Inspection Reports for Cadence Millbrae by Cogir
1201 Broadway, Millbrae, CA 94030, United States, CA, 94030
Back to Facility ProfileInspection Report Summary
Most inspections in recent years found no deficiencies, including the latest annual inspection on August 27, 2025, which was clean with no citations issued. Some earlier reports documented deficiencies related primarily to resident care and supervision, especially concerning fall risk management and medication administration errors in 2024. There were also issues with infection control and reporting during the COVID-19 pandemic in 2022, as well as a failure to maintain certain resident records and submit a new license application after a change in ownership. Several complaint investigations were unsubstantiated or unfounded, including allegations about pest control, food service, financial abuse, and resident rights. The facility appears to have improved over time, with the most recent inspections showing compliance and no new deficiencies.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 157
Capacity: 165
Deficiencies: 0
Aug 27, 2025
Visit Reason
An unannounced annual inspection visit was conducted to evaluate compliance with licensing requirements and ensure the safety and well-being of residents.
Findings
The facility was found to be generally compliant with regulations, including safety measures, medication management, and cleanliness. No citations were issued, but updated forms were requested to be submitted by 09/03/2025.
Report Facts
Residents in assisted living: 136
Residents in memory care: 21
Administrator certificate expiration: Jan 14, 2027
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Suiter | Executive Director | Met with Licensing Program Analyst during inspection and reviewed report |
| Jaime Vado | Licensing Program Analyst | Conducted the inspection and signed the report |
| April Cowan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 165
Deficiencies: 0
Aug 27, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2025-07-30 regarding pest control and adequacy of food service at the facility.
Findings
The investigation found the allegation of pest presence unsubstantiated as the facility was actively monitoring pest control and passed county food safety inspections. The allegation of inadequate food service was found unfounded, with no meals skipped during a temporary kitchen closure and adequate alternative food services provided.
Complaint Details
The complaint investigation was unsubstantiated for pest control issues and unfounded for inadequate food service. The allegations were either not supported by evidence or found to be false.
Report Facts
Facility capacity: 165
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation visit |
| Holly Suiter | Administrator | Facility administrator met during the investigation |
| April Cowan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 165
Deficiencies: 0
Apr 8, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations received regarding staff overcharging a resident in care and failure to communicate timely with the resident's POA, as well as re-evaluation of a resident's care plan without the POA present.
Findings
The investigation found the overcharging was an error corrected by the facility and communication issues could not be substantiated. The allegation regarding re-evaluation of the care plan without the POA present was found unfounded as POA attendance is not required by regulation. Overall, the allegations were unsubstantiated or unfounded.
Complaint Details
The complaint investigation was unsubstantiated for allegations of overcharging and communication delays, and unfounded for the allegation of re-evaluating the resident's care plan without the POA present.
Report Facts
Capacity: 165
Census: 141
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation visit |
| Davina Booker | Interim Administrator | Met with Licensing Program Analyst during investigation |
| Joan Newman | Administrator | Facility administrator named in report header |
| April Cowan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 165
Deficiencies: 1
Nov 8, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff mishandled a resident's medication.
Findings
The investigation found that the facility failed to provide a prescribed medication to a resident during two separate periods in 2024 without a physician's order to discontinue. This was due to facility error, and the allegation was substantiated.
Complaint Details
The complaint was substantiated based on interviews and documentation reviewed. The medication was not given as prescribed due to facility error.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to administer prescribed medication according to physician's directions, with medication stopped without physician discontinuation orders from 2/18/24 through 4/7/24 and 4/27/24 through 8/17/24. | Type A |
Report Facts
Capacity: 165
Census: 121
Plan of Correction Due Date: Nov 9, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joan Newman | Administrator | Facility administrator met with the Licensing Program Analyst during the investigation |
| April Cowan | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 121
Capacity: 165
Deficiencies: 0
Nov 8, 2024
Visit Reason
The visit was an unannounced case management - incident inspection conducted in response to an SOC 341 report received on 2024-11-07.
Findings
The facility staff investigated the reported incident but could not identify the person described by the resident. No staff or male residents matched the description, and the facility lacks cameras in common areas. As a precaution, the facility implemented a plan to prevent males from entering the resident's room, including assigning no male staff to the resident unless accompanied by a female care partner. The family is aware and cooperating. No citations were issued.
