Inspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on December 6, 2024, which was clean. Earlier reports showed isolated issues such as a failed fire extinguisher inspection in late 2022 and incomplete criminal record clearance transfers after the facility’s license was issued in April 2023. Several complaint investigations were unsubstantiated, including allegations of wrongful eviction and uncomfortable temperatures. There were no fines, enforcement actions, or severe findings reported. The facility’s record shows improvement over time, with recent inspections consistently meeting standards.
Deficiencies per Year
4
3
2
1
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 76
Capacity: 151
Deficiencies: 0
Dec 6, 2024
Visit Reason
The inspection was a required 1-Year Annual inspection conducted to evaluate the facility's compliance with licensing regulations.
Findings
The Licensing Program Analysts toured the facility and reviewed resident and staff records, finding no deficiencies. The facility was found to be in compliance with safety, environmental, and record-keeping standards.
Report Facts
Resident records reviewed: 5
Staff records reviewed: 5
Fire extinguisher last serviced: Dec 22, 2023
Emergency disaster drill last conducted: Oct 11, 2024
Hot water temperature: 118.6
Hallway temperature: 78
Food supply: 7
Food supply: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iryn Macamay | Assistant Executive Director | Met with Licensing Program Analysts during inspection |
| David Doidge | Licensing Program Analyst | Conducted the inspection |
| J. Sampair | Licensing Program Analyst | Conducted the inspection |
| Bennett Fong | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 151
Deficiencies: 0
Dec 6, 2024
Visit Reason
The inspection visit was conducted to investigate a complaint alleging wrongful eviction of a resident at the facility.
Findings
The investigation found that the resident required a higher level of care than the facility could provide. Although the allegation may have occurred, there was not a preponderance of evidence to substantiate the wrongful eviction claim; therefore, the allegation was unsubstantiated.
Complaint Details
The complaint alleged wrongful eviction of Resident R1. The allegation was investigated through document review and interviews with witnesses and facility staff. The allegation was determined to be unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 151
Census: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| David Doidge | Licensing Program Analyst | Conducted the complaint investigation |
| Iryn Macamay | Assistant Executive Director | Interviewed during the investigation |
| Graciela Canseco | Assisted Living Director | Interviewed during the investigation |
Inspection Report
Census: 172
Capacity: 151
Deficiencies: 0
Aug 1, 2024
Visit Reason
The visit was an unannounced case management inspection concerning a reported incident on 2024-07-25 involving a resident's missing debit card.
Findings
During the visit, the Executive Director and resident were interviewed about the incident. An internal investigation and police investigations were ongoing, with a former staff member identified as the main suspect. No citations were issued during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ricardo Romero | Executive Director | Interviewed during the visit regarding the incident. |
| James Sampair | Licensing Program Analyst | Conducted the inspection visit. |
| David Doidge | Licensing Program Analyst | Conducted the inspection visit. |
Inspection Report
Annual Inspection
Census: 162
Capacity: 151
Deficiencies: 0
Feb 23, 2024
Visit Reason
The visit was conducted to continue the annual inspection that began on 2024-02-13, as part of the required annual inspection process.
Findings
The annual inspection was completed with no citations issued. The Licensing Program Analyst reviewed records of staff and residents and conducted interviews with both groups.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ricardo Romero | Administrator | Met with during inspection and mentioned in the narrative. |
| James Sampair | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Bennett Fong | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Capacity: 151
Deficiencies: 0
Feb 13, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be appropriately furnished, well lit, and maintained with professional grade equipment. Food supplies, emergency lighting, medication storage, and safety measures such as fire extinguishers and pool fencing were all in compliance. No citations were issued during this incomplete inspection, which will be continued at a later date.
Report Facts
Facility capacity: 151
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ricardo Romero | Administrator | Met with Licensing Program Analyst during inspection |
| James Sampair | Licensing Program Analyst | Conducted the inspection |
| Bennett Fong | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 160
Capacity: 151
Deficiencies: 0
Jan 12, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility was not maintaining a comfortable temperature for residents.
Findings
The investigation found that the temperature in the main dining room was 69.5 degrees Fahrenheit during mealtime, and most residents interviewed did not find it uncomfortably cold. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff were not maintaining a comfortable temperature for residents. The allegation was unsubstantiated after investigation.
Report Facts
Temperature: 69.5
Residents interviewed: 6
Residents responding 'No' to uncomfortable temperature: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ricardo Romero | Executive Director | Met with during investigation and explained efforts to resolve temperature issue |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 151
Deficiencies: 0
Sep 19, 2023
Visit Reason
The visit was an unannounced case management inspection concerning an incident that occurred on 2023-09-12 involving residents R1 and W1, as described in an unusual incident report dated 2023-09-15.
