Inspection Report Summary
Most inspections found deficiencies related primarily to medication management, resident supervision, and reporting requirements, with several substantiated complaint investigations. The facility faced a $500 fine in August 2025 for medication mismanagement and lack of staff training, and there were multiple instances where required incident reports were not submitted timely. The most recent report from October 9, 2025, cited a deficiency for failing to report a medication error but did not include any fines or enforcement actions. Several complaint investigations were unsubstantiated, indicating that some concerns raised were not confirmed. While issues have recurred over time, the facility has also had clean annual inspections, including one in July 2025, showing some compliance improvements amid ongoing challenges.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
74% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 133
Capacity: 180
Deficiencies: 1
Date: Oct 9, 2025
Visit Reason
Licensing Program Analysts arrived unannounced to open a complaint investigation but discovered an unrelated deficiency during the investigation.
Complaint Details
The visit was complaint-related, triggered by an unannounced complaint investigation. The medication error was substantiated, and the facility was cited for failure to report the incident as required by 22 CCR Section 87211(a)(1)(D).
Findings
A medication error was identified where a resident missed four daily doses of a Parkinson's disease medication due to a transcription error. Additionally, the facility failed to report the incident to the Community Care Licensing Division as required by regulation.
Deficiencies (1)
Failure to submit an incident report to the licensing agency regarding a medication error that poses a potential health, safety, and/or personal rights risk.
Report Facts
Missed medication doses: 4
Plan of Correction due date: Oct 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennell Revera | Facility Administrator | Met with Licensing Program Analyst during the investigation and named in the exit interview. |
| Vincent Moleski | Licensing Program Analyst | Conducted the investigation and authored the report. |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 180
Deficiencies: 2
Date: Aug 12, 2025
Visit Reason
The visit was an unannounced case management inspection triggered by an incident report received on July 28, 2025, concerning a resident who experienced complications related to medication-releasing intravaginal rings.
Complaint Details
The visit was triggered by an incident report alleging improper management of intravaginal rings for a resident, which was substantiated by findings of medication mismanagement and lack of staff training.
Findings
The inspection found that staff nurses had been inserting intravaginal rings without proper initial training, resulting in a resident receiving multiple rings beyond the recommended 90-day usage period, causing injury. The facility was cited for deficiencies related to medication mismanagement and lack of staff training, and a $500 civil penalty was assessed.
Deficiencies (2)
Resident's medication was mismanaged, posing an immediate health, safety, and/or personal rights risk.
Staff nurses were not trained in the use of medication-releasing intravaginal rings, posing a potential health, safety, and/or personal rights risk.
Report Facts
Civil penalty amount: 500
Number of intravaginal rings removed: 5
Plan of Correction due date: Aug 13, 2025
Plan of Correction due date: Aug 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennell Revera | Facility Administrator | Met with licensing staff during the inspection and was involved in discussion of findings. |
| Vincent Moleski | Licensing Program Analyst | Conducted the inspection and reviewed incident reports and medication administration records. |
| Stephenie Doub | Regional Manager | Accompanied Licensing Program Analyst during the inspection. |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 180
Deficiencies: 1
Date: Jul 23, 2025
Visit Reason
The inspection was an unannounced case management visit triggered by an incident report received on 07/19/2025 regarding a resident who was missing during the evening medication pass and was found unsupervised in the community.
Complaint Details
The visit was complaint-related based on an incident report about a resident missing during medication pass time and found unsupervised in the community. The complaint was substantiated as the facility was cited for failure to supervise the resident.
Findings
The facility failed to ensure the safety of a resident who was missing for approximately four hours while unsupervised in the community, posing an immediate health, safety, and personal rights risk. Surveillance footage showed a staff member at the front desk did not notice the resident leaving the facility.
Deficiencies (1)
Failure to be aware of the resident's general whereabouts, allowing the resident to travel independently in the community unsupervised.