Report Facts
Capacity: 165
Census: 121
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joan Newman | Administrator | Met with Licensing Program Analyst during the visit and involved in incident discussion |
| Jaime Vado | Licensing Program Analyst | Conducted the unannounced case management - incident visit |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 112
Capacity: 165
Deficiencies: 1
Sep 27, 2024
Visit Reason
An unannounced case management visit was conducted to request documentation related to a prior complaint investigation from 2023 regarding a resident's ADL reference sheet.
Findings
The facility was unable to provide the requested resident document dated 06/27/2023, which is required to be retained for three years. This failure poses a potential health and safety risk and resulted in a citation being issued.
Complaint Details
The visit was related to complaint #14-AS-20230804102303. The facility was unable to provide the requested documentation related to the complaint, resulting in a citation.
Deficiencies (1)
| Description |
|---|
| Failure to retain original resident records or photographic reproductions for a minimum of three years following termination of service, specifically the missing document dated 06/27/2023. |
Report Facts
Capacity: 165
Census: 112
Plan of Correction Due Date: Oct 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the inspection and issued the citation |
| Tina Pedagat | Business Office Manager | Met with the Licensing Program Analyst during the visit |
| April Cowan | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 108
Capacity: 165
Deficiencies: 0
Aug 20, 2024
Visit Reason
An unannounced annual inspection visit was conducted to evaluate compliance with regulatory requirements for the assisted living and memory care facility.
Findings
The facility was found to be clean, safe, and well-maintained with proper medication storage and current staff and resident files. No citations were issued, and all safety equipment and emergency procedures were observed to be in place and current.
Report Facts
Residents in assisted living: 91
Residents in memory care: 17
Hospice clearance: 14
Water temperature: 111
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joan Newman | Administrator / Executive Director | Met with Licensing Program Analyst during inspection and reviewed report |
| Jaime Vado | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
Inspection Report
Monitoring
Capacity: 165
Deficiencies: 7
Jun 24, 2024
Visit Reason
The visit was a non-compliance conference meeting conducted by the San Bruno Regional Office to discuss violations and ensure compliance with Title 22 Regulations.
Findings
During the meeting, multiple violations related to personal rights, infection control, reporting requirements, observation of residents, basic services, and reappraisals were discussed. The licensee will receive more frequent monitoring inspection visits for two years to ensure compliance.
Deficiencies (7)
| Description |
|---|
| Violation of Personal Rights of Residents in All Facilities (87468.1(a)(2)) |
| Violation of Infection Control Requirements (87470(b)(2)) |
| Violation of Reporting Requirements (87211(a)(2)) |
| Violation of Observation of Resident (87466) |
| Violation of Basic Services (87464) |
| Violation of Additional Personal Rights of Residents in Privately Operated Facilities (87468.2(a)(4)) |
| Violation of Reappraisals (87463(a)(4)) |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joan Newman | Executive Director | Met with during non-compliance conference meeting |
| Joel Goldman | Attorney | Present during non-compliance conference meeting |
| Mark Maclaine | Regional VPO | Present during non-compliance conference meeting |
| Holly McMurry | Director of Compliance | Present during non-compliance conference meeting |
| Vivien Helbling | Regional Manager | Present during non-compliance conference meeting |
| April Cowan | Licensing Program Manager | Present during non-compliance conference meeting |
| Grace Donato | Licensing Program Analyst | Present during non-compliance conference meeting |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 165
Deficiencies: 0
May 8, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff were not providing medication as prescribed.
Findings
The investigation found inconsistent information regarding medication administration of Quetiapine in January 2024. Based on interviews and documentation, the allegation was determined to be unsubstantiated due to insufficient evidence to prove the violation.
Complaint Details
The complaint alleged that staff were not providing medication as prescribed. The investigation included review of client files, interviews with the client and staff, and examination of medication administration records. The allegation was found unsubstantiated.
Report Facts
Facility capacity: 165
Census: 105
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Evaluator | Conducted the complaint investigation |
| Kiel Stromgren | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 165
Deficiencies: 0
May 8, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of staff financially abusing a resident in care.
