Inspection Report Summary
Most inspections found no deficiencies, including the two most recent annual inspections on January 2 and January 10, 2025, which were both clean. However, some complaint investigations identified isolated issues, primarily related to resident care and dignity, such as delays in incontinence care and staff comments that caused a resident to feel ashamed in the March 20, 2025 report. Earlier deficiencies included a missed background check for a staff member in February 2023, which resulted in a $500 fine, and incomplete incident reporting and insufficient assistance leading to a resident fall in March 2021. Several complaint investigations, including allegations of poor wound care, staffing shortages, and abuse, were unsubstantiated. The facility appears to have improved over time, with recent inspections showing no deficiencies after addressing prior concerns.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
69% occupied
Based on a March 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 92
Capacity: 133
Deficiencies: 2
Date: Mar 20, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not assist residents with incontinence care and did not treat residents with dignity.
Complaint Details
The complaint investigation was substantiated regarding staff not assisting residents with incontinence care and not treating residents with dignity. Other allegations about repositioning, bathing, and clothing were unsubstantiated.
Findings
The investigation substantiated that staff did not assist residents with incontinence care in a timely manner, with response times ranging from five to forty minutes, and that staff made comments causing a resident to feel ashamed, thus not treating residents with dignity. Other allegations regarding repositioning, bathing, and clothing were unsubstantiated.
Deficiencies (2)
Failure to ensure incontinent residents were kept clean and dry and that the facility remained free of odors from incontinence.
Failure to ensure residents, including Resident #1, were treated with dignity in their personal relationships with staff.
Report Facts
Capacity: 133
Census: 92
Response time range: 40
Response time range: 5
Plan of Correction due date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Vonda Boller | Executive Director | Facility representative involved in the investigation and plan of correction |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation process |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 133
Deficiencies: 0
Date: Feb 26, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-05-20 regarding food quality, food sufficiency, activity provision, and adherence to admissions agreement at Canyon Villas facility.
Complaint Details
The complaint investigation was unsubstantiated based on interviews, observations, and record reviews. Allegations included poor food quality, insufficient food, lack of activities, and failure to follow admissions agreement, none of which were proven.
Findings
The investigation found contradicting statements about food quality but no substantiated evidence of violations. Food quantity was sufficient, activities were provided, and the facility complied with the admissions agreement regarding transportation. Therefore, all allegations were unsubstantiated.
Report Facts
Capacity: 133
Census: 96
Complaint Control Number: 08-AS-20240520114334
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Vonda Boller | Executive Director | Facility representative who assisted during the investigation |
| Emy Rivera | Housekeeping Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 133
Deficiencies: 0
Date: Jan 10, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that lack of supervision resulted in sexual abuse of a resident at the facility.
Complaint Details
The complaint alleged lack of supervision resulting in sexual abuse of Resident #1 by an unknown male on July 4th, 2023. The investigation found no substantiation for the allegation after reviewing interviews, staff reports, resident statements, and police investigation.
Findings
The investigation included interviews, record reviews, and surveillance footage analysis. The allegation of sexual abuse was found to be unsubstantiated due to lack of evidence and unclear identification of the unknown male involved.
Report Facts
Capacity: 133
Census: 95
Complaint Control Number: 08-AS-20230721120022
Incident time: 9.42
Incident time: 9.44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Aurora Madueno | Chief of Operations | Facility representative met during the investigation and exit interview |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 95
Capacity: 133
Deficiencies: 0
Date: Jan 10, 2025
Visit Reason
An unannounced continuation annual inspection visit was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, in good repair, with walkways free of obstructions. No pools, bodies of water, firearms, or ammunition were observed or stored on the premises. No deficiencies were cited during this inspection.
Report Facts
Hospice waiver residents: 16
Bedridden residents allowed: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced continuation annual inspection visit |
| Mari Perez | Human Resources Director | Met with the Licensing Program Analyst during the inspection |
| Aurora Madueno | Chief of Operations | Assisted during the visit and received the exit interview and report |
Inspection Report
Annual Inspection
Census: 95
Capacity: 133
Deficiencies: 0
Date: Jan 2, 2025
Visit Reason
An unannounced required annual inspection visit was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, sanitary, and in good repair with no obstructions or slip hazards. Safety equipment such as carbon monoxide detectors, fire extinguishers, and signal systems were tested and observed. Food and medications were properly stored and labeled. A review of facility records was initiated but could not be completed due to time constraints, necessitating an additional visit.
Report Facts
Licensed capacity: 133
Current census: 95
Hospice waiver capacity: 16
Bedridden resident capacity: 16
Perishable food supply: 2
Non-perishable food supply: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the inspection and introduced the purpose of the visit |
| Vonda Boller | Administrator | Facility administrator met with the Licensing Program Analyst and participated in the exit interview |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Capacity: 133
Deficiencies: 0
Date: Jul 10, 2024
Visit Reason
The visit was an unannounced Case Management visit conducted in response to an LIC 624 Incident Report involving Resident #1, which the licensee self-submitted to the CCLD San Diego Regional Office.
