Deficiencies (last 5 years)
Deficiencies (over 5 years)
13.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
240% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
82% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 15, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify the physician when a resident had a change in condition, specifically low blood pressure readings for Resident 1.
Complaint Details
The complaint investigation found that the facility failed to notify the physician about Resident 1's low blood pressure readings, which was substantiated by medical record review and staff interviews.
Findings
The facility failed to notify the physician when Resident 1 had multiple low systolic blood pressure readings, which had the potential for delayed treatment. There was no documented evidence of physician notification or change of condition initiated despite policy requirements.
Deficiencies (1)
Failure to notify the physician when Resident 1 had low blood pressure readings.
Report Facts
Deficiencies cited: 1
Blood pressure readings: 10
Consecutive days medication held: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PT 1 | Physical Therapist | Interviewed and verified low blood pressure readings and lack of physician notification |
| DON | Director of Nursing | Interviewed and verified multiple low blood pressure readings and lack of physician notification |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jul 15, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning and resident care requirements, focusing on the adequacy of care plans and interventions for Resident 1's changing condition and bowel management.
Findings
The facility failed to develop and update care plans reflecting Resident 1's episodes of nausea, vomiting, diarrhea, and constipation, and failed to provide timely interventions for bowel management, resulting in risk of inadequate, inconsistent, and untimely resident-centered care.
Deficiencies (3)
Failed to develop a care plan addressing Resident 1's change of condition with nausea, vomiting, and diarrhea.
Failed to revise the care plan to include different interventions to prevent constipation for Resident 1.
Failed to provide appropriate care and timely interventions for Resident 1's bowel function and constipation.
Report Facts
Deficiencies cited: 3
Resident 1 no bowel movement days: 6
Physician's order dates: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Interviewed and verified care plan deficiencies and bowel management issues for Resident 1 |
| DON | Director of Nursing | Interviewed and acknowledged findings related to care plan and bowel management deficiencies |
Inspection Report
Annual Inspection
Census: 103
Capacity: 125
Deficiencies: 1
Date: Jun 18, 2025
Visit Reason
The inspection was an unannounced required annual inspection conducted by Licensing Program Analyst Joseph Alejandre to assess compliance with licensing requirements at Capistrano Senior Living Facility.
Findings
The facility was generally found to be in compliance with licensing requirements, including clean and operational resident rooms, proper food storage, and emergency preparedness. However, a deficiency was cited for failure to provide 4 hours of required annual training specific to postural supports, restricted health conditions, and hospice care for 5 staff members.
Deficiencies (1)
Licensee did not comply with training requirements for 5 staff files, missing 4 hours of training specific to postural supports, restricted health conditions, and hospice care.
Report Facts
Staff files reviewed: 5
Resident files reviewed: 10
Emergency drill date: Apr 25, 2025
Plan of Correction Due Date: Jul 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bryan Hadley | Executive Director | Met with Licensing Program Analyst during inspection and named in report |
| Joseph Alejandre | Licensing Program Analyst | Conducted the inspection and authored the report |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 23, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding incomplete and inaccurate medical record documentation for Resident 1, specifically related to a low blood sugar event and failure to initiate a Change of Condition (COC) and notify the resident's representative.
Complaint Details
The complaint investigation found substantiated deficiencies related to incomplete medical record documentation for Resident 1, including failure to initiate a COC for hypoglycemia and failure to notify the resident's representative. The findings were verified through interviews with LVN 1 and the Director of Nursing (DON).
Findings
The facility failed to ensure the medical record was complete and accurately maintained for Resident 1, who had a blood sugar level of 58 mg/dL without documentation of a COC or notification to the resident's representative. Additionally, vital signs were documented as taken after the resident had been discharged. These deficiencies had the potential for not providing necessary care due to incomplete medical record information.
Deficiencies (2)
Failure to document a Change of Condition (COC) for Resident 1's low blood sugar level of 58 mg/dL and failure to notify the resident's representative.
Vital signs were documented as taken after Resident 1 had already been discharged from the facility.
Report Facts
Blood sugar level: 58
Blood sugar recheck level: 94
Date of survey completion: May 23, 2025
Resident transfer date: Jun 17, 2024
Vital signs: 88
Vital signs: 85
Vital signs: 58
Vital signs: 38
Vital signs: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding COC process and verified findings of missing COC documentation |
| DON | Director of Nursing | Interviewed and verified findings related to hypoglycemia COC and documentation of vital signs after discharge |
Inspection Report
Census: 111
Capacity: 125
Deficiencies: 0
Date: Dec 9, 2024
Visit Reason
Licensing Program Analyst Joseph Alejandre made an unannounced case management visit following receipt of an incident report concerning the health and safety of a resident.