Findings
The investigation included interviews with residents and review of client records. The allegation was determined to be unsubstantiated due to insufficient evidence to prove the violation did or did not occur. There was a related allegation of female staff 'flirting' with male residents to get cash tips, which may have occurred as an isolated incident but was not substantiated.
Complaint Details
The complaint alleged staff were financially abusing a resident in care. The allegation was found unsubstantiated after investigation. It was also alleged that female staff were 'flirting' with male residents to get cash tips; this was neither proven nor refuted conclusively.
Report Facts
Capacity: 165
Census: 105
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Cara Smith | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 165
Deficiencies: 0
May 8, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that staff do not ensure residents are adequately fed and that the facility is charging for services not rendered.
Findings
The investigation found the allegations to be unsubstantiated and unfounded. Observations, interviews, and record reviews showed that meal services were provided as ordered, and residents reported satisfaction with meal delivery. Charges for meal delivery were confirmed with discounts applied.
Complaint Details
The complaint alleging inadequate feeding of residents and charging for undelivered meal services was investigated and determined to be unsubstantiated and unfounded, respectively.
Report Facts
Capacity: 165
Census: 105
Meal delivery charge: 6
Daily meal delivery charge: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Evaluator | Conducted the complaint investigation |
| Kiel Stromgren | Administrator | Facility administrator named in the report |
| Joan Newman | Person met with during the investigation | |
| Cara Smith | Licensing Program Manager | Named in report as licensing program manager |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 165
Deficiencies: 2
Mar 1, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff failed to meet a resident's needs and that a resident sustained multiple falls and injuries while in care.
Findings
The investigation found that the resident had multiple documented falls between March 2022 and May 2023, including a significant fall on May 29, 2023, which resulted in hospitalization and arm separation. The facility failed to reassess the resident as a fall risk and did not establish or update safety measures to prevent further falls.
Complaint Details
The complaint was substantiated based on the preponderance of evidence. The resident sustained multiple falls, including a serious fall on May 29, 2023, with no staff supervision present at the time. The facility failed to reassess and update care plans to prevent falls.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to update pre-admission appraisal in writing to note significant changes and keep the appraisal accurate, including reassessment of resident identified as a fall risk. | Type A |
| Failure to provide care, supervision, and services that meet individual resident needs, including sufficient staff to supervise a resident identified as a fall risk. | Type A |
Report Facts
Capacity: 165
Census: 118
Deficiencies cited: 2
Plan of Correction Due Date: Mar 2, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 165
Deficiencies: 2
Feb 22, 2024
Visit Reason
Unannounced complaint investigation visit triggered by allegations that a resident sustained an arm separation and suffered from dehydration while in care.
Findings
The investigation substantiated the allegations, finding that the facility failed to provide adequate supervision to a fall-risk resident and failed to monitor and seek medical attention for changes in the resident's condition, resulting in injury and severe dehydration requiring hospitalization.
Complaint Details
The complaint was substantiated based on review of facility and medical records and staff interviews. The resident was admitted to ICU with severe sepsis and hypernatremia after missed meals and inadequate documentation and monitoring by staff.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure adequate supervision of a client who was a fall risk by leaving resident with fall risks alone, posing immediate health, safety, or personal rights risk. | Type A |
| Failed to regularly observe residents for changes in physical, mental, emotional and social functioning and failed to seek medical attention when changes were observed. | Type A |
Report Facts
Civil penalties: 1000
Capacity: 165
Census: 114
Inspection Report
Census: 137
Capacity: 165
Deficiencies: 1
Aug 3, 2023
Visit Reason
The visit was a Case Management - Deficiencies unannounced inspection to evaluate the facility's organizational changes and compliance with licensing requirements.
Findings
The facility was found deficient for failing to submit a new application for licensure following a change of ownership and management. Cogir Management USA Inc. acquired the facility but has not yet applied for RCFE licensure, posing a potential health, safety, or personal rights risk to clients.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit a new application for license following change of ownership and management by Cogir Management USA Inc. | Type B |
Report Facts
Capacity: 165
Census: 137
Plan of Correction Due Date: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cara Smith | Licensing Program Manager | Named as supervisor and licensing program manager |
| Audrey Jeung | Licensing Program Analyst | Named as licensing evaluator and program analyst |
| Michael Sharkey | Met with during inspection | |
| Margaret Madrid | Met with during inspection |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 165
Deficiencies: 2
Jun 8, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/19/2022 regarding the facility not providing a comfortable temperature for residents and not adhering to the admissions agreement.
