Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. The facility’s most recent report from September 23, 2025, was clean with no deficiencies, showing adherence to infection control protocols. Past issues included substantiated complaints about staff neglect resulting in a resident’s death in late 2021 and a failure to provide diabetic diets in April 2023, as well as pest control problems in 2021 and 2022; however, these were isolated events rather than ongoing problems. Enforcement actions included civil penalties totaling at least $1,500 related to staff background clearance violations and neglect leading to a resident’s death, but no license suspensions or revocations were noted. Recent reports suggest improvement in compliance and resident care, with no new serious deficiencies cited.
An unannounced complaint investigation visit was conducted in response to an allegation that the licensee was not ensuring that staff follow proper infection control protocols.
Findings
The investigation included staff and resident interviews and a facility tour. Observations showed that infection control protocols were being followed, including disinfection, resident isolation, mask wearing, and visitor restrictions. The allegation was deemed unsubstantiated with no deficiencies cited.
Complaint Details
The complaint alleged that the licensee was not ensuring staff followed proper infection control protocols. The allegation was found unsubstantiated based on interviews and observations during the investigation.
Report Facts
Residents interviewed: 8Staff interviewed: 5
Employees Mentioned
Name
Title
Context
Beena Singh
Licensing Program Analyst
Conducted the complaint investigation and visit
Amelia Aladin
Administrator
Facility administrator informed of the visit and present during investigation
The inspection visit was an unannounced health and safety check conducted due to a prior incident involving aggressive behavior between residents reported in an Unusual Incident Report.
Findings
No imminent health or safety concerns were observed during the visit. Staff were observed providing care and supervision, checking residents every 30 minutes, and adequate food supplies were noted. The needs of residents appeared to be met.
Report Facts
Staff interviews: 5Eviction notice period: 30
Employees Mentioned
Name
Title
Context
Beena Singh
Licensing Program Analyst
Conducted the unannounced health and safety inspection
Amelia Aladin
Licensee/Administrator
Facility administrator who provided information during the inspection
The visit was conducted as a Case Management - Legal/Non-Compliance follow-up to verify the facility's compliance with Health & Safety Code Section 1569.38 regarding posting of accusation and written notices.
Findings
The Licensing Program Analyst observed that the accusation and written notices were properly posted in conspicuous locations throughout the facility as required by law. No deficiencies were issued during this visit.
An unannounced complaint investigation visit was conducted to investigate allegations that staff were not properly addressing roaches in the facility and were not preventing residents from smoking inside the facility.
Findings
The investigation found that staff and residents reported no evidence of roaches in the facility and confirmed pest control maintenance occurs monthly. Staff and residents also confirmed that residents do not smoke inside the facility and use a designated outdoor smoking area. The allegations were deemed unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint investigation was unsubstantiated based on staff and resident interviews and document review. No preponderance of evidence was found to prove the alleged violations occurred.
The inspection was an unannounced complaint investigation visit triggered by an allegation that the licensee failed to provide immediate written notice of a resident's death to the public administrator.
Findings
The investigation substantiated the allegation that the licensee did not provide immediate written notice of the resident's death to the public administrator, although the facility notified relevant agencies within the required timeframe. A citation will be issued in accordance with California regulations.
Complaint Details
The complaint was substantiated based on record reviews and interviews. The facility notified the public administrator at the time of hospitalization but failed to provide immediate written notice of the resident's death to the public administrator responsible due to no known kin at the time.
Deficiencies (1)
Description
Licensee failed to provide immediate written notice of resident’s death to the public administrator.
Report Facts
Capacity: 74Census: 51
Employees Mentioned
Name
Title
Context
Beena Singh
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Amelia Aladin
Facility Administrator
Facility representative met during investigation and named in findings
An unannounced complaint investigation visit was conducted to investigate allegations of residents smoking in the hallway and pests in the rooms at Caloaks Senior Living Facility.
Findings
The investigation found no evidence to substantiate the allegations. Staff and residents confirmed no smoking inside the facility and the presence of a designated outdoor smoking area. No pests were observed, and pest control maintenance occurs monthly. No deficiencies were cited during the visit.
Complaint Details
The complaint investigation was unsubstantiated based on staff and resident interviews, facility tour, and document review. Allegations included resident smoking in the hallway and pests in the rooms, both found unsubstantiated.
