Complaint Details
The visit was triggered by a complaint (SOC 341) received on 08/29/2025 regarding a caregiver causing a skin tear on Resident 1's arm. The resident initially was unaware of the caregiver involved and later reported different names. The injury was not intentional.
Report Facts
Capacity: 160
Census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit |
| Christine Perez | Administrator/Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 160
Deficiencies: 1
Jul 11, 2025
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that the facility was mismanaging residents' medication.
Findings
The investigation found that initial medication management issues occurred for resident R1 after admission, and a prescription for resident R2 was not administered for four days due to pharmacy refill errors. The allegation was substantiated and a Type A deficiency was cited.
Complaint Details
The complaint alleged that the facility was mismanaging residents' medication. The investigation substantiated the allegation based on interviews, record reviews, and observations.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assist residents with self-administered medications as required by California Code of Regulations Section 87465(a)(4), resulting in at least two residents missing multiple doses of prescription medication due to supply issues. | Type A |
Report Facts
Days medication not administered: 4
Facility capacity: 160
Facility census: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Sheila Santos | Licensing Program Manager | Oversaw the complaint investigation. |
| Christine Perez | Executive Director | Facility representative who assisted during the visit. |
| John Goodwin | Administrator | Facility administrator named in the report header. |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 160
Deficiencies: 0
Jul 10, 2025
Visit Reason
An unannounced case management visit was conducted to follow up on incident reports received by the department on 06/23/2025 and 07/07/2025 involving allegations of caregiver misconduct and a resident fall.
Findings
The facility conducted an internal investigation into the allegation of a caregiver yelling and pushing a resident, which was closed based on interviews. Another incident involved a resident's unwitnessed fall resulting in a fractured hip, with the resident currently hospitalized post-surgery.
Complaint Details
The visit was triggered by complaints including a report that a caregiver yelled and pushed Resident 1, with police involvement and an internal investigation. Another complaint involved Resident 2's unwitnessed fall leading to a fractured hip. The facility's internal investigation was closed based on interviews.
Report Facts
Incident report dates: 06/23/2025 and 07/07/2025
Police report number: 25032623
Resident capacity: 160
Resident census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit |
| John Goodwin | Administrator/Director | Facility administrator named in report header |
| Christine Perez | Met with during inspection | |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 160
Deficiencies: 0
Jul 10, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that facility staff were not keeping resident rooms at a comfortable temperature.
Findings
The investigation found that temperatures in the resident's room and common areas were within regulatory guidelines, and the allegation was deemed unfounded. Documentation showed multiple maintenance visits and provision of additional cooling measures.
Complaint Details
The complaint alleged that facility staff were not keeping resident rooms at a comfortable temperature. The allegation was investigated and found to be unfounded, meaning it was false or without reasonable basis.
Report Facts
Facility capacity: 160
Census: 65
Room temperature: 76
Common area temperature: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| John Goodwin | Facility Administrator | |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
| Christine Perez | Met with the Licensing Program Analyst during the visit |
Inspection Report
Annual Inspection
Census: 67
Capacity: 160
Deficiencies: 0
Jun 18, 2025
Visit Reason
The visit was an unannounced annual required inspection conducted to evaluate compliance with licensing requirements for the facility.
Findings
The inspection found no deficiencies in the areas inspected, including resident care, physical plant, food service, medication storage and administration, and safety systems. Residents were observed participating in activities and staff responded promptly to emergency pendants.
Report Facts
Hospice residents: 6
Hospice waiver capacity: 12
Bedridden residents capacity: 21
Inspection start time: 8
Inspection end time: 17
Water temperature range Fahrenheit: 105.9-107.0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Tea | Licensing Program Analyst | Conducted the inspection visit |
| John Goodwin | Executive Director | Facility Executive Director assisting with the visit |
| Christine Perez | Executive Director | Facility Executive Director assisting with the visit and participated in exit interview |
| Jose Contreras-Silva | Maintenance Director | Assisted with facility tour during inspection |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 160
Deficiencies: 0
May 29, 2025
Visit Reason
An unannounced case management visit was conducted to follow up on an SOC 341 report regarding an incident where a staff member was alleged to have propositioned a resident.
Findings
The investigation found that the resident denied any injuries and no relations had occurred. The staff member was suspended pending investigation but was allowed to return to work on the day of the visit. The resident appeared clean, well cared for, and verbalized feeling safe at the facility. The incident requires further investigation.