Findings
The investigation substantiated the allegations that the facility failed to maintain a comfortable temperature in residents' apartments during extreme heat and did not adhere to the admissions agreement which stated apartments were air conditioned. The residency agreements were subsequently revised to remove the air conditioning claim.
Complaint Details
The complaint was substantiated based on observations during the initial visit on 09/22/2022, information from facility staff and the complainant, meeting with the business office manager and new executive director, and review of residency agreements.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain a comfortable temperature for residents during extreme heat, with rooms on the west side not comfortably cool, posing a potential health, safety, or personal rights risk. | Type B |
| Failure to comply with terms of the admission agreement by not providing air conditioning in residents' apartments as previously stated, posing a potential health, safety, or personal rights risk. | Type B |
Report Facts
Facility capacity: 165
Census: 131
Temperature range: 97
Plan of Correction due date: Jun 22, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Cara Smith | Licensing Program Manager | Named in relation to the complaint investigation report |
Inspection Report
Census: 131
Capacity: 165
Deficiencies: 0
Jun 8, 2023
Visit Reason
The visit was a Case Management - Health Checks to discuss recent move-ins and review admission documentation compliance.
Findings
No health or safety deficiencies were observed during the visit. The administrator was reminded to ensure completion of required admission documents and to submit documentation for administrator designation.
Report Facts
Recent move-ins: 8
Apartments observed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Madrid | Met during visit | |
| Michael Sharkey | Met during visit; discussed administrator designation | |
| Kiel Stromgren | Administrator | Facility administrator mentioned in report |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 165
Deficiencies: 0
Dec 8, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was operating without an Administrator and that transportation vehicles were in disrepair.
Findings
The investigation found that the previous administrator's last working day was 9/21/22 and the vice president of operations has been acting as interim administrator. The facility's only vehicle, a Ford Starcraft bus, has not been driven for over 3 months due to the resignation of the Class B driver, and will be inspected before use. Despite expired registration stickers, vehicle registration was paid and proof provided. The complaint was determined to be unfounded.
Complaint Details
The complaint was investigated and determined to be unfounded, meaning the allegations could not have happened and/or were without a reasonable basis.
Report Facts
Facility capacity: 165
Census: 127
Date complaint received: Nov 29, 2022
Date administrator last worked: Sep 21, 2022
Date Class B driver resigned: Aug 18, 2022
Date vehicle registration paid: Jun 1, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Licensing Program Analyst | Conducted the complaint investigation |
| Cara Smith | Licensing Program Manager | Named as Licensing Program Manager on report |
| Kiel Stromgren | Administrator | Named as facility administrator (last working day 9/21/22) |
| Kelly Metz | Interim Administrator/RCFE Administrator | Interim administrator and vice-president of operations acting in administrator role |
| Margaret Madrid | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 165
Deficiencies: 0
Dec 8, 2022
Visit Reason
The visit was conducted as a case management follow-up on a Suspected Abuse Report submitted to the Community Care Licensing Division on 9/12/22 regarding suspected financial abuse of a client.
Findings
No deficiencies were cited during this visit. The licensing program analyst obtained details of the incident, including law enforcement case number and sheriff contact information, but no additional information was provided as the incident was handled by a former executive director.
Complaint Details
The visit was related to a suspected financial abuse complaint involving client #1. The complaint was investigated, but no deficiencies were cited. The incident was handled by the former executive director who is no longer employed.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Licensing Program Analyst | Met with business office manager to follow up on Suspected Abuse Report and obtained incident details. |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 165
Deficiencies: 0
Sep 22, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-06-02 regarding concerns that a resident's needs were not being met, the resident was not being fed, and the resident's room was unkempt.
Findings
The investigation found the allegations to be unsubstantiated after reviewing the client's file, observing the client's room, and interviewing the client, staff, and witnesses. Staff provided assistance when needed, including during a COVID infection, and the food delivered was not eaten by the client.