Report Facts
Resident missing duration: 4
Facility capacity: 180
Resident census: 134
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the case management visit and authored the report. |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Olivia Sterba | Executive Assistant | Met with Licensing Program Analyst during the visit and received the report. |
| Jennell Revera | Administrator | Facility Administrator named in the report. |
Inspection Report
Annual Inspection
Census: 139
Capacity: 180
Deficiencies: 0
Date: Jul 10, 2025
Visit Reason
An unannounced annual inspection was conducted by Licensing Program Analyst Vincent Moleski to evaluate compliance with licensing requirements at Carlton Plaza of Elk Grove.
Findings
The inspection found no deficiencies. The facility met all regulatory requirements including adequate furnishings, proper temperature controls, sufficient food supplies, and appropriate storage of medications and cleaning solutions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennell Revera | Facility Administrator | Met with Licensing Program Analyst during the inspection and was present for the exit interview. |
| Vincent Moleski | Licensing Program Analyst | Conducted the annual inspection and reviewed resident and staff files. |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 180
Deficiencies: 2
Date: Dec 30, 2024
Visit Reason
The visit was an unannounced case management inspection conducted during a complaint investigation related to the care of a resident (R1) who was hospitalized following a period of quarantine and illness.
Complaint Details
The complaint investigation was triggered by concerns regarding the care of resident R1, who was hospitalized on 8/8/24 with serious medical conditions including lactic acidosis and acute renal insufficiency. Interviews and record reviews revealed inadequate monitoring and assistance during R1's quarantine and failure to report the incident timely.
Findings
The investigation found that appropriate assistance was not provided to R1 during their quarantine period, leading to severe health complications. Additionally, the facility failed to submit a required incident report within seven days of R1's hospitalization.
Deficiencies (2)
Failure to ensure residents are regularly observed for changes in physical, mental, emotional and social functioning and to provide appropriate assistance when unmet needs are revealed, specifically during R1's quarantine period.
Failure to submit a written incident report to the licensing agency within seven days of R1's hospitalization on 8/8/24.
Report Facts
Census: 140
Total Capacity: 180
Deficiency Count: 2
Incident Report Due Date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennell Revera | Administrator | Facility administrator interviewed regarding resident care and deficiencies |
| Vincent Moleski | Licensing Program Analyst | Conducted the case management visit and complaint investigation |
Inspection Report
Census: 140
Capacity: 180
Deficiencies: 0
Date: Dec 30, 2024
Visit Reason
The visit was an unannounced case management visit conducted by Licensing Program Analyst Vincent Moleski to review death reports and resident records for two residents.
Findings
No deficiencies were cited during this visit. The Licensing Program Analyst reviewed death reports and resident records and interviewed the facility administrator and a staff member regarding these reports.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the case management visit and reviewed reports and records. |
| Jennell Revera | Administrator | Met with Licensing Program Analyst during the visit and was interviewed. |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 180
Deficiencies: 1
Date: Dec 30, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-08-13 regarding concerns about the cleanliness of a resident's room and other care issues.
Complaint Details
The complaint alleged that staff did not ensure the resident's room was kept clean, that due to negligence the resident became dehydrated and developed sepsis resulting in hospitalization, and that staff did not administer the resident's medication as prescribed. The allegation regarding cleanliness was substantiated, while the allegations regarding dehydration, sepsis, and medication administration were unsubstantiated.
Findings
The investigation substantiated that staff did not ensure a resident's room was kept clean, specifically related to uncleaned cat feces posing health and safety risks. Allegations that a resident became dehydrated and developed sepsis, and that staff failed to administer medication as prescribed, were unsubstantiated.
Deficiencies (1)
The facility failed to maintain a resident's room in a clean, safe, sanitary condition, as evidenced by uncleaned cat feces on the floor and resident, posing an immediate health and safety risk.
Report Facts
Capacity: 180
Census: 140
Deficiency count: 1
Plan of Correction Due Date: Dec 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jennell Revera | Facility Administrator | Facility administrator met during investigation and named in findings |
| Stephen Richardson | Licensing Program Manager | Oversaw the licensing program and signed the report |
Inspection Report
Annual Inspection
Census: 141
Capacity: 180
Deficiencies: 2
Date: Jul 31, 2024
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and assess the facility's operations and resident care.