The inspection visit was an unannounced health and safety check conducted due to an incident reported on 10/22/2024 involving aggressive behavior between two residents.
Findings
No imminent health or safety concerns were observed during the visit. Staff were providing adequate care and supervision, residents' needs appeared to be met, and no health or safety hazards were found inside or outside the facility.
Unannounced complaint investigation visit conducted in response to allegations that facility staff do not change resident bedding regularly, did not provide required furniture for residents, and do not safeguard residents' personal belongings.
Findings
The investigation found the allegations to be unsubstantiated based on interviews with residents and staff, observations, and record reviews. No deficiencies were cited during the visit, although some deficiencies were initially cited but later dismissed with plans of correction.
Complaint Details
Complaint investigation was unannounced and conducted by Licensing Program Analysts Beena Singh and Melody Brown. The complaint was received on 2021-04-19. The allegations were found unsubstantiated after interviews and observations. No deficiencies were cited per Title 22, Division 6, of the California Code of Regulations during the visit.
Severity Breakdown
Type B: 3
Deficiencies (3)
Description
Severity
Facility did not ensure residents' bedding was changed regularly as required, posing potential health, safety, and personal rights risks.
Type B
Facility did not ensure chairs were provided to residents as required, posing potential health, safety, and personal rights risks.
Type B
Facility did not follow safeguards for residents’ personal property, resulting in several residents having personal belongings stolen, posing potential health, safety, or personal rights risks.
Type B
Report Facts
Capacity: 74Census: 57Deficiencies cited: 3Plan of Correction Due Date: Mar 3, 2025
Employees Mentioned
Name
Title
Context
Beena Singh
Licensing Program Analyst
Conducted the complaint investigation and cited deficiencies
Melody Brown
Licensing Program Analyst
Conducted the complaint investigation
Amelia Aladin
Licensee/Administrator
Facility administrator met during investigation and named in findings
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-05-17 regarding allegations against the facility.
Findings
The investigation found the allegations unsubstantiated after interviews with residents and staff, and observations during the visit. Residents were allowed to leave the facility freely, no insects were observed, and staff were found to safeguard residents' personal property adequately.
Complaint Details
The complaint included allegations that staff were not allowing residents to leave the facility, the facility had insects, and staff did not safeguard residents' personal property. The investigation found these allegations unsubstantiated.
Report Facts
Capacity: 74Census: 57
Employees Mentioned
Name
Title
Context
Amelia Aladin
Facility Licensee/Administrator
Met with during the investigation and exit interview
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff do not keep resident bedrooms clean.
Findings
The allegation was unsubstantiated based on interviews with 10 residents and 8 staff members, all of whom denied the claim. Observations on 02/26/2025 confirmed bedrooms and living areas were clean, with clean bedding and no odors.
Complaint Details
The complaint was unsubstantiated after investigation. Interviews with residents and staff, as well as observations, did not support the allegation that staff failed to keep resident bedrooms clean.
Report Facts
Residents interviewed: 10Staff interviewed: 8
Employees Mentioned
Name
Title
Context
Beena Singh
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Amelia Aladin
Licensee/Administrator
Facility administrator met during the investigation and exit interview
The visit was an unannounced required comprehensive annual inspection of the facility conducted by Licensing Program Analysts.
Findings
The inspection found several deficiencies including improper hot water temperature, lack of assistance with self-administered medications for some residents, pre-pouring medications, broken blinds and window screens, lack of required emergency supplies, and absence of non-slip mats in a resident bathroom. Some deficiencies were corrected during the visit, and plans of correction were established for others.
Severity Breakdown
Type A: 3Type B: 4
Deficiencies (7)
Description
Severity
No non-slip mats in resident's bathroom in room 29.
Type B
Hot water temperature in residents' rooms 36 and 39 exceeded allowed limits before adjustment.
Type A
Staff not assisting three of four residents with self-administration of medication.
Type A
Facility staff pre-pouring medications/transferring AM medicines to different containers early in the day.
Type A
Blinds in rooms 20 and 37 were in disrepair.
Type B
Window screens in rooms 4, 34, 38, and 40 were broken.
Type B
Facility does not have required emergency supplies maintained (beyond food and water).