Findings
No health or safety concerns were noted during the visit. No deficiencies were cited as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Dannea Maurer | Memory Care Director | Met with the Licensing Program Analyst during the visit. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care, and food service in the facility.
Findings
The facility was found deficient in multiple areas including failure to provide equal access to nutritional services for a resident, failure to inform residents about their rights and complaint procedures, failure to carry out a physician's order regarding discontinuation of a sling, and failure to follow puree diet recipes for residents.
Deficiencies (4)
Failed to provide equal access to nutritional services for one nonsampled resident, causing risk to resident rights.
Failed to ensure residents were informed of their rights and how to formally complain to the State Agency.
Failed to carry out physician's order to discontinue use of sling for one resident, risking inconsistent care.
Failed to follow puree diet recipes for seven residents, risking nutritive value of food.
Report Facts
Residents affected: 1
Residents affected: 6
Residents affected: 1
Residents affected: 7
Date of observation: Nov 12, 2024
Date of resident council meeting: Nov 13, 2024
Date of puree meal observation: Nov 14, 2024
Inspection Report
Routine
Deficiencies: 22
Date: Nov 15, 2024
Visit Reason
The inspection was a routine regulatory survey conducted to assess compliance with healthcare facility regulations, including resident rights, medication management, infection control, dietary services, and safety.
Findings
The facility was found deficient in multiple areas including failure to honor resident rights to timely meal service, unsafe medication self-administration, inadequate response to resident council concerns, incomplete PASARR screening, failure to follow physician orders, unsafe smoking practices, inadequate bladder care, unclear oxygen orders, pharmaceutical service deficiencies, medication administration errors, improper medication storage, dietary service deficiencies, inaccurate medical record documentation, inadequate infection control practices, and incomplete bed entrapment assessments.
Deficiencies (22)
Failure to provide equal access to nutritional services resulting in delayed meal delivery to Resident 25.
Failure to ensure safe self-administration of medications for Residents 14 and 132 due to lack of physician orders and assessments.
Failure to address resident council concerns and notify residents of investigation outcomes.
Failure to inform residents of their rights and how to file complaints with the State Agency.
Failure to refer Resident 16 for PASARR Level II evaluation despite mental disorder diagnosis.
Failure to discontinue use of sling on Resident 132's right shoulder as ordered by physician.
Failure to provide safe environment and supervision for residents who smoke, including lack of smoking aprons and fire extinguishers.
Failure to assess and provide smoking safety measures for Resident 383 who smoked secretly.
Failure to provide appropriate continence care and bladder retraining for Residents 285 and 436.
Failure to clarify physician orders for oxygen administration for Residents 132 and 282 regarding continuous or PRN use.
Failure to ensure accurate accounting and documentation of controlled medications for Resident 432; failure to sign pharmacy delivery slips; failure to document medication disposal dates.
Failure to accurately perform orthostatic blood pressure monitoring for Resident 132 on antipsychotic medication.
Medication administration errors by LVN 4 including failure to administer calcium carbonate chewable tablet as ordered and failure to administer Effexor XR with food.
Failure to ensure proper medication storage including expired medications on cart, mixing external and internal medications, improper storage of feeding formula, and lack of temperature monitoring.
Dietary staff lacked competency in food service functions including improper dishwasher temperature monitoring and sanitizer ppm testing.
Failure to follow menu and diet orders including missing documentation of chicken salad on cool down log, incorrect serving scoop size, failure to monitor milk and cottage cheese temperatures, inaccurate tray tickets, and serving inappropriate food items.
Failure to serve therapeutic diets as prescribed for Residents 16 and 284, including serving unlisted supplement and incorrect diet consistency.
Unsanitary conditions in satellite and main kitchens including dirty sinks, gnats, rusted equipment, improper food storage, and staff without hair/beard restraints.
Failure to ensure infection control practices including hand hygiene before and after medication administration and feeding, improper laundry storage, and lack of Legionella water management program.
Failure to monitor and address antibiotic use according to McGeer's criteria for Residents 7 and 10.
Failure to maintain medication refrigerator freezer compartment free of ice buildup and failure to monitor freezer temperature.