Findings
During the visit, records including a physician's report, identification emergency profile, pre-appraisal, and care plan were reviewed. Guidance was provided by the Licensing Program Analyst and no deficiencies were cited on the date of the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced Case Management visit and provided guidance. |
| Vonda Boller | Executive Director | Met with the Licensing Program Analyst during the visit and received the report. |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 133
Deficiencies: 1
Date: Mar 29, 2024
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that facility staff did not conduct emergency drills.
Complaint Details
The complaint was substantiated. The allegation was that facility staff did not conduct emergency drills. The investigation confirmed the deficiency related to emergency drills not being conducted quarterly for each shift, posing a potential health, safety, and personal rights risk to all 103 residents.
Findings
The investigation found that while the facility conducted multiple emergency drills in 2023, they were not conducted quarterly for each shift as required by the Health and Safety Code. A deficiency was cited and a plan of correction was jointly formulated and cleared on the date of the visit.
Deficiencies (1)
Facility did not conduct emergency drills quarterly for each shift as required by Health and Safety Code 1569.695(c).
Report Facts
Residents in care: 103
Total licensed capacity: 133
Deficiency type count: 1
Estimated days of completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Vonda Boller | Executive Director | Facility representative involved in the investigation and plan of correction |
Inspection Report
Annual Inspection
Census: 102
Capacity: 133
Deficiencies: 0
Date: Dec 20, 2023
Visit Reason
An unannounced required 22-month annual inspection was conducted to evaluate compliance with licensing regulations and facility operations.
Findings
The facility was found to be in compliance with regulations, including proper food storage, medication security, sanitary conditions, and sufficient staffing. No significant licensing concerns were identified during staff and client interviews or record reviews.
Report Facts
Licensed capacity: 133
Census: 102
Hospice waiver residents: 16
Supply duration: 2
Supply duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the inspection and interviews |
| Vonda Boller | Administrator | Facility administrator who accompanied the inspection and received report |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 133
Deficiencies: 0
Date: Aug 29, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff did not perform proper resident wound care, did not ensure an incontinent resident was kept clean, and did not give resident medication as directed by the physician.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included improper wound care, inadequate incontinence care, and failure to administer medication as prescribed. Evidence gathered did not support these claims.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews and record reviews revealed that wound care was provided as needed, residents were assisted with incontinence care appropriately, and medication was administered as ordered after clarifications were obtained.
Report Facts
Capacity: 133
Census: 106
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vonda Boller | Executive Director | Met with during investigation and exit interview |
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 133
Deficiencies: 0
Date: Aug 24, 2023
Visit Reason
The visit was conducted in response to an LIC624 Incident Report and SOC 341 Report of Suspected Elder Abuse involving Resident #1, which the licensee self-submitted to the Community Care Licensing Division San Diego Regional Office.
Complaint Details
The visit was complaint-related due to a suspected elder abuse report involving Resident #1. The complaint was self-reported by the licensee. No deficiencies were found during this investigation.
Findings
During the unannounced Case Management - Incident visit, no deficiencies were observed or cited. Pertinent records were secured and interviews conducted, with the possibility of future visits if necessary.
Report Facts
Capacity: 133
Census: 106
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vonda Boller | Administrator / Executive Director | Participated in exit interview and was provided with report and related documents |
| Aurora Madueno | Chief of Operations | Discussed purpose of visit with Licensing Program Analyst |
| Ilene Lund | Executive Nursing Coordinator | Participated in exit interview and was provided with report and related documents |
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
| Lizzette Tellez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 133
Deficiencies: 0
Date: Jul 20, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that residents' needs were not being met because of lack of staffing.
Complaint Details
The complaint alleged that residents' needs were not being met due to lack of staffing. The allegation was unsubstantiated based on interviews and record reviews.
Findings
The investigation found no evidence to support the allegation. Interviews with residents and outside sources, as well as record reviews, revealed no concerns or documentation of insufficient staffing or unmet resident needs during the time in question.
Report Facts
Capacity: 133
Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Mari Perez | HR Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 133
Deficiencies: 0
Date: Jul 13, 2023
Visit Reason
The visit was conducted to investigate a complaint alleging lack of supervision resulting in inappropriate interactions between residents.
Complaint Details
The complaint alleged lack of supervision resulting in inappropriate interactions between residents. The investigation included facility tour, record reviews, staff interviews, and review of police logs. The allegations were found unsubstantiated.
Findings
The investigation found that on 06/11/2020, Resident 2 struck Resident 1, causing distress, but no physical injuries were observed. Staff responded appropriately, and the allegations were unsubstantiated due to lack of corroborating evidence.
Report Facts
Capacity: 133
Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Pena | Licensing Program Analyst | Conducted the complaint investigation |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
| Vonda Boller | Administrator | Facility Administrator met during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 133
Deficiencies: 0
Date: Jul 12, 2023
Visit Reason
The visit was conducted in response to an Incident Report self-submitted by the licensee involving Resident #1, received on 2023-07-07.