Type B
Report Facts
Residents present: 57Total licensed capacity: 74Hospice waiver capacity: 10Bedridden residents capacity: 8Hot water temperature before adjustment: 136Hot water temperature before adjustment: 130Hot water temperature after adjustment: 118Hot water temperature after adjustment: 114Non-perishable food supply: 7Perishable food supply: 2Resident files reviewed: 6Staff files reviewed: 6Residents audited for medication: 4Residents not assisted with medication: 3Plan of Correction due date: 2025
Employees Mentioned
Name
Title
Context
Amelia Aladin
Licensee/Administrator
Contacted and informed of the visit; accompanied LPAs during inspection.
The visit was an unannounced Case Management follow-up to assess the facility's compliance with Health & Safety Code Section 1569.38 regarding posting of licensing and accusation notices.
Findings
The facility failed to post the required written notice and accusation notices in conspicuous locations as mandated by law since 02/12/2025, which poses potential health, safety, and personal rights risks to residents.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Failure to post the written notice and accusation notice in conspicuous locations in the facility as required by Health and Safety Code 1569.38.
Type B
Report Facts
Deficiency Type B: 1Capacity: 74Census: 57Plan of Correction Due Date: Mar 5, 2025
Employees Mentioned
Name
Title
Context
Amelia Aladin
Licensee/Administrator
Named in relation to the deficiency for failure to post notices
Melissa Bridges
Resident Care Director
Met during inspection and verbally confirmed the deficiency
The visit was a follow-up on a substantiated complaint investigation regarding staff neglect that resulted in a resident's death.
Findings
The Department concluded that a civil penalty is warranted due to the facility staff failing to meet the resident's needs and properly supervise, resulting in the resident's death from hyperthermia after an unwitnessed fall.
Complaint Details
The complaint investigation was substantiated, confirming staff neglect that led to the death of resident R1 due to environmental heat exposure after an unwitnessed fall.
Deficiencies (1)
Description
Violation of Health and Safety Code § 1569.269(a)(6) Enumerated rights; severability related to staff neglect resulting in resident death.
The visit was an unannounced Case Management visit conducted to verify compliance with Health & Safety Code Section 1569.38 regarding notification requirements related to an accusation against the facility.
Findings
The facility posted the required accusations in conspicuous locations and provided written notification to residents, their responsible parties, and the local long-term care ombudsman within the required 10-day timeframe as mandated by law.
Report Facts
Capacity: 74Census: 58Notification timeframe: 10
Employees Mentioned
Name
Title
Context
Amelia Aladin
Licensee/Administrator
Met with Licensing Program Analyst during the inspection and verbally confirmed notification compliance
The visit was an unannounced required comprehensive annual inspection of the facility.
Findings
The facility was generally compliant with regulations but had deficiencies related to the absence of a required Community Care Licensing Division complaint poster, lack of physician documentation for a resident's half bed rail, and initially improper hot water temperature in Room #2 which was corrected during the visit.
Deficiencies (3)
Description
No Community Care Licensing Division (CCLD) complaint poster was posted in the common area.
Resident #1 had half bed rails without written physician documentation indicating the need for them.
Hot water temperature in Room #2 was initially 72 degrees Fahrenheit, below the required 105-120 degrees Fahrenheit range.
The inspection was an unannounced complaint investigation visit conducted due to allegations that facility staff sold a television to a resident in care and that facility staff were financially abusing a resident.
Findings
The allegation that facility staff sold a television to a resident was substantiated based on interviews and document review confirming the sale of a 55-inch television by Staff #3 to Resident #1. The allegation of financial abuse by staff was unsubstantiated after interviews with residents and staff found no evidence of financial abuse.
Complaint Details
The complaint investigation was substantiated for the allegation that facility staff sold a television to a resident in care. The allegation of financial abuse by staff was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The Licensee did not comply by allowing Staff #3 to violate facility policy by selling a television to Resident #1, posing potential personal rights risk.
Type B
Report Facts
Facility capacity: 74Census: 60Deficiency count: 1Plan of Correction due date: Dec 8, 2023
Employees Mentioned
Name
Title
Context
Amelia Aladin
Licensee/Administrator
Met with Licensing Program Analyst and named in relation to findings and interviews
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident sustained injury while in care due to lack of supervision.
Findings
The investigation found no evidence to corroborate the allegation. Staff interviews and observations confirmed appropriate supervision with residents being checked every two hours or more frequently as needed. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that a resident sustained injury due to lack of supervision. The investigation included file reviews, staff and resident interviews, and observations. The allegation was found unsubstantiated as no evidence supported the claim.
