Deficiencies (last 6 years)
Deficiencies (over 6 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
73% occupied
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Census: 138
Capacity: 190
Deficiencies: 0
Date: Jan 2, 2026
Visit Reason
The visit was an unannounced Case Management inspection conducted regarding an incident reported on 2025-11-05 involving multiple residents claiming that personal belongings and valuable items went missing from resident rooms between August and November 2025.
Complaint Details
The visit was complaint-related due to reports of missing personal belongings from resident rooms. Sixteen residents reported missing items, and eleven residents refused to file personal property inventory lists.
Findings
During the visit, sixteen residents reported missing items, and it was noted that eleven of these residents had refused to file personal property inventory lists and signed declination forms. The facility was also undergoing construction, which was not interfering with residents' daily living functions.
Report Facts
Residents reporting missing items: 16
Residents refusing to file inventory list: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Banner | Executive Director | Met with Licensing Program Analyst during the inspection and provided information about the facility and ongoing construction |
| Vadim Gorban | Licensing Program Analyst | Conducted the unannounced Case Management inspection |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 143
Capacity: 190
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
The inspection visit was an unannounced Case Management regarding an incident reported on 11/05/2025 involving multiple residents reporting missing personal belongings and valuable items from their rooms.
Findings
During the visit, the Licensing Program Analyst met with the senior executive assistant and followed up on the facility's investigation. The facility had recently implemented visitor badges and additional video cameras for security. The analyst was also notified of a planned water shut off due to construction and the facility's efforts to provide alternative water access for residents and staff.
Report Facts
Water shut off duration: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Banner | Administrator | Reported the incident of missing personal belongings |
| Geoven Snaer | Senior executive assistant | Met with Licensing Program Analyst during the visit |
| Vadim Gorban | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Brenda Chan | Licensing Program Manager | Named in the report header |
Inspection Report
Annual Inspection
Census: 142
Capacity: 190
Deficiencies: 0
Date: Sep 4, 2025
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 clean, in good repair, and compliant with safety and health regulations. No deficiencies were issued during this inspection.
Report Facts
Capacity: 190
Census: 142
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vadim Gorban | Licensing Program Analyst | Conducted the inspection and authored the report |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Geoven Snaer | Senior Executive Assistant | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Ryan Banner | Administrator/Director | Facility Administrator named in the report |
Inspection Report
Annual Inspection
Census: 142
Capacity: 190
Deficiencies: 0
Date: Sep 4, 2025
Visit Reason
The inspection was an unannounced Required Annual Inspection conducted by the Licensing Program Analyst to evaluate compliance with licensing requirements.
Findings
The facility was found to be clean, in good repair, and compliant with safety and health regulations. No deficiencies were issued during this inspection. Residents and staff files were reviewed and found to be up to date.
Report Facts
Facility Capacity: 190
Census: 142
Inspection Duration: 220
Fire Extinguisher Service Date: May 20, 2025
Last Disaster Drill Date: Jun 12, 2025
Refrigerator Temperature: 39
Freezer Temperature: 2
Forms Submission Deadline: Sep 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vadim Gorban | Licensing Program Analyst | Conducted the annual inspection and signed the report |
| Geoven Snaer | Senior Executive Assistant | Met with Licensing Program Analyst during inspection and received report |
| Ryan Banner | Administrator/Director | Facility Administrator named in report header |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Routine
Deficiencies: 11
Date: Sep 13, 2024
Visit Reason
Routine inspection of Canterbury Woods skilled nursing facility to assess compliance with regulatory requirements and quality of care standards.
Findings
The facility was found deficient in multiple areas including failure to notify the Long-Term Care Ombudsman of resident transfers, incomplete person-centered care plans, inadequate activity programs, insufficient nutritional interventions for weight loss, lack of informed consent for bed rails, medication administration documentation errors, medication errors, failure to follow food preparation recipes, improper storage of resident and visitor foods, failure to ensure resident understanding of binding arbitration agreements, and lapses in infection control hand hygiene practices.
Deficiencies (11)
F 0623: Facility failed to provide timely written notification to the Long-Term Care Ombudsman for a resident transferred to acute care hospital.
F 0656: Facility failed to develop and implement a comprehensive person-centered communication care plan for a resident using a cellphone as a communication tool.
F 0679: Facility failed to provide an activity program meeting the needs and preferences of a resident with Alzheimer's and dementia.