Failure to accurately complete bed entrapment assessments and measure entrapment zones for Resident 132's bilateral grab rails.
Report Facts
Medication error rate: 7.14
Controlled medication count discrepancy: 1
Residents receiving food prepared from kitchen: 41
Residents on puree diet: 7
Residents on therapeutic diets: 2
Residents affected by infection control failures: 3
Residents with inaccurate bed entrapment assessments: 1
Residents with antibiotic monitoring issues: 2
Temperature of cottage cheese: 53
Residents observed with medication errors: 2
Residents with incomplete PASARR screening: 1
Residents affected by smoking safety failures: 2
Residents affected by bladder care failures: 2
Residents with unclear oxygen orders: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 4 | Licensed Vocational Nurse | Made medication administration errors and failed hand hygiene |
| DON | Director of Nursing | Verified multiple findings including medication errors, infection control, and bed entrapment assessments |
| CDM 1 | Certified Dietary Manager | Involved in dietary service deficiencies and food temperature monitoring |
| CDM 2 | Certified Dietary Manager | Involved in dietary service deficiencies and kitchen sanitation |
| MDS Coordinator | Verified medication and oxygen order issues, bed entrapment assessments | |
| Maintenance Director | Responsible for bed entrapment measurements and water management program | |
| DSD/IP | Verified antibiotic stewardship and infection control findings | |
| LVN 1 | Licensed Vocational Nurse | Failed hand hygiene during medication administration |
| OT staff | Occupational Therapist | Failed hand hygiene during feeding assistance |
Inspection Report
Annual Inspection
Census: 106
Capacity: 125
Deficiencies: 1
Date: Jun 22, 2024
Visit Reason
The Licensing Program Analyst conducted an unannounced required annual inspection of the Capistrano Senior Living Facility to assess compliance with regulatory standards.
Findings
The facility was generally found to be clean, organized, and compliant with most regulations, including proper food storage, fire safety equipment, and resident room conditions. However, a deficiency was cited due to Resident 1 missing 2 of their 12 prescribed medications, posing an immediate health and safety risk.
Deficiencies (1)
Resident 1 was missing 2 out of their 12 prescribed medications (MiraLax Packet 17 GM and Oxycodone HCI tablet 5 MG), indicating noncompliance with medication administration regulations.
Report Facts
Deficiencies cited: 1
Resident medications missing: 2
Resident medications prescribed: 12
Plan of Correction due date: Jun 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Sheila Santos | Licensing Program Manager | Supervisor overseeing the inspection |
| Bryan Hadley | Executive Director | Facility administrator met during inspection and involved in exit interview |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure a resident (Resident 1) remained free from accident hazards, specifically related to multiple falls and inadequate supervision.
Complaint Details
The complaint investigation found that Resident 1 had multiple falls, with the facility failing to provide the recommended 1 to 1 supervision consistently. The last fall on 10/24/23 resulted in serious injury requiring surgery. The facility's Director of Nursing confirmed the failure to maintain constant supervision and the expectation that another staff member should have been assigned before leaving Resident 1 unattended.
Findings
Resident 1 sustained six falls during their stay, with the facility's interdisciplinary team recommending 1 to 1 supervision after the fourth fall. However, the supervision was not consistently provided, resulting in a fall on 10/24/23 that caused multiple rib fractures requiring surgery. The facility failed to provide constant supervision as required, and staff left Resident 1 unattended, leading to the injury.
Deficiencies (1)
Failure to ensure one of two sampled residents remained free from accident hazards, resulting in multiple falls and injury due to inadequate supervision.
Report Facts
Number of falls: 6
Date of last fall: Oct 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Reported that CNA 1 left Resident 1 unattended at the time of the fall on 10/24/23. |
| CNA 1 | Certified Nursing Assistant | Assigned as 1 to 1 staff for Resident 1 but left Resident 1 unattended to answer another call light, leading to the fall. |
| RN 1 | Registered Nurse | Assigned to care for Resident 1 at the time of the fall and confirmed the failure of constant supervision. |
| DON | Director of Nursing | Verified IDT recommendations for 1 to 1 supervision and confirmed the failure to maintain supervision at the time of the fall. |
Inspection Report
Annual Inspection
Deficiencies: 17
Date: Nov 17, 2023
Visit Reason
The inspection was conducted as an annual recertification survey to assess compliance with federal and state regulations for nursing home operations, including resident care, medication management, food service, infection control, and safety.