Complaint Details
The complaint was unsubstantiated based on the investigation findings. Although some concerns may have occurred or be valid, there was insufficient evidence to prove the alleged violations.
Report Facts
Facility capacity: 165
Census: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Jackie Jin | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 165
Deficiencies: 0
Sep 22, 2022
Visit Reason
The visit was conducted as a case management incident related to a suspected abuse report submitted to the Community Care Licensing Division (CCLD).
Findings
The investigation is still pending and was handled by the former executive director who is no longer employed. Additional information is not available at this time. An updated Personnel Report (LIC500) is to be submitted to CCLD by 9/29/22.
Complaint Details
Investigation of suspected abuse report is pending; handled by former executive director; additional information unavailable.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Licensing Program Analyst | Met with business office manager to obtain additional information about suspected abuse report. |
| Jackie Jin | Licensing Program Manager | Named as Licensing Program Manager on report. |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 165
Deficiencies: 4
May 27, 2022
Visit Reason
The visit was conducted in response to information about COVID infections among staff and clients at the facility, to assess compliance with infection control and reporting requirements.
Findings
The facility failed to report COVID cases to the Community Care Licensing Division and local public health department, lacked proper PPE supplies, did not maintain daily symptom and temperature logs for staff and clients, and did not follow proper isolation procedures for COVID-positive residents. Staff were observed not wearing full PPE when assisting COVID clients.
Complaint Details
The visit was complaint-related due to reports of COVID infections among staff and clients. The complaint was substantiated as multiple deficiencies related to infection control and reporting were found.
Severity Breakdown
Type A: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to report COVID infections to CCLD and County Public Health Department within required timeframe. | Type A |
| Failure to ensure staff with direct contact to COVID clients wore appropriate PPE including gloves, gowns, masks, and respirators. | Type A |
| Failure to designate rooms of COVID clients as restricted entry and lack of isolation carts outside rooms for PPE donning and doffing. | Type A |
| Failure to maintain daily screening logs for temperature and COVID symptoms for staff and clients. | Type A |
Report Facts
Staff with COVID: 11
Clients with COVID: 7
Caregivers on duty without symptom checks: 4
Facility capacity: 165
Facility census: 127
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kiel Stromgren | Administrator | Met with licensing analyst and confirmed COVID cases |
| Audrey Jeung | Licensing Program Analyst | Conducted inspection and authored report |
| Julio Montes | Licensing Program Manager | Supervisor overseeing inspection |
Inspection Report
Census: 127
Capacity: 165
Deficiencies: 0
May 27, 2022
Visit Reason
The visit was an unannounced case management incident review related to a memory care client who left the building unattended on 03/13/22 and was found an hour later at his residence.
Findings
The staff were unable to determine how the resident exited the building given security measures in place. Physician's Report, updated Service Plans, and documentation of staff participation in an Elopement Drill were reviewed and submitted. No deficiencies were cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kiel Stromgren | Administrator | Met with during the visit |
| Audrey Jeung | Licensing Program Analyst | Observed client and authored report narrative |
| Julio Montes | Licensing Program Manager | Named in report |
Inspection Report
Census: 118
Capacity: 188
Deficiencies: 3
Jan 6, 2022
Visit Reason
The visit was conducted in response to a capacity change application for 165 elderly residents, including touring a new memory care unit and evaluating its readiness.
Findings
The new memory care unit was found not ready to accommodate residents due to missing COVID signage, lack of liquid soap and paper towels in bathrooms, and concerns about the vestibule egress. Fire clearance and safety features were approved, but some hygiene and signage deficiencies were noted.
Deficiencies (3)
| Description |
|---|
| No COVID signage in the memory care unit, including handwashing, mask wearing, and social distancing reminder signs. |
| Liquid soap and paper towels are not present in bathrooms. |
| Vestibule on ground floor accesses memory care unit and parking lot; its use as an egress is advised against during the pandemic. |
Report Facts
Residents in existing memory care unit: 14
Capacity: 188
Census: 118
Memory care unit rooms: 12
Dining chairs: 12
Residents proposed: 165
Non-ambulatory residents proposed: 105
Ambulatory residents proposed: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kiel Stromgren | Administrator | Discussed observations and facility details during inspection |
| Audrey Jeung | Licensing Program Analyst | Conducted the tour and inspection of the memory care units |
| Julio Montes | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 105
Capacity: 188
Deficiencies: 0
Jul 26, 2021
Visit Reason
The inspection was a required unannounced 1-year visit to evaluate the facility's compliance with regulations and overall operations.