F 0692: Facility failed to ensure interdisciplinary team assessed and intervened timely for significant weight loss in a resident, including documentation and feeding support.
F 0700: Facility failed to obtain informed consent prior to installing bed rails for a resident.
F 0755: Facility failed to document administration of controlled medication on the accountability sheet for a resident.
F 0760: Facility failed to follow physician's order for Lasix medication, administering it three times daily instead of three times weekly.
F 0803: Facility failed to follow recipe for making chicken teriyaki puree, potentially affecting food palatability for residents on puree diets.
F 0813: Facility failed to ensure safe and sanitary storage of resident and visitor foods, including accessible refrigerator and expired food in dining area cabinet.
F 0847: Facility failed to ensure a resident understood the binding arbitration agreement prior to signing, risking uninformed consent.
F 0880: Facility failed to implement infection control hand hygiene practices when staff did not perform hand hygiene before and after assisting a resident.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Food items: 41
Food items: 8
Food items: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in medication administration documentation and medication error findings |
| MDSC A | Minimum Data Set Coordinator | Named in communication care plan and medication error findings |
| DON | Director of Nursing | Named in multiple findings including weight loss intervention, medication error, and binding arbitration agreement |
| LVN B | Licensed Vocational Nurse | Named in infection control hand hygiene finding |
| EC | Executive Chef | Named in puree recipe preparation finding |
| RD | Registered Dietitian | Named in nutritional and food service findings |
| AC | Activities Coordinator | Named in binding arbitration agreement and activity program findings |
| DDS | Director of Dining Services | Named in food storage findings |
| SSD | Social Services Designee | Named in Ombudsman notification and binding arbitration agreement findings |
Inspection Report
Annual Inspection
Census: 140
Capacity: 190
Deficiencies: 0
Date: Aug 19, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations for the facility.
Findings
The facility was found to be clean, in good repair, and compliant with safety and health standards. No deficiencies were issued during this inspection. Resident and staff files were reviewed and found to be in order.
Report Facts
Facility capacity: 190
Census: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvyra Abare | Administrator | Met with Licensing Program Analyst during inspection |
| Vadim Gorban | Licensing Program Analyst | Conducted the inspection |
| Brenda Chan | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 140
Capacity: 190
Deficiencies: 0
Date: Aug 19, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations at the facility.
Findings
The facility was found to be clean, in good repair, and compliant with safety and health standards. No deficiencies were issued during this inspection.
Report Facts
Fire extinguisher service date: May 29, 2024
Refrigerator temperature: 42
Freezer temperature: -5
Hot water temperature: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvyra Abare | Administrator | Met with Licensing Program Analyst during inspection and participated in facility tour |
| Vadim Gorban | Licensing Program Analyst | Conducted the inspection and signed the report |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Plan of Correction
Census: 125
Capacity: 190
Deficiencies: 0
Date: Dec 15, 2023
Visit Reason
The inspection was conducted as an unannounced Plan of Correction visit to verify compliance with previously identified issues.
Findings
During the inspection, the Licensing Program Analyst toured the facility and found no deficiencies. A copy of the report was provided and an exit interview was conducted.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvyra Abare | Executive Director | Met with Licensing Program Analyst during the inspection |
| David Ayers | Licensing Program Analyst | Conducted the Plan of Correction inspection |
| Brenda Chan | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Plan of Correction
Census: 125
Capacity: 190
Deficiencies: 0
Date: Dec 15, 2023
Visit Reason
The inspection was conducted as an unannounced Plan of Correction (POC) visit to verify compliance with previously identified issues.
Findings
During the inspection, the Licensing Program Analyst toured the facility and found no deficiencies. A copy of the report was provided and an exit interview was conducted.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvyra Abare | Executive Director | Met with Licensing Program Analyst during the inspection |
| David Ayers | Licensing Program Analyst | Conducted the Plan of Correction inspection |
| Brenda Chan | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 190
Deficiencies: 0
Date: Sep 13, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 07/25/2023 regarding allegations of inadequate resident care and facility conditions.
Complaint Details
The complaint included allegations that staff did not ensure residents had clean clothing, residents' hygiene needs were not properly met, the facility was not free of pests, and residents were not provided proper food service. The investigation found no preponderance of evidence to prove these violations occurred, resulting in an unsubstantiated finding.