Complaint Details
The complaint involved Resident 1 reporting that Staff 1 had propositioned the resident. The resident denied any injuries and no relations occurred. Staff 1 was suspended pending investigation and returned to work on May 29, 2025.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and investigation. |
| John Goodwin | Administrator | Named as facility administrator. |
| Christine Perez | Met with Licensing Program Analyst during the visit. | |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 160
Deficiencies: 0
Feb 24, 2025
Visit Reason
Unannounced case management visit conducted to follow up on an incident report received by the department regarding a resident's elevated heart rate, lethargy, increased respirations, and a displaced fracture.
Findings
The incident report referred to a previous fracture from December 2024. The resident had an unwitnessed fall in December 2024 but was able to leave the facility unassisted at that time. Fall precautions such as a low bed and scoop mattress were observed during the visit. The resident had no prior falls.
Complaint Details
Visit was triggered by an incident report dated 02/12/2025 concerning Resident 1's elevated heart rate and fracture. The report was found to reference a prior fracture from December 2024. The resident's primary diagnosis is difficulty walking. Fall precautions were in place and observed.
Report Facts
Incident report date: Feb 12, 2025
Incident report received date: Feb 19, 2025
Care plan date: Oct 8, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit |
| Patricia Perez | Administrator | Facility administrator named in the report |
| Chiquita Morris | Met with Licensing Program Analyst during the visit | |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager in the report |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 160
Deficiencies: 0
Jan 15, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not respond to a resident's call in a timely manner and that staff utilized an inappropriate lock on a resident's door.
Findings
The investigation found that on 02/13/2024, a resident requested staff to call 911 for knee pain, EMS arrived and transported the resident downstairs. The resident's door was locked with an exterior lock per resident request while staff was on break for approximately 10-15 minutes. The lock allowed residents to exit from inside. Based on interviews and observations, the allegations were deemed unfounded.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or were without a reasonable basis.
Report Facts
Elapsed time staff was on break: 10
Elapsed time staff was on break: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melissa Weibel | Administrator | Facility administrator involved in the incident |
Inspection Report
Plan of Correction
Census: 60
Capacity: 160
Deficiencies: 2
Jan 15, 2025
Visit Reason
Unannounced plan of correction visit to follow up on citations issued on 2025-01-08.
Findings
Deficiencies cited under Title 22 Regulation 87464(f)(4) pertaining to Basic Services and Title 22 Regulation 87628(a) pertaining to Diabetes have been cleared. Licensee provided proof of correction and complied with the terms of the plan of correction.
Deficiencies (2)
| Description |
|---|
| Deficiency cited under Title 22 Regulation 87464(f)(4) pertaining to Basic Services |
| Deficiency cited under Title 22 Regulation 87628(a) pertaining to Diabetes |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Made the unannounced plan of correction visit |
| Patricia Perez | Administrator | Facility Administrator named in report header |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 160
Deficiencies: 1
Jan 8, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints alleging lack of care and supervision, and improper medication administration at the facility.
Findings
The allegation of lack of care and supervision was found to be unsubstantiated after interviews and observations. However, the allegation that the facility was not administering medications properly was substantiated, with evidence of missed diabetes-related injections and 13 missed medications in December 2023 due to lack of glucose test strips.
Complaint Details
The complaint investigation was triggered by allegations of lack of care and supervision and improper medication administration. The lack of care allegation was unsubstantiated, while the medication administration allegation was substantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure medication assistance was provided to resident, resulting in missed multiple medications and injections. | Type A |
Report Facts
Missed medications: 13
Facility capacity: 160
Census: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
| Melissa Weibel | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 160
Deficiencies: 1
Jan 8, 2025
Visit Reason
An unannounced case management visit was conducted in conjunction with a complaint investigation (22-AS-20240205143436) to assess compliance with regulations regarding glucose testing by appropriately skilled professionals.
Findings
The investigation found that two staff members performed glucose checks on a resident without being appropriately skilled professionals, violating California Code of Regulations, Title 22, Division 6, Chapter 8. This posed an immediate health and safety risk to residents.
Complaint Details
The visit was triggered by complaint 22-AS-20240205143436. The deficiency was substantiated based on staff interviews and observations.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee failed to ensure glucose testing was performed by an appropriately skilled professional, posing an immediate health and safety risk to residents. | Type A |
Report Facts
Capacity: 160
Census: 61
Plan of Correction Due Date: Jan 9, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and complaint investigation |
| Alisa Ortiz | Licensing Program Manager / Supervisor | Named as Licensing Program Manager and Supervisor in the report |
| Patricia Perez | Administrator | Facility Administrator named in the report |
| Chiquita Morris | Met with during the inspection |
Inspection Report
Follow-Up
Census: 62
Capacity: 160
Deficiencies: 0
Dec 27, 2024
Visit Reason
The visit was an unannounced case management follow-up on an incident report regarding a resident who was hospitalized due to a fracture after a fall in their room.