Findings
The facility was found deficient in multiple areas including medication self-administration assessments, bed-hold policy notification, care plan implementation, activity programming, neurological monitoring after falls, respiratory care, pharmaceutical services, psychotropic medication use, food service management and sanitation, infection control practices, antibiotic stewardship, and bed safety entrapment assessments. Several equipment maintenance issues were also identified.
Deficiencies (17)
Failed to determine if residents were safe to self-administer medications left at bedside, lacking physician orders, assessments, and care plans for self-administration.
Failed to notify resident or representative in writing about bed-hold policy upon transfer to hospital.
Failed to implement care plan to provide padded side rails as ordered for resident.
Failed to provide individualized and ongoing activity program matching resident interests.
Failed to monitor neurological status after fall with head injury.
Failed to provide proper respiratory care including storage of nebulizer mask and tubing, and oxygen administration as ordered.
Failed to secure narcotic disposition bin, inaccurate controlled medication records, and medication administration errors.
Failed to implement non-pharmacological interventions and monitor psychotropic medication use appropriately.
Failed to store medications and supplies safely, including expired medications and failure to replace emergency medication kits timely.
Failed to employ full-time qualified dietitian and ensure competency of dietary manager; multiple food service violations including expired food served, improper handwashing, and sanitation issues.
Failed to ensure proper manual dishwashing procedures by dietary aide, risking sanitation concerns.
Failed to ensure food safety and sanitation in kitchen including improper cooling and thawing of foods, expired food served, improper hand hygiene, improper storage, lack of hair/beard coverings, and unclean utensils and equipment.
Failed to ensure safe handling and storage of food brought in by family or visitors, including lack of education and storage/reheating policies.
Failed to maintain infection control in laundry area by allowing employee personal belongings in clean linen area.
Failed to monitor and address antibiotic use when infection criteria were not met.
Failed to maintain essential equipment including ice machines and dishwashing machine at proper sanitation and temperature levels.
Failed to regularly inspect beds and side rails for safety and entrapment risks, including lack of entrapment assessments and inspections after bed or mattress changes.
Report Facts
Residents affected: 12
Residents affected: 33
Hours worked per week: 26
Temperature: 110
Temperature: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 4 | Licensed Vocational Nurse | Verified medication and neurological monitoring deficiencies |
| DON | Director of Nursing | Verified multiple deficiencies including medication self-administration, bed-hold policy, care plans, neurological monitoring, respiratory care, and bed safety |
| CDM | Certified Dietary Manager | Responsible for food service management; verified multiple food service and sanitation deficiencies |
| RD | Registered Dietitian | Part-time dietitian; verified food service and dietary management deficiencies |
| Maintenance Director | Maintenance Director/Housekeeping Supervisor | Verified bed inspection and equipment maintenance deficiencies |
| IP/DSD | Infection Preventionist/Director of Staff Development | Verified antibiotic stewardship deficiencies |
| LVN 3 | Licensed Vocational Nurse | Verified medication administration errors and respiratory care deficiencies |
| DA 3 | Dietary Aide | Observed not following proper manual dishwashing procedures |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 125
Deficiencies: 1
Date: May 10, 2023
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that the facility was mismanaging a resident's medication.
Complaint Details
The complaint alleging mismanagement of resident's medication was substantiated based on evidence including interviews, medication administration records, and facility documentation.
Findings
The investigation found that Resident 1 did not receive several prescribed medications from 4/22/23 to 4/26/23 and on 4/30/23, posing an immediate risk to health and safety. Conflicting reports were noted regarding medication administration, but the preponderance of evidence substantiated the allegation of medication mismanagement.
Deficiencies (1)
Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: based on a review of records R1 was not administered any medications from 4/22/23 to 4/26/23 and on 4/30/23. This poses an immediate risk to the health & safety of residents in care.
Report Facts
Census: 97
Total Capacity: 125
Deficiency Due Date: May 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bryan Hadley | Executive Director | Met with during investigation and named in report |
| Nina Dadabhoy | Health and Wellness Director | Met with during investigation and named in report |
| Luz Adams | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 125
Deficiencies: 1
Date: Oct 28, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that unqualified staff administered injections to residents in care.
Complaint Details
The complaint alleging unqualified staff administering injections was substantiated based on interviews, record reviews, and staff reports. Memory care residents could not verify the information. The preponderance of evidence standard was met.