Findings
No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 were cited. The facility is undergoing renovations and maintains adequate infection control practices, proper storage of medications and sharps, and sufficient PPE supply. Technical violations and advisories were issued.
Report Facts
Number of studio and 1-bedroom units: 158
Memory care unit rooms: 18
Requested submission deadline: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kiel Stromgren | Administrator | Facility administrator overseeing operations, certified RCFE administrator |
| Audrey Jeung | Licensing Program Analyst | Conducted facility tour and inspection |
| Julio Montes | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 102
Capacity: 188
Deficiencies: 0
May 28, 2021
Visit Reason
The visit was a case management follow-up to investigate the circumstances of a client's death reported on 02/24/2021.
Findings
The investigation determined the client's death on 02/23/2021 was natural and not questionable, caused by heart failure. The client was independent and did not require care or supervision. No deficiencies were cited based on this incident.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kiel Stromgren | Administrator | Met with Licensing Program Analyst during follow-up visit related to death report. |
| Audrey Jeung | Licensing Program Analyst | Conducted the follow-up investigation and met with the Administrator. |
| Julio Montes | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 188
Deficiencies: 0
Mar 16, 2021
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that facility staff failed to give resident medication on time, restricted resident visitors, and restricted resident phone calls.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Medication was administered timely, visitor restrictions were due to COVID-19 safety policies, and residents had access to phones. Therefore, all allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on review of medical records, facility policies related to COVID-19 visitor restrictions, and resident phone access. Allegations included medication timing, visitor restrictions, and phone call restrictions.
Report Facts
Capacity: 188
Census: 105
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bertha Raygoza | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kiel Stromgren | Administrator | Facility administrator met during investigation |
| Margaret Madrid | Staff in Charge | Spoke with Licensing Program Analyst during virtual follow-up |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 188
Deficiencies: 0
Mar 4, 2021
Visit Reason
Unannounced visit/investigation of a complaint received on 2020-06-09 regarding allegations of unlawful eviction and unexplained injuries.
Findings
The investigation found no preponderance of evidence to substantiate the allegations of unlawful eviction and unexplained injuries. The allegations were deemed unsubstantiated based on record reviews and interviews.
Complaint Details
The complaint involved allegations of unlawful eviction and unexplained injuries. The investigation concluded these allegations were unsubstantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bertha Raygoza | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Kiel Stromgren | Administrator | Met with the investigator during the visit and was involved in the findings discussion. |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 188
Deficiencies: 0
Mar 3, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-06-23 regarding inadequate lighting at the facility.
Findings
The investigation found that the facility's lighting, including emergency lighting in stairwells, complied with applicable codes from 1984 and 1982 fire codes. The facility has a backup generator for power outages and is undergoing renovations that would address lighting upgrades. The complaint was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged the facility was without adequate lighting. The investigation included a virtual tour and interviews with the administrator and fire marshal. The complaint was deemed unsubstantiated.
Report Facts
Facility capacity: 188
Census: 101
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kiel Stromgren | Administrator | Met with Licensing Program Analyst during complaint investigation and discussed findings |
| Bertha Raygoza | Licensing Program Analyst | Conducted complaint investigation and virtual tour |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Capacity: 188
Deficiencies: 0
Feb 25, 2021
Visit Reason
An unannounced case management televisit was conducted regarding a Death Report submitted to the Community Care Licensing Office on 02/24/2021.
Findings
Resident R1 missed a routine dialysis appointment and was found unresponsive at the facility, with paramedics called to the scene. The Sheriff's Deputy investigating suspects the cause of death was a heart attack related to the resident's health conditions, and the coroner's office likely will not perform an autopsy. The facility is reaching out to the family and has secured the resident's room.
Report Facts
Residents under 60: 4
Percentage of residents over 60: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kiel Stromgren | Administrator | Met with during the case management televisit and provided information about the resident's death |
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