Findings
The inspection found deficiencies related to staff fingerprinting and annual medical assessments for residents with dementia. A civil penalty was assessed for an employee working without proper association and fingerprinting. The facility was otherwise found to have adequate supplies, environment, and resident care conditions.
Deficiencies (2)
Employee S6 was working without being re-associated and fingerprinted, posing an immediate health, safety, or personal rights risk.
Residents R1 and R2 did not have annually updated LIC 602 medical assessments on file, posing a potential health, safety, or personal rights risk.
Report Facts
Civil penalty amount: 500
Number of resident files reviewed: 10
Number of staff files reviewed: 5
Number of staff interviewed: 5
Number of residents interviewed: 5
Facility temperature: 72
Facility water temperature: 113
Facility capacity: 180
Facility census: 141
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennell Revera | Administrator | Facility administrator met with Licensing Program Analysts and was involved in exit interview and discussions about findings. |
| Vincent Moleski | Licensing Program Analyst | Conducted inspection, reviewed records, interviewed staff and residents, and authored the report. |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection process. |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 180
Deficiencies: 0
Date: Jul 1, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on 2024-03-27 regarding inadequate food service, unmet toileting and showering needs, disrespectful treatment, overcharging, and medication mismanagement at Carlton Plaza of Elk Grove.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was insufficient evidence to prove the alleged violations occurred. Allegations included inadequate food service, unmet toileting and showering needs, disrespectful treatment, overcharging, and medication mismanagement.
Findings
Based on interviews, observations, and record reviews, all allegations were found to be unsubstantiated with no deficiencies cited. Residents and staff interviews, as well as documentation reviews, showed no evidence of the alleged violations.
Report Facts
Capacity: 180
Census: 142
Call button response time: 9
Showers received: 6
PRN laxative doses: 1
Room service delivery charge rate: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jennell Revera | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 180
Deficiencies: 1
Date: May 9, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that facility staff did not safeguard residents' belongings.
Complaint Details
The complaint was substantiated. The allegation was that facility staff did not safeguard residents' belongings. The investigation included interviews, observations, and record reviews, confirming deficiencies in the facility's theft and loss program.
Findings
The investigation found that the facility failed to implement several required elements of its theft and loss program, including lack of documentation of missing items, absence of estimated values for missing property, failure to conduct semiannual reviews of theft and loss procedures, and failure to provide required legal sections to the resident or responsible party. The allegation was substantiated.
Deficiencies (1)
Failure to implement a theft and loss program as required by HSC Section 1569.153, including documentation of missing items, estimated values, semiannual reviews, and provision of required legal information.
Report Facts
Census: 137
Total Capacity: 180
Deficiency Type B Count: 1
Plan of Correction Due Date: Jun 6, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennell Revera | Facility Administrator | Interviewed regarding the complaint and findings |
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation report |
| Andrea Quintanilla | Director of Resident Services | Met with Licensing Program Analyst during investigation |
Inspection Report
Plan of Correction
Census: 121
Capacity: 180
Deficiencies: 0
Date: Jan 8, 2024
Visit Reason
The visit was an unannounced case management follow-up to verify the plan of correction for a citation issued on October 10, 2023.
Findings
No deficiencies were cited during this visit. The Licensing Program Analyst interviewed the facility administrator and staff, and an exit interview was conducted.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennell Revera | Facility Administrator | Met with Licensing Program Analyst during the visit and interviewed. |
| Vincent Moleski | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 180
Deficiencies: 1
Date: Oct 10, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that due to lack of staffing, staff do not answer resident call buttons timely, and that staff are not following infectious disease protocols.
Complaint Details
The complaint investigation was substantiated for the allegation that due to lack of staffing, staff do not answer resident call buttons timely. The allegation that staff are not following infectious disease protocols was unsubstantiated.