Complaint Details
The visit was triggered by an incident report involving Resident #1. No deficiencies were found and no immediate concerns were noted.
Findings
During the unannounced Case Management - Incident visit, no immediate health or safety concerns were observed, and no deficiencies were issued. A facility tour, welfare check, and record review were completed.
Report Facts
Capacity: 133
Census: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vonda Boller | Executive Director | Met during the visit and participated in the exit interview |
| Aurora Madueno | Chief of Operations | Met during the visit and participated in the exit interview |
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 133
Deficiencies: 1
Date: Feb 24, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2022-12-14 alleging that facility staff did not have cleared background checks.
Complaint Details
The complaint was substantiated based on evidence obtained through interviews and record reviews confirming one staff member lacked a cleared background check.
Findings
The investigation confirmed that one staff member had not been background cleared, substantiating the allegation. A deficiency was cited and a $500 civil penalty was assessed. A plan of correction was formulated with the Executive Director.
Deficiencies (1)
Staff #1 did not receive a criminal background clearance prior to working, posing an immediate health, safety, and personal rights risk to 97 residents.
Report Facts
Civil penalty amount: 500
Residents at risk: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vonda Boller | Executive Director | Met during investigation and involved in plan of correction |
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Denise Powell | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 82
Capacity: 133
Deficiencies: 0
Date: Dec 15, 2021
Visit Reason
Licensing Program Analyst Rebecca Ruiz conducted an unannounced Required 1-Year Visit to evaluate the facility's compliance with regulations, including infection control measures related to COVID-19.
Findings
The facility was observed and evaluated for implementation of their COVID-19 Mitigation Plan, including disinfection, testing, vaccination, screening protocols, and use of personal protective equipment. No deficiencies were cited or observed during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the unannounced Required 1-Year Visit and evaluation. |
| Vonda Boller | Facility Administrator met with Licensing Program Analyst during the visit and exit interview. |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 133
Deficiencies: 1
Date: Oct 13, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility was not taking necessary precautions to prevent the spread of COVID-19.
Complaint Details
The complaint was substantiated based on observations of staff not wearing masks properly, violating COVID-19 precautions. A citation was issued in accordance with California Code of Regulations, Title 22.
Findings
The investigation found that staff were not consistently wearing masks as required by the facility's Mitigation Plan and California regulations, posing a potential health risk to residents. The allegation was substantiated and a citation was issued.
Deficiencies (1)
Facility staff did not provide a safe and healthful environment to the residents in care, failing to maintain premises in a state of good repair and safety as required.
Report Facts
Capacity: 133
Census: 88
Deficiencies cited: 1
Plan of Correction Due Date: Nov 15, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alexandre Vo | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation |
| Richard John Rowe | Administrator | Facility administrator during the inspection |
| Vonda Boller | Business Director | Met with Licensing Program Analyst during the inspection and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 133
Deficiencies: 1
Date: Mar 26, 2021
Visit Reason
The visit was a Case Management inspection conducted via video conference in conjunction with a complaint investigation to assess deficiencies at the facility.
Complaint Details
The visit was conducted in conjunction with a complaint investigation; however, the deficiencies identified were unrelated to the complaint.
Findings
The investigation revealed that Resident 1 required a two-person assist due to health and mobility limitations, but the facility failed to update the resident's care plan accordingly, resulting in a cited deficiency.
Deficiencies (1)
Licensee failed to update Resident 1's care plan to include the needs for a two-person assist, posing a potential risk to the resident in care.
Report Facts
Census: 94
Total Capacity: 133
Deficiency count: 1
Plan of Correction Due Date: Apr 9, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laarni Santiago | Licensing Program Analyst | Conducted the Case Management visit and identified deficiencies |
| Simon Jacob | Licensing Program Manager | Supervisor overseeing the inspection |
| Vonda Boller | Business Director | Facility representative met during the inspection |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 133
Deficiencies: 2
Date: Mar 26, 2021
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff neglect resulted in a resident's fall leading to hospitalization and that staff omitted information on the incident report.
Complaint Details
The complaint alleged staff neglect caused Resident 1's fall resulting in hospitalization and that staff falsified the incident report. The allegations were substantiated based on interviews, records review, and evidence obtained.
Findings
The investigation substantiated that staff failed to provide necessary assistance to a two-person assist resident, resulting in a fall and minor injuries. Additionally, the incident report was found to be incomplete and omitted key details about the fall.
Deficiencies (2)
Personnel Requirements – General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Licensee did not ensure staff provided necessary assistance to resident, posing immediate health and safety risk.
Reporting Requirements: A written report shall be submitted to the licensing agency including full details of the incident. Licensee did not provide a full scope of the nature of the incident involving the resident, impacting the facility’s plan of operation.
Report Facts
Capacity: 133
Census: 94
Deficiency Type A POC Due Date: Mar 27, 2021
Deficiency Type B POC Due Date: Apr 9, 2021
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