Report Facts
Staff count: 7Capacity: 74Census: 51
Employees Mentioned
Name
Title
Context
Amelia Aladin
Licensee/Administrator
Met with Licensing Program Analysts during the investigation and named in the report.
Melody Brown
Licensing Program Analyst
Conducted the complaint investigation.
Mary Rico
Licensing Program Analyst
Assisted in the complaint investigation.
Melissa Bridges
Health and Wellness Director
Reported staff supervision practices during the facility visit.
Efren Malagon
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation.
An unannounced complaint investigation was conducted in response to an allegation that staff yelled at a resident.
Findings
The investigation found no evidence to corroborate the allegation. Observations and interviews with residents and staff indicated that no staff yelled at residents during the visit.
Complaint Details
The allegation that staff yelled at a resident was unsubstantiated based on the investigation findings.
Report Facts
Capacity: 74Census: 58
Employees Mentioned
Name
Title
Context
Melody Brown
Licensing Program Analyst
Conducted the complaint investigation
Amelia Aladin
Licensee/Administrator
Met with Licensing Program Analyst during the investigation
The inspection was an unannounced complaint investigation initiated due to allegations that staff were not providing a diabetic diet for residents and that food was not of nutritious value to meet residents' needs.
Findings
The complaint that staff were not providing a diabetic diet for residents was substantiated, with evidence showing no diabetic menu or sugar-free options were provided, posing potential health risks. The allegation that food was not nutritious was unsubstantiated, with observations confirming residents were served nutritious meals.
Complaint Details
The complaint investigation was substantiated regarding the failure to provide diabetic diets, with evidence including staff and resident interviews, menu and kitchen observations. The allegation regarding food not being nutritious was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Failure to provide modified diabetic diets as prescribed by residents' physicians, including lack of diabetic menu and sugar-free options.
Type B
Report Facts
Facility capacity: 74Census: 56Deficiencies cited: 1Plan of Correction due date: Apr 24, 2023
Employees Mentioned
Name
Title
Context
Melody Brown
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Amelia Aladin
Licensee/Administrator
Facility administrator met during investigation and named in findings
Efren Malagon
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
The inspection was conducted as an unannounced complaint investigation visit following a complaint alleging that staff does not ensure residents attend medical appointments.
Findings
The investigation found no evidence to support the allegation. Interviews with residents and staff confirmed that residents attend their scheduled medical appointments and no cancellations by the facility were reported. The complaint was determined to be unfounded and dismissed.
Complaint Details
The complaint alleged that staff does not ensure residents attend medical appointments. The complaint was investigated and found to be unfounded, meaning the allegations were false or without reasonable basis.
Report Facts
Capacity: 74Census: 59
Employees Mentioned
Name
Title
Context
Melody Brown
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Aldrin Aladin
Registered Nurse (RN)
Met with Licensing Program Analyst during investigation and exit interview
The visit was an unannounced collateral visit on a complaint investigation to interview residents and staff regarding complaint control number 56-AS-20230214082530.
Findings
The Licensing Program Analyst conducted interviews and an exit interview was held with the facility administrator. A copy of the report was provided to the administrator.
Complaint Details
Complaint control number 56-AS-20230214082530 was the basis for the collateral visit and investigation.
Employees Mentioned
Name
Title
Context
Amelia Aladin
Administrator
Met with Licensing Program Analyst during complaint investigation visit.
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-01-25 regarding staff yelling at a resident and facility overcharging a resident.
Findings
The investigation found the allegations to be unfounded after reviewing documents, conducting interviews with staff and residents, and observing staff interactions. Staff were reported to treat residents with respect and the facility charged only the allowed rate for basic services as per state regulations.
Complaint Details
The complaint alleged that staff yelled at a resident and that the facility overcharged a resident. The investigation found these allegations to be unfounded, meaning they were false or without reasonable basis.
Report Facts
Capacity: 74Census: 54
Employees Mentioned
Name
Title
Context
Melody Brown
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Efren Malagon
Licensing Program Manager
Named as Licensing Program Manager on the report
Aldrin Aladin
Registered Nurse
Met with Licensing Program Analyst during the investigation and participated in exit interview
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-07-29 regarding staff supervision and medication administration at Caloaks Senior Living Facility.
Findings
The investigation found no evidence to substantiate the allegations that staff failed to prevent a resident from wandering away or failed to ensure medication was taken as prescribed. Records review and interviews confirmed proper supervision and medication administration practices.