Findings
The investigation substantiated the allegation of insufficient staffing leading to delayed response to resident call buttons, citing multiple instances of calls taking over 15 minutes to be answered. The allegation regarding failure to follow infectious disease protocols was unsubstantiated based on observations and interviews.
Deficiencies (1)
Personnel Requirements: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by insufficient staff to answer resident calls timely, posing a potential health and safety risk.
Report Facts
Call responses over 15 minutes: 46
Call responses over 20 minutes: 30
Call responses over 30 minutes: 10
Call responses over 40 minutes: 4
Call responses over 15 minutes: 15
Call responses over 20 minutes: 10
Call responses over 30 minutes: 4
Call responses over 40 minutes: 2
Call responses over 15 minutes: 43
Call responses over 20 minutes: 26
Call responses over 30 minutes: 15
Call responses over 40 minutes: 5
Call responses over 15 minutes: 6
Call responses over 20 minutes: 5
Call responses over 15 minutes: 10
Call responses over 20 minutes: 7
Call responses over 30 minutes: 4
Call responses over 40 minutes: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation |
| Jennell Revera | Administrator | Interviewed regarding staffing and call response expectations |
| Andrea Quintanilla | Director of Resident Services | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Census: 121
Capacity: 180
Deficiencies: 0
Date: Aug 17, 2023
Visit Reason
The visit was an unannounced case management follow-up to an incident report regarding an alleged theft in a resident's apartment.
Findings
The Licensing Program Analyst reviewed the incident involving theft of a ring and money, interviewed involved residents and staff, and found no deficiencies during the visit. Two staff members were terminated related to the incident.
Report Facts
Residents present: 121
Facility capacity: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennell Revera | Administrator | Met with Licensing Program Analyst during the visit and involved in incident report follow-up |
| Vincent Moleski | Licensing Program Analyst | Conducted the case management visit and investigation |
| Stephen Richardson | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 121
Capacity: 180
Deficiencies: 1
Date: Jul 10, 2023
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements at Carlton Plaza of Elk Grove.
Findings
The inspection found expired first aid/CPR certifications for three staff members (S3, S4, and S7), posing a potential health and safety risk. Other facility conditions such as temperature, food supply, and safety equipment were compliant.
Deficiencies (1)
Staff S3, S4, and S7 did not maintain active first aid certifications, which poses a potential health, safety or personal rights risk to persons in care.
Report Facts
Deficiency count: 1
Plan of Correction Due Date: Aug 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennell Revera | Facility Administrator | Met with Licensing Program Analyst during inspection and exit interview. |
| Vincent Moleski | Licensing Program Analyst | Conducted the annual inspection and authored the report. |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 124
Capacity: 180
Deficiencies: 0
Date: Jun 20, 2023
Visit Reason
The visit was an unannounced follow-up on an incident report received on 2023-06-15 regarding a possible medication error involving a resident on 2023-06-06.
Complaint Details
The complaint involved a possible medication error reported by the responsible party of a resident. The medication was administered once instead of twice on 6/6/23, but no harm occurred. The complaint was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The investigation found that the medication administration records were followed as per instructions, but a medication bottle received was already opened and one tablet was missing. The resident did not experience any serious side effects, and the facility obtained a new medication order from the prescribing doctor. No deficiencies were cited during this visit.
Report Facts
Medication dosage: 50
Census: 124
Total capacity: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennell Revera | Administrator | Met with Licensing Program Analyst during the visit and provided information about the medication incident. |
| Vincent Moleski | Licensing Program Analyst | Conducted the unannounced follow-up visit and investigation. |
Inspection Report
Census: 122
Capacity: 180
Deficiencies: 0
Date: Apr 24, 2023
Visit Reason
The visit was a case management visit conducted regarding the immediate exclusion of an employee.