Findings
The investigation substantiated that non-licensed staff performed glucose testing and administered insulin injections to residents without their aid, which violates California regulations and poses an immediate health and safety risk.
Deficiencies (1)
The licensee failed to ensure that only appropriately skilled professionals administer medication including injections to diabetic residents, as non-licensed staff administered insulin injections and performed glucose testing without assistance.
Report Facts
Capacity: 125
Census: 93
Deficiency count: 1
Plan of Correction Due Date: Oct 29, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bryan Hadley | Administrator | Facility administrator met during the investigation and named in the report |
| Luz Adams | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Routine
Deficiencies: 13
Date: Oct 20, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, medication administration, respiratory care, food services, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to follow up on resident council concerns, incomplete care plans for oxygen therapy, inadequate colostomy care, improper PICC line dressing changes, unsafe respiratory care practices, improper use of bed rails, inaccurate glucometer QC checks, high medication error rates, improper medication storage, failure to provide resident food preferences, unsanitary kitchen practices, improper handling of food brought in by visitors, and inaccurate medical records documentation.
Deficiencies (13)
Failed to follow up on residents' concerns during resident council meetings.
Failed to develop a comprehensive care plan for Resident 36's oxygen therapy.
Failed to ensure colostomy bag was emptied routinely to prevent leakage for Resident 24.
Failed to perform PICC line dressing change as ordered for Resident 31.
Failed to provide safe respiratory care including improper storage and tubing changes for Residents 7, 36, and 488.
Failed to assess and obtain consent for use of bed rails for Residents 17, 36, 488, and 489.
Failed to ensure nursing staff competency in performing glucometer QC checks.
Medication error rate was 17.24%, exceeding acceptable limits.
Failed to ensure medications were properly stored, including expired allergy medication, outdated multidose vial, and unlabeled protein shake.
Failed to provide resident food preferences for Resident 7, resulting in resident receiving undesired foods.
Failed to ensure sanitary condition of kitchen equipment and proper dishwashing practices.
Failed to ensure food brought in by visitors was handled according to facility policy, risking non-compliance with therapeutic diet for Resident 24.
Failed to maintain accurate medical records regarding advance directives for Resident 31.
Report Facts
Medication error rate: 17.24
Residents sampled: 15
Date of survey: Oct 20, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Involved in glucometer QC checks and interview about food brought in by family |
| LVN 3 | Licensed Vocational Nurse | Had medication errors during medication administration observations |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including care plans, respiratory care, side rails, and glucometer QC |
| Dietitian | Interviewed regarding food preferences and food brought in by visitors | |
| Maintenance Supervisor | Interviewed regarding ice machine cleaning and sanitization | |
| Dishwasher 1 | Observed and interviewed regarding hand hygiene and dishwashing practices | |
| Dishwasher 2 | Observed stacking wet dishes without air drying | |
| Activities Director | Interviewed regarding resident council follow-up and medication storage | |
| DSS | Interviewed regarding conflicting advance directive documentation |
Inspection Report
Census: 92
Capacity: 125
Deficiencies: 0
Date: Jul 21, 2022
Visit Reason
An unannounced case management visit was conducted to review health checks and provide consultation regarding reporting requirements and the Guardian System.
Findings
No citations were issued during this visit. The facility had suspended community and group activities, used disposable utensils for meal preparation, and had infection control measures in place in the memory care unit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bryan Hadley | Executive Director | Met with Licensing Program Analysts during the visit and received consultation. |
| Albert Marin | Licensing Program Analyst | Conducted the unannounced case management visit and provided consultation. |
| Celine De Perio | Licensing Program Analyst | Conducted the unannounced case management visit and provided consultation. |
Inspection Report
Annual Inspection
Census: 92
Capacity: 125
Deficiencies: 0
Date: Jun 7, 2022
Visit Reason
Licensing Program Analyst Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation) of the facility.
Findings
The facility was found to be clean, organized, and compliant with no deficiencies observed. Staff were wearing masks, hand sanitizing stations were present, medications were secured, fire extinguishers were charged, and emergency equipment was in place. The facility has an approved Covid-19 mitigation plan.
Report Facts
Perishable food supply: 2
Non-perishable food supply: 7
PPE supply: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Hadley | Executive Director | Met with Licensing Program Analyst during inspection and consulted regarding Covid-19 mitigation and reporting requirements |
| Joseph Alejandre | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 125
Deficiencies: 0
Date: May 19, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not assist a resident with their shower.