Complaint Details
The complaint involved two allegations: 1) Staff does not prevent resident from wandering away from the facility, and 2) Staff does not ensure that resident takes medication as prescribed. Both allegations were found to be unsubstantiated based on investigation evidence.
Report Facts
Capacity: 74Census: 54
Employees Mentioned
Name
Title
Context
Melody Brown
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Amelia Aladin
Administrator
Facility administrator met during investigation and exit interview
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-07-11 regarding allegations that a resident appeared unkempt, was not adequately hydrated, and did not receive medical attention while in care.
Findings
The investigation found all allegations to be unfounded after reviewing resident documents, conducting staff and resident interviews, and observing the facility. Staff were found to assist residents with hygiene, hydration, and medical needs, and the resident had regular physician visits.
Complaint Details
Complaint allegations included that a resident appeared unkempt, was not adequately hydrated, and did not receive medical attention. The complaint was found to be unfounded and dismissed.
Report Facts
Capacity: 74Census: 56
Employees Mentioned
Name
Title
Context
Melody Brown
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Amelia Aladin
Administrator
Facility administrator met during the investigation and discussed findings
The visit was a Case Management Office Visit initiated to investigate deficiencies related to staff criminal background clearance and association with the facility.
Findings
The facility allowed staff members S7 and S8 to work without criminal background clearance, posing immediate health, safety, and personal rights risks to residents. Additionally, staff S6 and S9 had criminal background clearance but were not properly associated with the facility, posing potential risks. Civil penalties of $500 per individual were assessed for these violations.
Complaint Details
The visit was complaint-related as it involved investigation of staff working without proper criminal background clearance and failure to associate staff clearances with the facility. The report does not explicitly state substantiation status.
Severity Breakdown
Type A: 1Type B: 1
Deficiencies (2)
Description
Severity
Allowed Staff #7 and Staff #8 to work without criminal background clearance, posing immediate health, safety, and personal rights risks to residents.
Type A
Allowed Staff #6 and Staff #9 to work without transferring or failing to transfer their criminal background clearance, posing potential health, safety, and personal rights risks to residents.
Type B
Report Facts
Civil penalty amount: 500Number of individuals fined: 4
Employees Mentioned
Name
Title
Context
Amelia Aladin
Administrator
Facility administrator who confirmed staff hire dates and was involved in the exit interview discussing the findings.
Melody Brown
Licensing Program Analyst
Conducted the investigation and authored the report.
Magda Malcore
Licensing Program Analyst
Participated in the investigation and office visit.
An unannounced visit was conducted to investigate a complaint received on 2022-11-30 regarding allegations of staff misconduct towards residents at Caloaks Senior Living Facility.
Findings
The investigation included interviews with residents, staff, and witnesses, as well as records review. All allegations, including staff throwing socks at a resident, making inappropriate comments, and refusing to assist a resident, were found to be unsubstantiated due to lack of evidence.
Complaint Details
The complaint involved allegations that staff threw socks at a resident, made inappropriate comments towards a resident, and refused to assist a resident. All allegations were investigated and found to be unsubstantiated.
Report Facts
Facility capacity: 74Census: 51
Employees Mentioned
Name
Title
Context
Anna Bueno
Licensing Program Analyst
Conducted the complaint investigation
Melissa Bridges
Care Manager
Met with Licensing Program Analyst during investigation
Amelia Aladin
Administrator
Facility administrator named in the report
Nedra Brown
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-11-04 regarding allegations of staff failing to seek timely medical attention, failing to meet resident hygiene needs, facility cleanliness, and staff not assisting residents with feedings.
Findings
The investigation found that the facility appropriately addressed the medical needs of Resident R1, maintained hygiene and cleanliness standards, and provided feeding assistance to Resident R2. There was insufficient evidence to substantiate the allegations, and all four allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to seek timely medical attention, failure to meet hygiene needs, unclean facility, and lack of feeding assistance. Interviews and document reviews showed the facility met medical, hygiene, cleanliness, and feeding requirements. No evidence was found to prove violations occurred.
Report Facts
Capacity: 74Census: 61
Employees Mentioned
Name
Title
Context
Ryan Gardner
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Efren Malagon
Licensing Program Manager
Oversaw the complaint investigation
Melissa Bridges
Wellness Director/Manager
Facility representative met during the investigation and involved in exit interview
The visit was an unannounced case management visit to conduct inquiry into health and safety care concerns of residents.