Findings
The investigation included a facility tour, interviews, and record reviews. Although some concerns such as ants in a resident's apartment and hygiene issues were noted, there was insufficient evidence to substantiate the allegations. The complaint was determined to be unsubstantiated.
Report Facts
Capacity: 190
Census: 144
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvyra Abare | Executive Director | Met with Licensing Program Analyst during the investigation |
| David Ayers | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 190
Deficiencies: 1
Date: Sep 13, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 07/25/2023 regarding a resident who became severely dehydrated.
Complaint Details
The complaint was substantiated. Resident 1 was admitted on 2/20/2023 and assessed as independent in nutrition and meals on 3/1/2023. On 7/17/2023, the resident collapsed due to hypotension and was treated for dehydration and acute kidney injury.
Findings
The investigation found that one resident did not receive adequate personal assistance, resulting in dehydration and acute kidney injury. The allegations were substantiated based on interviews, record reviews, and observations.
Deficiencies (1)
Failure to ensure that 1 out of 25 assisted living residents received adequate personal assistance, resulting in dehydration and acute kidney injury.
Report Facts
Capacity: 190
Census: 144
Residents affected: 1
Assisted living residents: 25
Plan of Correction Due Date: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvyra Abare | Executive Director | Met with during the investigation and named in findings |
| David Ayers | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 190
Deficiencies: 0
Date: Sep 13, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2023-07-25 regarding allegations of inadequate resident care including hygiene, clothing cleanliness, pest control, and food service.
Complaint Details
The complaint investigation was unsubstantiated as there was insufficient evidence to prove the alleged violations occurred.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. The facility was inspected, interviews conducted, and records reviewed, revealing that residents received adequate care, pest control measures were in place, and food service was sufficient.
Report Facts
Capacity: 190
Census: 144
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Ayers | Licensing Program Analyst | Conducted the complaint investigation |
| Elvyra Abare | Executive Director | Met with Licensing Program Analyst during inspection |
| Brenda Chan | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 190
Deficiencies: 1
Date: Sep 13, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 07/25/2023 regarding a resident who became severely dehydrated.
Complaint Details
The complaint was substantiated based on evidence including resident records, interviews, and documentation. The resident was admitted on 2/20/2023, assessed as independent in nutrition and meals on 3/1/2023, but was hospitalized on 7/17/2023 for dehydration and acute kidney injury after collapsing in the facility.
Findings
The investigation found that one resident was treated for dehydration and acute kidney injury due to inadequate personal assistance, substantiating the complaint. The facility was cited for failure to provide adequate personal assistance as required by regulations.
Deficiencies (1)
Failure to ensure that 1 out of 25 assisted living residents received adequate personal assistance, resulting in dehydration and acute kidney injury.
Report Facts
Capacity: 190
Census: 144
Residents affected: 1
Plan of Correction Due Date: Sep 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Ayers | Licensing Program Analyst | Conducted the complaint investigation |
| Elvyra Abare | Executive Director | Met with Licensing Program Analyst during investigation and signed report |
| Brenda Chan | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Annual Inspection
Census: 144
Capacity: 190
Deficiencies: 0
Date: Sep 13, 2023
Visit Reason
The inspection was an unannounced Required Annual Inspection conducted by Licensing Program Analyst D. Ayers to assess compliance with licensing regulations.
Findings
The facility was found to be in compliance with no deficiencies cited. The inspection included a tour of the facility, review of emergency preparedness, medication storage and administration, and resident and staff files.
Report Facts
Capacity: 190
Census: 144
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvyra Abare | Executive Director | Met with Licensing Program Analyst during inspection and named in report |
| David Ayers | Licensing Program Analyst | Conducted the inspection |
| Brenda Chan | Supervisor | Supervisor named in report |
Inspection Report
Annual Inspection
Census: 144
Capacity: 190
Deficiencies: 0
Date: Sep 13, 2023
Visit Reason
The inspection was an unannounced Required Annual Inspection conducted by Licensing Program Analyst D. Ayers to assess compliance with licensing requirements.
Findings
The facility was found to be in compliance with no deficiencies cited. The inspection included tours of the facility, review of emergency preparedness, medication storage and administration, and resident and staff files.