Findings
The Licensing Program Analyst confirmed the resident was ambulatory prior to the incident and had attended a facility event. No deficiencies were cited during this visit.
Report Facts
Service calls placed by resident: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Samer Haddadin | Licensing Program Analyst | Conducted the unannounced case management visit |
| Jeri Miles | Executive Director | Met with Licensing Program Analyst during the visit |
| Patricia Perez | Administrator | Named as facility administrator |
Inspection Report
Census: 55
Capacity: 160
Deficiencies: 0
Aug 16, 2024
Visit Reason
The visit was conducted as a follow-up on an eviction letter received on May 6, 2024, concerning Resident #1 (R1).
Findings
The Licensing Program Analyst was informed that Resident #1 had passed away on May 30, 2024, and obtained a copy of the death report. An exit interview was conducted with the Executive Director and a copy of the report and files were provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Perez | Executive Director | Met with Licensing Program Analyst during the visit and participated in exit interview. |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 50
Capacity: 160
Deficiencies: 0
Jun 17, 2024
Visit Reason
The Licensing Program Analyst conducted an unannounced visit to perform the required annual inspection of the facility.
Findings
The facility was found to be well maintained with no deficiencies observed. Resident rooms and bathrooms were clean and operational, fire extinguishers were fully charged, and safety systems were functional. Staff files and resident medications reviewed showed no discrepancies.
Report Facts
Resident rooms inspected: 6
Resident files reviewed: 5
Resident medications reviewed: 5
Staff files reviewed: 5
Emergency drill date: May 6, 2024
Signal system response time: 3
Hot water temperature: 105
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Perez | Executive Director | Met with Licensing Program Analyst during inspection and involved in facility tour. |
| Joseph Alejandre | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 160
Deficiencies: 0
May 7, 2024
Visit Reason
An unannounced case management visit was conducted to follow up on incident reports submitted to the department regarding thefts reported by residents.
Findings
The investigation confirmed multiple thefts of checks and cash from residents' rooms by a staff member who admitted to the thefts and was terminated. Police responded and charges are pending. All residents with missing checks were reimbursed.
Complaint Details
The visit was triggered by incident reports of thefts involving missing checks and cash from residents. The staff member responsible admitted to the thefts and was terminated. Police involvement and pending charges were noted.
Report Facts
Amount of missing checks: 900
Amount of missing cash: 140
Amount of missing checks: 1000
Amount of missing cash: 1000
Attempted cash amount: 6260
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit |
| Patricia Perez | Administrator | Met with during the inspection visit |
| Staff 1 | Staff member who admitted to thefts and was terminated |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 160
Deficiencies: 2
Mar 4, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that facility staff were not properly trained, the facility was unsanitary, and the facility failed to safeguard resident belongings.
Findings
The investigation substantiated that staff were not properly trained as a non-skilled professional administered a vaginal suppository, and the facility was unsanitary due to failure to clean a resident's soiled floor and wheelchair. The allegation that the facility failed to safeguard resident belongings was found to be unfounded.
Complaint Details
The complaint investigation was substantiated for allegations that facility staff were not properly trained and that the facility was unsanitary. The allegation that the facility failed to safeguard resident belongings was found to be unfounded.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee failed to ensure an appropriately skilled professional administered a suppository. S1 administered a suppository to R1 and is not a skilled professional, posing an immediate health and safety risk. | Type A |
| Licensee failed to ensure facility is clean and sanitary. S2 failed to clean up resident's soiled floor and wheelchair, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 160
Census: 49
Deficiencies cited: 2
Plan of Correction Due Date: Mar 6, 2024
Plan of Correction Due Date: Mar 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Melissa Weibel | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 160
Deficiencies: 0
Oct 3, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2023-09-01 regarding dietary restrictions not being followed and delayed medical treatment for a resident.
Findings
The investigation found that the resident was not on a special diet at the time of the complaint and dietary restrictions were followed as evidenced by observations and staff interviews. The allegation of delayed medical treatment was also unfounded as the resident was assessed promptly, paramedics were called, and the resident was transported to the hospital and returned the same day with no new orders.