Findings
No deficiencies were cited during this visit. The employee in question was terminated immediately after receiving the immediate exclusion letter.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennell Revera | Administrator | Met with Licensing Program Analysts during the visit and provided information about the terminated employee. |
Inspection Report
Complaint Investigation
Capacity: 180
Deficiencies: 1
Date: Apr 19, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-01-26 alleging that the facility was not following infection control procedures.
Complaint Details
The complaint was substantiated. The allegation that the facility was not following infection control procedures was validated based on staff interviews and administrator statements regarding PPE gown reuse during a shortage.
Findings
The investigation found that during a recent COVID-19 outbreak, staff did not dispose of gowns as required, with staff reusing disposable gowns instead of discarding them. This substantiated the allegation that the facility failed to follow infection control procedures.
Deficiencies (1)
"PPE shall be removed and discarded in the nearest appropriate waste receptacle with a tight-fitting cover immediately upon completing a task." This was not met based on Licensing Program Analyst interviews with staff members.
Report Facts
Capacity: 180
Deficiency due date: Apr 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennell Revera | Administrator | Met during investigation and provided information on PPE gown reuse |
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 123
Capacity: 180
Deficiencies: 0
Date: Mar 2, 2023
Visit Reason
Unannounced case management visit in response to an unusual incident report for a resident who fell and suffered a fractured wrist.
Findings
No deficiencies were cited during this visit. Licensing Program Analysts reviewed resident records and care plans but were unable to speak with the resident or staff involved due to their absence.
Report Facts
Capacity: 180
Census: 123
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the inspection and reviewed records |
| Jason Lund | Licensing Program Analyst | Conducted the inspection and reviewed records |
| Jennell Revera | Administrator | Facility administrator named in the report header |
| Krystal Cosaino | Executive Assistant | Met with Licensing Program Analysts during the visit |
| Stephen Richardson | Licensing Program Manager | Named in the report |
Inspection Report
Census: 121
Capacity: 180
Deficiencies: 1
Date: Feb 3, 2023
Visit Reason
The visit was an office meeting conducted by Licensing Program Analyst Jamie Ivey Canady with the facility administrator Jennell Revera to discuss facility incident reporting requirements based on Title 22 Regulations.
Findings
A deficiency was cited for failure to report a Covid-19 outbreak that began on 1/15/2023 within the regulatory timelines, posing an immediate health and safety risk to persons in care.
Deficiencies (1)
Failure to report a Covid-19 outbreak that began on 1/15/2023 within regulatory timelines as required by Title 22 Regulations.
Report Facts
Capacity: 180
Census: 121
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennell Revera | Facility Administrator | Met with Licensing Program Analyst during the office visit |
| Jamie Ivey Canady | Licensing Program Analyst | Conducted the office meeting and inspection |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 180
Deficiencies: 0
Date: Jul 28, 2022
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation of lack of supervision resulting in resident wandering from the facility.
Complaint Details
The complaint was unsubstantiated as the preponderance of evidence standards were not met. The allegation involved lack of supervision resulting in resident wandering.
Findings
The investigation found the allegation to be unsubstantiated due to lack of evidence, and no deficiencies were cited.
Report Facts
Estimated Days of Completion: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Stephen Richardson | Licensing Program Manager | Named in report header |
| Jennell Revera | Administrator | Facility administrator met during investigation |
Inspection Report
Annual Inspection
Census: 119
Capacity: 180
Deficiencies: 0
Date: Jul 25, 2022
Visit Reason
Licensing Program Analyst Ruth Wallace conducted an unannounced Required Annual 1 Year Inspection Visit to evaluate compliance with regulations and ensure resident safety.
Findings
The facility was found to be in full compliance with no deficiencies observed. The physical plant, safety systems, medication storage, kitchen, and resident files were all inspected and met regulatory standards.