Report Facts
Capacity: 190
Census: 144
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvyra Abare | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| David Ayers | Licensing Program Analyst | Conducted the inspection |
| Brenda Chan | Licensing Program Manager | Named in report header |
Inspection Report
Routine
Deficiencies: 12
Date: Jul 21, 2023
Visit Reason
Routine inspection of Canterbury Woods nursing home to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to maintain sanitary environments, inadequate notification procedures, inaccurate resident assessments, insufficient activity programming, unsafe bed safety practices, improper respiratory care, lack of registered nurse coverage, improper psychotropic medication use, medication storage issues, food safety and sanitation lapses, and infection control failures.
Deficiencies (12)
F 0584: The facility failed to maintain an organized and sanitary environment for Resident 14 when the bathroom was disorganized and the toilet bowl was dirty.
F 0623: The facility failed to provide timely notification to the Long-Term Care Ombudsman when Resident 18 was transferred to the hospital.
F 0641: The facility failed to accurately code the minimum data set assessment for Resident 7, omitting hospice care status.
F 0679: The facility failed to provide an ongoing activity program meeting Resident 11's needs, as the activity care plan was not updated or implemented.
F 0689: The facility failed to ensure wheels on beds of Residents 4 and 220 were locked, risking accidents.
F 0695: The facility failed to provide appropriate respiratory care when a CNA administered oxygen to Resident 4, which is restricted to licensed nurses.
F 0727: The facility failed to provide a registered nurse on duty for at least 8 consecutive hours a day, 7 days a week.
F 0758: The facility failed to ensure Resident 7 was free from unnecessary psychotropic medications, as Lorazepam was ordered without a specific duration.
F 0761: The facility failed to ensure proper storage and labeling of medications, including an unlabeled box of Omeprazole.
F 0801: The facility failed to ensure the director of dining services performed monthly kitchen audits, resulting in multiple food safety and sanitation issues.
F 0812: The facility failed to store, prepare, and serve food in accordance with professional standards, including expired condiments, ice buildup in freezer, improper hair restraints, unsanitary water dispenser, expired sanitizer test strips, water pooling, and improper glove use by kitchen staff.
F 0880: The facility failed to implement infection prevention and control practices, including improper hand hygiene by nurses and environmental services staff, and improper disinfecting of medical equipment.
Report Facts
Days without RN coverage: 4
Medication PRN duration limit: 14
Quat test strip expiration date: 2023
Kitchen audits missed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in infection control and medication administration deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including bathroom sanitation, RN coverage, oxygen administration, and psychotropic medication use |
| Certified Nursing Assistant A | CNA | Named in oxygen administration deficiency |
| Director of Dining Services | Director of Dining Services | Named in kitchen audit and food safety deficiencies |
| Environmental Services Technician | EST | Named in infection control deficiency for improper glove use |
| Pharmacy Consultant | Pharmacy Consultant | Interviewed regarding psychotropic medication review |
| Registered Dietitian | Registered Dietitian | Interviewed regarding kitchen audits and food safety |
| Director of Nutrition and Wellness | Director of Nutrition and Wellness | Interviewed regarding food safety and sanitation deficiencies |
Inspection Report
Census: 140
Capacity: 190
Deficiencies: 0
Date: Jun 20, 2023
Visit Reason
The visit was an unannounced Case Management regarding an incident reported on 2023-06-15 by the Administrator Elvyra Abare.
Findings
The Licensing Program Analyst (LPA) interviewed the Administrator, obtained copies of staff and resident files, and will request additional police and medical records related to the incident. A follow-up visit may occur if necessary.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvyra Abare | Administrator | Named as the Administrator interviewed regarding the incident. |
| Shawna Doucette | Licensing Program Analyst | Conducted the case management visit and interviews. |
| Sergiy Pidgirny | Supervisor | Listed as the supervisor overseeing the evaluation. |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 190
Deficiencies: 0
Date: Jun 20, 2023
Visit Reason
The visit was an unannounced case management inspection regarding an incident reported on 2023-06-15 by the facility Administrator Elvyra Abare.
Complaint Details
The visit was triggered by a complaint or incident report dated 2023-06-15. No substantiation status is provided.
Findings
The Licensing Program Analyst interviewed the Administrator, reviewed staff and resident files, and planned to request additional police and medical records related to the incident. A follow-up visit may occur if necessary.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvyra Abare | Administrator | Named in relation to the incident report and interview during the case management visit. |
| Shawna Doucette | Licensing Program Analyst | Conducted the case management visit and interview. |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 23
Capacity: 190
Deficiencies: 2
Date: Jan 20, 2023
Visit Reason
The visit was a Case Management - Incident investigation triggered by a reported incident involving rough care provided by a staff member to a resident.