Complaint Details
The complaint was deemed unfounded after investigation, meaning the allegations were false or without reasonable basis.
Report Facts
Capacity: 160
Census: 64
Witnesses interviewed: 8
Witnesses confirming dietary restrictions followed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melissa Weibel | Executive Director | Facility representative met during the investigation |
| Luz Adams | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 160
Deficiencies: 1
Feb 27, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint alleging that lack of staffing resulted in the facility not meeting residents' needs.
Findings
The investigation found that staffing issues were confirmed by all interviewed staff and residents during the alleged time frame, with evidence that Resident 1 required two-person assistance but sometimes only one caregiver was working. Staffing issues were reported to have improved by the time of complaint filing. The allegation was substantiated.
Complaint Details
The complaint alleging lack of staffing resulting in unmet resident needs was substantiated based on interviews with staff and residents and review of documentation. The facility failed to provide the pendant response log to the department. The preponderance of evidence standard was met.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel were not sufficient in numbers and competent to meet resident needs, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 160
Census: 55
Deficiencies cited: 1
Plan of Correction Due Date: Due date was 03/02/2023 (date only, no numeric value to extract)
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Melissa Weibel | Executive Director | Met with Licensing Program Analyst during the investigation |
| Michelle Drinkard | Wellness Director | Present during the investigation visit |
| Daniel Lines | Administrator | Facility administrator named in the report |
| Alisa Ortiz | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 160
Deficiencies: 0
Jan 12, 2023
Visit Reason
The inspection visit was conducted to investigate a complaint alleging that the facility was increasing residents' rent without proper notice.
Findings
The investigation found that although there was some confusion regarding billing due to rescheduling of care conferences, adequate notice was given for both personal service rate adjustments and cost-of-living rate changes. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that the facility was increasing residents' rent without proper notice. The investigation included interviews with the administrator, former Health and Wellness Director, and the alleged victim, as well as review of documentation. The allegation was found unsubstantiated.
Report Facts
Capacity: 160
Census: 52
Date complaint received: Complaint received on 11/15/2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation |
| Sheila Santos | Licensing Program Manager | Named in report as Licensing Program Manager |
| Daniel Lines | Administrator | Facility administrator interviewed during investigation |
| Melissa Weibel | Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Census: 49
Capacity: 160
Deficiencies: 0
Nov 22, 2022
Visit Reason
The visit was a Case Management visit conducted by Licensing Program Analysts and the Executive Director to inform the facility about the requirement to notify the Community Care Licensing division within 30 days of a change in Administrator.
Findings
The Administrator was reminded of the regulation and reporting requirements when hiring a new Administrator. A Technical Assistance was issued. An exit interview was conducted and a copy of the report and Technical Advisory was provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Weibel | Executive Director | Met with during the Case Management visit and informed about reporting requirements. |
| Kevin Saborit-Guash | Licensing Program Analyst | Conducted the Case Management visit. |
| Alvaro Ramirez | Licensing Program Analyst | Conducted the Case Management visit. |
Inspection Report
Annual Inspection
Census: 54
Capacity: 160
Deficiencies: 0
May 5, 2022
Visit Reason
The visit was an unannounced annual inspection focused on infection control at the facility.
Findings
The inspection found that infection control measures were in place including posted Covid signs, temperature checks, vaccination verification, hand sanitizing stations, sufficient PPE supply, and social distancing. No deficiencies were noted during the visit.
Report Facts
PPE supply duration: 30
Covid testing frequency: 7
Resident temperature checks: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Reed | Licensing Program Analyst | Conducted the inspection visit |
| Esmiralda Behonsky | Health and Wellness Director | Met with Licensing Program Analyst during inspection |
| Daniel Lines | Administrator | Facility administrator contacted and present during inspection |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 160
Deficiencies: 1
Dec 1, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility was charging fees and rent for services not provided.
Findings
The investigation substantiated the allegation, finding a billing discrepancy where Resident 1 was overcharged. The facility provided a credit during the visit, but the billing records did not accurately reflect this credit, indicating financial exploitation.
Complaint Details
The complaint was substantiated. The allegation was that the facility charged fees and rent for services not provided. The investigation revealed a billing discrepancy for Resident 1, who was overcharged. The facility provided a credit during the visit.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee failed to ensure Resident 1 was free from financial exploitation, resulting in overcharging and posing a potential health and safety risk to residents. | Type B |
Report Facts
Resident census: 56
Total capacity: 160
Amount owed discrepancy: 76
Amount Resident 1 allegedly owed: 1594
Plan of Correction due date: Dec 15, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Lines | Executive Director | Met with during investigation and provided information regarding billing |
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Follow-Up
Census: 56
Capacity: 160
Deficiencies: 0
Dec 1, 2021
Visit Reason
Unannounced case management visit to follow up on an incident report submitted to Community Care Licensing on 11/22/2021 regarding a resident found outside the facility.