Findings
Based on the review of records, tour of the facility, and interviews with residents and staff, no deficiencies were cited under Title 22, Division 6 of the California code of regulations.
Employees Mentioned
Name
Title
Context
Amelia Aladin
Administrator
Facility administrator met during the visit.
Melissa Bridges
LVN
Met during the visit and involved in the inspection.
The visit was an unannounced complaint investigation triggered by an allegation that the facility has roaches.
Findings
The investigation confirmed the presence of roaches in multiple resident rooms despite cleaning and spraying efforts. The facility's contracted exterminator was not servicing all rooms, and the treatment was insufficient to aggressively control the infestation. The complaint was substantiated.
Complaint Details
The complaint was substantiated based on observations, interviews, and document review. The allegation that the facility has roaches was found valid by the preponderance of the evidence standard.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
The facility was not clean, safe, sanitary, and in good repair due to the presence of roaches, and the licensee did not aggressively address the roach issue, posing immediate health, safety, and personal rights risks to residents.
Type A
Report Facts
Capacity: 74Census: 54Rooms sprayed: 10Plan of Correction Due Date: 1
Employees Mentioned
Name
Title
Context
Melody Brown
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Amelia Aladin
Administrator
Reported on exterminator treatment and follow-up plans
Melissa Bridges
Wellness Director
Met with Licensing Program Analyst and reported on exterminator plans
An unannounced complaint investigation visit was conducted in response to an allegation that a resident sustained multiple injuries due to lack of supervision from staff.
Findings
The investigation included interviews, observations, and records review, and found no evidence to substantiate the allegation. Staff and residents denied neglect or lack of supervision, and appropriate protocols were followed after the resident's fall.
Complaint Details
The allegation that a resident sustained multiple injuries due to lack of supervision was determined to be unsubstantiated based on the evidence gathered during the investigation.
Report Facts
Facility capacity: 74Census: 58
Employees Mentioned
Name
Title
Context
Melody Brown
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Amelia Aladin
Administrator
Facility administrator present during the investigation
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2022-03-09 regarding neglect, overmedication, unsanitary conditions, lack of meals, unmet hygiene needs, and fraudulent signing of documents at Caloaks Senior Living Facility.
Findings
The investigation, which included interviews, observations, and records review, found all allegations to be unsubstantiated. Staff, residents, and witnesses denied neglect, overmedication, unsanitary conditions, lack of meals, unmet hygiene needs, and fraudulent signing of documents. The facility was observed to be clean, residents were provided meals and hygiene assistance, and medication administration was appropriate.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred. Allegations included neglect resulting in injury, overmedication, unsanitary conditions, failure to provide meals, unmet hygiene needs, and fraudulent signing of documents. Interviews with staff, residents, and witnesses all denied these allegations.
Report Facts
Facility capacity: 74Resident census: 60
Employees Mentioned
Name
Title
Context
Stephanie Williams
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Melissa Bridges
Wellness Coordinator
Met with Licensing Program Analyst during the investigation
An unannounced complaint investigation visit was conducted in response to allegations received on 12/28/2021 regarding rough handling of residents and unclean facility conditions.
Findings
The investigation included observations, interviews, and records review. Allegations of rough handling of residents and unclean conditions were found to be unsubstantiated due to lack of evidence. The facility demonstrated ongoing pest control measures and cooperation with an extermination company.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff handling residents roughly and the facility being unclean. Interviews with residents and staff denied rough handling, and pest control records showed ongoing treatment. No evidence supported the allegations.
Report Facts
Facility capacity: 74Census: 57
Employees Mentioned
Name
Title
Context
Stephanie Williams
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Amelia Aladin
Administrator
Facility administrator present during investigation
Melissa Bridges
Wellness Director
Facility wellness director present during investigation
The inspection was an unannounced required annual inspection with an emphasis on infection control due to the COVID-19 pandemic.
Findings
The facility was found to be in compliance with regulatory requirements, with no deficiencies cited. Infection control measures were in place and staff were trained, PPE was available, and the facility was clean and in good repair with no apparent health and safety risks.
Employees Mentioned
Name
Title
Context
Amelia Aladin
Administrator
Interviewed during inspection regarding infection control measures.
Melissa Bridges
Wellness Director
Interviewed during inspection regarding infection control measures.