Complaint Details
The complaint involved a staff member being rough when providing care to a resident over the last month and a half, causing pain in the resident's legs. The complaint was substantiated by interviews and observations.
Findings
The inspection found that the facility elevator was out of service for two weeks, limiting resident mobility, and that a staff member was rough in providing care to a resident, causing pain and discomfort. Deficiencies were cited related to maintenance and operation of the facility and personal rights of residents.
Deficiencies (2)
The facility elevator has been out of service for several weeks leaving assisted living residents unable to get downstairs which poses a potential health, safety, or personal rights risk to residents in care.
Resident was provided care that made him uncomfortable which poses an immediate health, safety, or personal rights risk to residents in care.
Report Facts
Capacity: 190
Census: 23
Plan of Correction Due Date: Feb 2, 2023
Plan of Correction Due Date: Jan 23, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vicki Zufelt | Facility Nurse | Met with Licensing Program Analyst during inspection and named in findings related to elevator repair and staff training |
| Sarah Hurt | Licensing Program Analyst | Conducted the Case Management (Incident) visit and authored the report |
| Brenda Chan | Supervisor | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 23
Capacity: 190
Deficiencies: 2
Date: Jan 20, 2023
Visit Reason
The visit was a Case Management - Incident investigation triggered by a reported incident of rough care provided by a staff member to a resident.
Complaint Details
The complaint involved allegations that Staff 1 was rough when providing care to Resident 1, causing pain in his legs when assisting with dressing. Resident 1 reported the issue had been ongoing for about a month and a half.
Findings
The inspection found that the facility elevator was out of service for several weeks, limiting resident mobility, and that a staff member was rough when providing care to a resident, causing pain and discomfort. Deficiencies were cited related to maintenance and operation as well as personal rights of residents.
Deficiencies (2)
The facility elevator has been out of service for several weeks leaving assisted living residents unable to get downstairs which poses a potential health, safety, or personal rights risk to residents in care.
Based on interviews, Resident 1 was provided care that made him uncomfortable which poses an immediate health, safety, or personal rights risk to residents in care.
Report Facts
Capacity: 190
Census: 23
Plan of Correction Due Date: Feb 2, 2023
Plan of Correction Due Date: Jan 23, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vicki Zufelt | Facility Nurse | Met with Licensing Program Analyst during the visit and involved in exit interview |
| Sarah Hurt | Licensing Program Analyst | Conducted the Case Management (Incident) visit and authored the report |
| Brenda Chan | Licensing Program Manager / Supervisor | Supervisor and Licensing Program Manager named in the report |
Inspection Report
Census: 140
Capacity: 190
Deficiencies: 0
Date: Jan 4, 2023
Visit Reason
An unannounced Case Management - Incident visit was conducted by Licensing Program Analyst B. Miranda to evaluate the facility and interview resident R1 and the Administrator.
Findings
No citations were issued per the California Code of Regulations Title 22. The Licensing Program Analyst conducted a tour, interviewed the resident and administrator, and reviewed relevant documentation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvyra Abare | Administrator | Met with Licensing Program Analyst during the visit and interviewed. |
| Brianna Miranda | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
Inspection Report
Census: 140
Capacity: 190
Deficiencies: 0
Date: Jan 4, 2023
Visit Reason
An unannounced Case Management - Incident visit was conducted by Licensing Program Analyst B. Miranda to evaluate the facility and interview a resident and the administrator.
Findings
No citations were issued during the visit per the California Code of Regulations Title 22. The Licensing Program Analyst conducted a tour, interviewed a resident and the administrator, and reviewed relevant documentation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvyra Abare | Administrator | Met with Licensing Program Analyst during the visit and provided documentation. |
| Brianna Miranda | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 144
Capacity: 190
Deficiencies: 0
Date: Sep 29, 2021
Visit Reason
An unannounced Required - 1 Year Annual Inspection was conducted to include an Infection Control site visit.
Findings
The facility was toured inside and out, including assisted living areas, with no citations issued. Infection control measures were reviewed, including COVID-19 symptom screening, PPE usage, and vaccination clinics.