Findings
The visit confirmed that Resident 1, diagnosed with Mild Cognitive Impairment, was found outside the facility but was redirected back and placed on hourly checks. The resident was moved to a memory care unit with no adverse effects, and the Executive Director reported a gradual decline in behavior.
Report Facts
Incident report date: Nov 22, 2021
Resident diagnosis date: Oct 12, 2021
Resident moved date: Nov 24, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Lines | Executive Director | Facility representative who greeted LPAs and provided information about the resident |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit |
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the unannounced case management visit |
| Alisa Ortiz | Licensing Program Manager | Named in the report header |
Inspection Report
Annual Inspection
Census: 57
Capacity: 160
Deficiencies: 0
Oct 5, 2021
Visit Reason
Licensing Program Analyst Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required annual visit.
Findings
The facility appeared clean, sanitary, and well maintained with residents appearing happy and well cared for. No deficiencies were noted during the visit. COVID-19 precautions and mitigation plans were reviewed and approved.
Report Facts
Facility capacity: 160
Resident census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Lines | Executive Director | Met with Licensing Program Analyst during the inspection and holds a current administrator certificate |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 160
Deficiencies: 0
Oct 5, 2021
Visit Reason
The visit was an unannounced case management follow-up on an incident report received regarding a resident eloping from the facility.
Findings
The investigation confirmed that Resident 1 left the facility through a delayed egress door before the alarm was active, was found safe with no injuries, and appeared happy and well cared for during the visit.
Complaint Details
The complaint involved Resident 1 eloping from the facility to McDonald's. The incident was substantiated by the facility's investigation showing the resident left through a delayed egress door at approximately 6:30 PM, before the alarm activation time.
Report Facts
Facility capacity: 160
Resident census: 57
Incident report date: Sep 12, 2021
Incident report received date: Sep 20, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Lines | Executive Director | Facility representative who greeted Licensing Program Analyst and was involved in the incident follow-up |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 160
Deficiencies: 0
Aug 12, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff were not responding to resident needs, resident dishes were left in the hallway, and staff were sleeping in common areas.
Findings
The investigation found no evidence to support the allegations. No dishes were observed in the hallway, staff were reported to pick up dishes promptly, residents with diet modifications were being properly cared for, and no staff were observed sleeping during the visit. The allegations were deemed unfounded.
Complaint Details
The complaint investigation was initiated based on allegations of staff not responding to resident needs, resident dishes left in hallways, and staff sleeping in common areas. The allegations were found to be unfounded after interviews, observations, and documentation review.
Report Facts
Capacity: 160
Census: 58
Witnesses interviewed: 8
Witnesses interviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Daniel Lines | Executive Director | Facility administrator interviewed during investigation |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 160
Deficiencies: 0
Jun 23, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations of staff neglect resulting in a resident's hospitalization and neglect of resident's calls for help multiple times.
Findings
The investigation found that the resident involved was not currently living at the facility and had only been there for respite care in May 2020. The allegations were determined to be unfounded as the resident had moved out and had not returned, and there was no evidence to support the claims.
Complaint Details
The complaint was investigated and deemed unfounded, meaning the allegations were false, could not have happened, and/or were without a reasonable basis.
Report Facts
Capacity: 160
Census: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Lines | Executive Director | Met with during the investigation and discussed the purpose of the visit |
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 160
Deficiencies: 0
Feb 25, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations of inadequate staffing and personal rights violations at the facility.
Findings
The investigation found that all interviewed staff denied the allegations of residents being covered in ants or urine, and staffing levels were consistent with the facility's schedule. The allegations were deemed unfounded as there was no evidence to support them.
Complaint Details
The complaint investigation was initiated based on allegations of inadequate staffing and personal rights violations. The allegations were found to be unfounded after interviews, documentation review, and observation.
Report Facts
Facility capacity: 160
Census: 57
Dates of ant treatment: 2
Staffing levels: 3
Staffing levels: 1
Staffing levels: 1
Staffing levels: 2
Staffing levels: 1
Staffing levels: 1
Staffing levels: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Daniel Lines | Administrator | Facility administrator interviewed during investigation |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Loading inspection reports...