The inspection was an unannounced complaint investigation triggered by an allegation of staff neglect resulting in a resident's death.
Findings
The investigation substantiated that staff neglect led to the death of resident R1, who sustained an unwitnessed fall and lay outside for hours, resulting in hyperthermia due to environmental heat exposure. The facility failed to properly supervise the resident, posing an immediate health and safety risk.
Complaint Details
The complaint was substantiated. The allegation that staff neglect resulted in a resident's death was supported by evidence including staff interviews, medical records, law enforcement reports, and environmental data. An Immediate Civil Penalty of $500 was assessed.
Severity Breakdown
Type A: 2
Deficiencies (2)
Description
Severity
Residents of residential care facilities for the elderly shall have rights to care, supervision, and services that meet their individual needs and are delivered by competent staff. This requirement was not met.
Type A
Facility staff were not competent in meeting R1 needs. Facility staff failed to properly supervise R1. Following an unwitnessed fall, R1 laid outside for hours and died of hyperthermia due to environmental heat exposure.
Type A
Report Facts
Capacity: 74Census: 63Body surface area affected: 30Body surface area affected: 40Body temperature: 109.2Immediate Civil Penalty: 500
Employees Mentioned
Name
Title
Context
David Cuevas
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Joel Esquivel
Licensing Program Manager
Oversaw the complaint investigation report
Melissa Bridges
LVN
Staff member met with during investigation and named in findings
An unannounced complaint investigation was conducted in response to allegations received on 2021-11-08 regarding dietary needs, facility cleanliness, insect presence, diapering care, and staffing sufficiency at Caloaks Senior Living Facility.
Findings
The investigation found all allegations to be unsubstantiated. Staff and residents confirmed that special dietary needs were met, the facility was clean and free of insects, diapering needs were addressed appropriately, and staffing levels were sufficient to meet resident needs.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to meet residents' special dietary needs, failure to keep the facility free of insects, failure to keep the facility clean, failure to ensure residents' diapering needs were met, and insufficient staffing. Interviews, observations, and record reviews did not support these allegations.
Report Facts
Capacity: 74Census: 62Staffing: 10Staffing: 2Extermination service date: Nov 11, 2021
An unannounced visit was conducted to investigate a complaint alleging staff mismanaged a resident's money.
Findings
The investigation found that after Resident #1's death, the facility notified the Social Security Administration (SSA), which continued payments until May 2021. All funds received were returned to SSA, and the allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged staff mismanaged a resident's money. The investigation was unsubstantiated, meaning there was insufficient evidence to prove the alleged violation occurred.
The inspection was an unannounced complaint investigation visit triggered by an allegation received on 2021-04-12 that staff did not keep the facility free from pests.
Findings
The investigation found at least thirteen cockroaches at different growth stages throughout the facility and inside resident furniture, corroborated by resident interviews and observations. The allegation was substantiated and a citation will be issued for failure to maintain a clean, safe, and sanitary environment.
Complaint Details
The complaint was substantiated based on the preponderance of evidence including resident interviews, observations of cockroaches, and records review. The facility had not arranged for interior fumigation in five or more months.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
The facility was not kept clean, safe, and sanitary as evidenced by the presence of at least 13 cockroaches throughout the facility and inside resident furniture, posing a health and personal rights risk to residents.
Type B
Report Facts
Number of cockroaches observed: 13Facility capacity: 74Census: 62Plan of Correction due date: 5
Employees Mentioned
Name
Title
Context
Stephanie Torres
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Amelia Aladin
Administrator
Facility administrator interviewed and involved in exit interview
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-06-17 regarding allegations of inadequate resident care and medication administration at Caloaks Senior Living Facility.
Findings
The investigation found no evidence to substantiate the allegations that facility staff failed to notice changes in resident condition, seek medical attention, safeguard resident property, or administer medications as prescribed. All allegations were determined to be unsubstantiated.
Complaint Details
The complaint involved four allegations: failure to notice a change in resident's condition, failure to seek medical attention, failure to safeguard resident's property, and failure to dispense medications as prescribed. All allegations were investigated through staff interviews and records review and were found unsubstantiated.
Report Facts
Facility capacity: 74Census: 60
Employees Mentioned
Name
Title
Context
Robbie Johnson
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Amelia Aladin
Administrator
Facility administrator involved in the investigation and communication
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