Report Facts
Residents in Assisted Living: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marybeth Donovan | Licensing Program Analyst | Conducted the inspection and reviewed the report with the Executive Director. |
| Elvyra Abare | Executive Director | Met with the Licensing Program Analyst during the inspection. |
Inspection Report
Annual Inspection
Census: 144
Capacity: 190
Deficiencies: 0
Date: Sep 29, 2021
Visit Reason
An unannounced Required - 1 Year Annual Inspection was conducted to include an Infection Control site visit.
Findings
The facility was toured inside and out, including assisted living areas, with no obstructions found in fire exit routes. Medications and hazardous items were secured. Infection control measures including COVID-19 symptom screening, PPE usage, and vaccination clinics were reviewed. No citations were issued per California Code of Regulations Title 22.
Report Facts
Residents in Assisted Living: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvyra Abare | Executive Director | Met with Licensing Program Analyst during inspection and reviewed report |
| Marybeth Donovan | Licensing Program Analyst | Conducted the inspection |
| Jackie Jin | Supervisor | Supervisor of the Licensing Program Analyst |
Inspection Report
Census: 147
Capacity: 190
Deficiencies: 0
Date: Sep 14, 2021
Visit Reason
The visit was conducted to provide technical assistance for Infection Prevention and Control guidelines for Adult and Senior Care facilities during the COVID-19 pandemic.
Findings
The Licensing Program Analyst and Program Clinical Consultant reviewed facility policies and procedures related to screening, isolation, disinfecting, staffing, training, PPE usage, and visitation. Recommendations included posting hand washing signs, maintaining an isolation room PPE cart, and continuing staff training on infection prevention and control.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvyra Abare | Administrator | Met with during the visit and involved in review of report |
| Marybeth Donovan | Licensing Program Analyst | Conducted the Technical Assist visit |
| Jackie Jin | Licensing Program Manager | Present during the visit |
| Helen Shi | Program Clinical Consultant | Participated in the visit and policy review |
Inspection Report
Monitoring
Census: 147
Capacity: 190
Deficiencies: 0
Date: Sep 14, 2021
Visit Reason
The visit was conducted as a Case Management - COVID-19 unannounced technical assistance visit to provide guidance on Infection Prevention and Control guidelines for Adult and Senior Care facilities.
Findings
The Licensing Program Analyst and Program Clinical Consultant reviewed the facility's policies and procedures related to screening, isolation, disinfecting, staffing, training, PPE usage, and visitation. Recommendations included posting hand washing signs, maintaining an isolation room PPE cart, and continuing staff training on infection prevention and control.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvyra Abare | Administrator | Met during the visit and reviewed the report |
| Marybeth Donovan | Licensing Program Analyst | Conducted the Technical Assist visit |
| Jackie Jin | Licensing Program Manager | Present during the visit |
| Helen Shi | Program Clinical Consultant | Present during the visit |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 11, 2020
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to follow post-fall neurological assessment protocols and other regulatory compliance issues.
Complaint Details
The complaint investigation found substantiated failures in post-fall neurological assessments for three residents, improper medication storage with expired medication present, and use of expired sanitizing test strips in the kitchen.
Findings
The facility failed to perform neurological checks as required after unwitnessed falls for three residents, failed to ensure safe storage of medications by having expired medication in the medication cart, and used expired sanitizing test strips in the kitchen. These failures posed potential risks to resident health and safety.
Deficiencies (3)
F 0689: The facility failed to follow post-fall neurological assessment protocols for three residents after unwitnessed falls, as neurological checks were not performed per facility protocol.
F 0761: The facility failed to ensure safe storage of medications when an expired Atropine 1% eyedrop was found in the medication cart, risking resident safety.
F 0812: The facility failed to ensure safe sanitary practice in the kitchen by using expired sanitizing test strips during dishwashing solution testing, potentially risking foodborne illness.
Report Facts
Residents affected: 3
Expired medication date: 201911
Expired sanitizing test strip date: Jan 30, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding neurological checks and medication storage | |
| Registered Nurse C | Interviewed about neurological checks after falls | |
| Regional Nurse Consultant | Interviewed about computer system triggering neurological assessments | |
| Licensed Vocational Nurse A | Found expired Atropine medication in medication cart | |
| Registered Nurse B | Confirmed expired medication in medication cart | |
| Director of Dining Services | Observed expired sanitizing test strips in kitchen | |
| Dietary Staff | Used expired sanitizing test strips during dishwashing solution testing |
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