Findings
During the visit, the Assisted Living Director retold the incident and provided an update on the status of resident R1, who had returned to the facility after hospitalization and skilled nursing, currently receiving 24/7 private caregiver assistance. No citations were issued during this visit.
Complaint Details
The visit was triggered by a complaint related to an incident involving residents R1 and W1. The report does not state whether the complaint was substantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Gurnack | Assisted Living Director | Interviewed during the visit and provided details about the incident and resident status. |
| Ricardo Romero | Executive Director | Facility administrator and recipient of the stated purpose of the visit. |
| Iryn Macamay | Assistant Executive Director | Met during the visit and participated in the exit interview. |
| James Sampair | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Capacity: 151
Deficiencies: 0
Jul 28, 2023
Visit Reason
Unannounced case management visit concerning an incident reported on 06/29/2023 related to medication errors occurring between 06/12/2023 and 06/23/2023.
Findings
The Administrator explained communication errors that led to running out of and not dispensing a resident's medication for the specified period. Staff retraining and protocol review were conducted, and no citations were issued during the visit.
Report Facts
Incident date: Jun 23, 2023
Medication non-dispensing period start: Jun 12, 2023
Medication non-dispensing period end: Jun 23, 2023
Staff meeting date: Jul 5, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ricardo Romero | Administrator | Explained medication errors during visit |
| Danica Aquino | Resident Care Supervisor | Met with Licensing Program Analyst during visit |
| Jessica Gurnack | Assisted Living Director | Met with Medication Technicians to review refill protocol |
Inspection Report
Follow-Up
Census: 86
Capacity: 151
Deficiencies: 0
Apr 18, 2023
Visit Reason
The visit was an unannounced follow-up to the 04/10/2023 Post-Licensing inspection visit to assess compliance and corrective actions.
Findings
During the inspection, the Licensing Program Analyst inspected the physical plant, kitchen, staff and resident files, and interviewed staff and residents. No citations were issued.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gia Aron | Resident Relations Director | Assisted the Licensing Program Analyst throughout the inspection and participated in the exit interview. |
Inspection Report
Original Licensing
Census: 88
Capacity: 151
Deficiencies: 1
Apr 10, 2023
Visit Reason
The inspection visit was an unannounced Post-Licensing inspection conducted to evaluate compliance following the issuance of a new license for the facility.
Findings
The inspection identified one deficiency related to incomplete criminal record clearance transfers, with 3 of 72 transfers not completed after the new license was issued. The inspection was incomplete and will be continued at a future date.
Deficiencies (1)
| Description |
|---|
| Based on record review, the licensee did not comply with criminal record clearance transfer requirements in 3 of 72 cases after new license issuance, posing potential health, safety, or personal rights risks. |
Report Facts
Deficiencies cited: 1
Incomplete criminal record clearance transfers: 3
Total criminal record clearance transfers reviewed: 72
Facility capacity: 151
Facility census: 88
Hot water temperature: 118
Room temperature: 75.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Gia Aron | Resident Relations Director | Met with Licensing Program Analyst during inspection and exit interview |
| Harpreet Humpal | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Original Licensing
Census: 88
Capacity: 151
Deficiencies: 0
Jan 4, 2023
Visit Reason
The inspection was an unannounced change of ownership prelicensing visit conducted to evaluate the facility for licensing approval.
Findings
No citations or deficiencies were found during the visit. The pre-licensing process is complete and the facility has no deficiencies.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ernesto Navas | Environmental Services Director | Met with Licensing Program Analyst during the inspection visit. |
Inspection Report
Original Licensing
Census: 88
Capacity: 151
Deficiencies: 1
Dec 27, 2022
Visit Reason
The visit was an unannounced prelicensing inspection conducted due to a change of ownership application for the facility, which is currently in operation.
Findings
The facility was toured and inspected thoroughly, including common areas, resident rooms, and safety equipment. Most conditions were satisfactory, including COVID-19 screening, PPE storage, and safety features. However, a citation was issued for fire extinguishers that did not pass inspection.
Deficiencies (1)
| Description |
|---|
| Fire extinguishers did not pass inspection |
Report Facts
Total capacity: 151
Non-ambulatory capacity: 141
Bedridden capacity: 10
Hot water temperature: 115
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gia Aron | Resident Relations Director | Met with Licensing Program Analyst during the inspection |
| James Sampair | Licensing Program Analyst | Conducted the inspection and signed the report |
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