Complaint Details
The complaint alleged that staff did not assist a resident with their shower. The investigation was unannounced and included interviews, facility tour, and document review. The allegation was found to be unfounded.
Findings
The investigation found that the resident had a preferred caregiver who switched shifts, resulting in the resident refusing showers at the preferred time. The facility attempted to accommodate the resident's preferences and documented refusals. The allegation was deemed unfounded as the resident was refusing showers and the facility provided varied meal options.
Report Facts
Capacity: 125
Census: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brian Hadley | Facility representative who met with the Licensing Program Analyst during the visit | |
| Alisa Ortiz | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Original Licensing
Census: 86
Capacity: 125
Deficiencies: 0
Date: Mar 23, 2022
Visit Reason
An unannounced post licensing visit (mitigation) was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The Licensing Program Analyst observed that the facility was clean, organized, and well-maintained with no deficiencies noted. All safety systems, including fire extinguishers, delayed egress exits, and fire sprinkler systems, were operational and no hazards were observed.
Report Facts
Fire drill date: Mar 14, 2022
Fire sprinkler system test date: Feb 24, 2022
PPE supply duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ninad Dadabhoy | Health & Wellness Director | Met with Licensing Program Analyst during the visit and toured the facility |
| Joseph Alejandre | Licensing Program Analyst | Conducted the unannounced post licensing visit |
Inspection Report
Census: 66
Capacity: 125
Deficiencies: 1
Date: Sep 21, 2021
Visit Reason
An unannounced case management visit was made to follow up on an incident report submitted regarding a resident who eloped from the facility on 09/15/2021.
Findings
The facility failed to ensure adequate care and supervision as evidenced by a resident eloping due to staff not responding to a door alarm, posing an immediate health and safety risk to residents.
Deficiencies (1)
Licensee did not ensure care and supervision was provided to Resident 1 who eloped from the facility because staff did not respond to the door alarm.
Report Facts
Deficiency due date: Sep 22, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the unannounced case management visit and cited the deficiency |
| Luz Adams | Licensing Program Manager | Named as supervisor and licensing program manager in the report |
| Cynthia Garcia | Administrator | Facility administrator named in the report |
| Ninad Dadabhoy | Met with during the visit |
Inspection Report
Census: 62
Capacity: 125
Deficiencies: 0
Date: Jun 1, 2021
Visit Reason
The visit was conducted as part of a Change of Ownership application process for the facility.
Findings
The applicant and administrator participated in a COMP II telephone interview to verify identification and confirm understanding of California Code Title 22 regulations, covering facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and pre-licensing readiness.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Bradshaw | Participant in COMP II telephone interview | |
| Jude De La Concepcion | Licensing Program Manager | Named as Licensing Program Manager |
| Bethany Hunter | Licensing Program Analyst | Named as Licensing Program Analyst |
| Cynthia Garcia | Administrator | Facility Administrator |
Inspection Report
Original Licensing
Census: 64
Capacity: 125
Deficiencies: 0
Date: Jun 1, 2021
Visit Reason
Licensing Program Analyst Joseph Alejandre conducted an announced pre-licensing inspection visit to evaluate the facility for licensure as a continuing care retirement community.
Findings
The facility was toured and inspected including resident rooms, kitchen, dining rooms, laundry, medication room, and common areas. No hazards or obstacles were observed, safety systems were operational, and fire clearance was approved. The facility meets Title 22 Division 6 regulations and is ready for licensure.
Report Facts
Hot water temperature: 105
Facility capacity: 125
Census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Garcia | Administrator | Administrator present during inspection and named in report |
| Joseph Alejandre | Licensing Program Analyst | Conducted the pre-licensing inspection visit |
Inspection Report
Census: 62
Capacity: 125
Deficiencies: 0
Date: May 27, 2021
Visit Reason
The visit was conducted as part of a Change of Ownership application process for the facility.
Findings
The applicant/administrator participated in a COMP II telephone interview to verify identification and confirm understanding of California Code Title 22 regulations, including facility operation, admission policies, staffing, emergency preparedness, and other regulatory areas.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Garcia | Executive Director | Applicant/administrator participating in COMP II interview |
| Jude De La Concepcion | Licensing Program Manager | Named as Licensing Program Manager |
| Bethany Hunter | Licensing Program Analyst | Named as Licensing Program Analyst |
Report
January 29, 2026
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