Most inspections found no deficiencies, with routine annual and complaint investigations consistently showing compliance and proper care. The only deficiency occurred in a complaint investigation on January 22, 2024, where the facility was cited for inadequate supervision after a resident eloped and was injured; the facility responded by enhancing supervision and safety measures. Several other complaint investigations were unsubstantiated, including concerns about COVID protocols, accessibility, and medication administration. The most recent report from February 25, 2025, was clean with no deficiencies noted. This suggests the facility has maintained or improved its compliance over time, addressing isolated issues effectively.
The visit was an unannounced required comprehensive annual inspection of the Residential Care Facility for Elderly (RCFE).
Findings
The facility was found to be operating within approved capacity and in good repair with no obstructions, sufficient furniture, clean bathrooms, and proper safety equipment. Staff had required clearances and certifications, medications were dispensed appropriately, and no deficiencies were cited.
Report Facts
Resident files reviewed: 6Staff files reviewed: 5
Employees Mentioned
Name
Title
Context
Cynthia Figueroa
Facility Administrator
Met with Licensing Program Analyst during inspection and named in report.
Paola Guerrero
Licensing Program Analyst
Conducted the unannounced annual inspection visit.
An unannounced annual required visit was conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be operating within licensed capacity and maintaining safe physical conditions, adequate food supply, competent staffing, and proper medication management. No deficiencies were cited during the inspection.
An unannounced complaint investigation was conducted due to an allegation that a resident eloped from the facility without staff knowledge, sustaining an injury.
Findings
The investigation substantiated the complaint that staff did not provide adequate care and supervision when the resident left the facility unsupervised and sustained an injury. The facility has since increased supervision, added door alarms, provided staff training on elopement, and the resident's family arranged additional supervision and physician intervention.
Complaint Details
The complaint was substantiated based on observations, record reviews, and staff interviews. The resident eloped on 01/15/24, sustaining a knee injury. The facility was found to be inadequately supervising the resident at that time.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Failure to provide care and supervision as necessary to meet the client's needs, resulting in a resident eloping from the facility unsupervised and sustaining an injury.
The inspection was an unannounced complaint investigation conducted in response to allegations received on 2023-02-09 regarding staff not following COVID protocols, not meeting the needs of COVID positive residents, and insufficient staffing affecting timely meal service, feeding assistance, and toileting assistance.
Findings
The investigation found that the facility was following COVID protocols with proper PPE and sanitation stations, and staff were meeting the needs of COVID positive residents. Interviews with staff and residents confirmed that meals, feeding, and toileting assistance were provided in a timely manner. Therefore, the allegations were deemed unsubstantiated due to lack of sufficient evidence.
Complaint Details
The complaint investigation was unsubstantiated. There was not enough evidence to prove that staff failed to follow COVID protocols or meet resident needs related to COVID positive care and timely assistance with meals, feeding, and toileting.
Report Facts
Capacity: 117Census: 74
Employees Mentioned
Name
Title
Context
Javier Prieto
Licensing Program Analyst
Conducted the complaint investigation
Karen Clemons
Licensing Program Manager
Named in the report as Licensing Program Manager
Gen Diaz
Business Office Director
Met with investigators during the complaint investigation
The inspection was conducted as a complaint investigation regarding allegations that the facility doors are too heavy for residents in wheelchairs to open and exit at will, and that sinks are not wheelchair accessible.
Findings
The investigation found that the facility doors are fire doors installed since 2020 and while some doors are heavy, residents have means to request assistance. The facility has wheelchair accessible sinks limited to the memory care section. The allegations were deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint was unsubstantiated based on the investigation findings. The Licensing Program Analyst met with the Executive Director, toured the facility, and interviewed residents. The Executive Director acknowledged concerns and stated plans for renovations to meet building codes.
Report Facts
Capacity: 117Census: 75
Employees Mentioned
Name
Title
Context
Javier Prieto
Licensing Program Analyst
Conducted the complaint investigation
Cynthia Figueroa
Executive Director
Met with Licensing Program Analyst and involved in addressing concerns
An unannounced complaint investigation visit was conducted in response to allegations received on 2022-02-09 regarding medication administration, notification of change in condition, and missed medication at the facility.
Findings
The investigation found that although some medication administration issues were noted, the evidence was insufficient to substantiate the allegations. The complaint was determined to be unsubstantiated after review of records and interviews.
Complaint Details
The complaint included three allegations: 1) Staff did not administer medications according to physician orders; 2) Staff did not notify authorized representative of change in condition; 3) Resident missed medication. After investigation, all allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 117Census: 75
Employees Mentioned
Name
Title
Context
Ben Jilbert
Memory Care Director
Met with Licensing Program Analysts during the investigation
An unannounced annual inspection was conducted with an emphasis on infection control to assess compliance with regulatory requirements.
Findings
The facility was found to be in compliance with infection control practices, including COVID-19 mitigation measures, and no deficiencies were observed or cited during the visit.
Employees Mentioned
Name
Title
Context
Alexis Perez
Executive Director
Met with Licensing Program Analysts during the inspection.
Inspection Report Original LicensingCapacity: 117Deficiencies: 0Feb 8, 2021
Visit Reason
An announced pre-licensing video conference inspection was conducted due to COVID-19 to evaluate the facility's readiness for licensure as a Residential Care Facility for the Elderly (RCFE).
Findings
The facility was observed to have appropriate screening procedures, adequate PPE supplies, fire safety equipment, and suitable living accommodations including assisted living and memory care units. The fire inspection was conducted and approved, and the facility appears ready for licensure.
Report Facts
Facility capacity: 117Census: 0
Employees Mentioned
Name
Title
Context
Alexis Perez
Director
Met with Licensing Program Analyst during inspection
Shaunte Henry
Licensing Program Analyst
Conducted the pre-licensing inspection
Edna Musoke
Licensing Program Manager
Named in report header
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