Report Facts
Hospice residents: 6
Home Health residents: 8
Staff files reviewed: 4
Resident files reviewed: 8
Fire extinguisher check date: Feb 2, 2022
Facility temperature: 75
Hot water temperature: 113.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennell Revera | Administrator | Met with Licensing Program Analyst during inspection |
| Ruth Wallace | Licensing Program Analyst | Conducted the inspection visit |
| Stephen Richardson | Licensing Program Manager | Named in report header and footer |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 180
Deficiencies: 1
Date: May 16, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations including wrong medication administration, unskilled insulin injections, failure to ensure meals, short staffing, failure to provide services as per care plan, and unauthorized disclosure of resident information.
Complaint Details
Complaint investigation was unannounced and based on allegations received on 03/03/2022. The allegations included wrong medication administration, unskilled insulin injections, failure to ensure meals, short staffing, failure to provide services as per care plan, and unauthorized disclosure of resident information. All allegations were unsubstantiated except the diabetic diet allegation which was substantiated.
Findings
All allegations except one were found to be unsubstantiated after interviews, record reviews, and observations. One allegation regarding failure to provide a diabetic diet to a resident was substantiated, with evidence that a maple syrup product inconsistent with the prescribed diabetic diet was given to the resident.
Deficiencies (1)
Failure to provide modified diabetic diet as prescribed by resident's physician, evidenced by providing a maple syrup product not low or sugar free.
Report Facts
Capacity: 180
Census: 122
Deficiencies cited: 1
Plan of Correction Due Date: May 26, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennell Revera | Administrator | Met during investigation and named in findings |
| Michael Bilger | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 180
Deficiencies: 1
Date: May 16, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations received on 2022-04-08 regarding resident hygiene, toileting needs, visitor restrictions, and medication management.
Complaint Details
Complaint investigation was unannounced and conducted by Licensing Program Analyst Michael Bilger. Allegations included unmet hygiene and toileting needs, prevention of visitors, and medication mismanagement. The hygiene, toileting, and visitor allegations were unsubstantiated. The medication mismanagement allegation was substantiated due to missing medication and poor documentation.
Findings
The investigation found the allegations regarding resident hygiene, toileting needs, and visitor restrictions to be unsubstantiated. However, the allegation of medication mismanagement was substantiated due to missing medication pills and inadequate documentation of medication administration.
Deficiencies (1)
Failure to properly manage Quetiapine medication order for resident, including missing 22 pills and lack of documentation on administration and resident response.
Report Facts
Census: 122
Total Capacity: 180
Missing Medication Pills: 22
Medication Bottle Fill Date: Jul 17, 2021
Plan of Correction Due Date: May 17, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Bilger | Licensing Program Analyst | Conducted the complaint investigation and medication audit |
| Jennell Revera | Administrator | Facility administrator interviewed during investigation |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 180
Deficiencies: 5
Date: Apr 28, 2022
Visit Reason
The inspection was conducted due to an incident report received on 2022-04-26 indicating that a resident (R1) left the facility without staff knowledge.
Complaint Details
The visit was complaint-related due to an incident report of resident elopement. The complaint was substantiated as the resident eloped twice, one incident was unreported, and deficiencies were cited.
Findings
The investigation found that resident R1 eloped twice from the facility, including an unreported incident on 2022-04-22, and that the front door alarm did not activate during one elopement. The facility failed to implement adequate safety measures to prevent wandering and did not provide first aid after R1 sustained a scrape. The facility also failed to submit a required incident report for one elopement.
Deficiencies (5)
Care of Persons with Dementia - The resident eloped twice and the facility did not implement new measures to prevent future elopements, posing an immediate health and safety risk.
Care of Persons with Dementia - The licensee failed to have an auditory device or staff alert feature to monitor exits; the front door alarm did not sound during elopement.
Care of Persons with Dementia - The licensee did not ensure supervision resulting in resident wandering away twice, including an approximately 8-hour elopement.
Reporting Requirements - The licensee failed to submit an incident report for the elopement on 2022-04-22.
Incidental Medical and Dental Care - Resident did not receive first aid for a scrape due to eating and family taking resident on an outing.
Report Facts
Incident duration: 8
Census: 122
Total capacity: 180
Deficiency count: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection. |
| Jennell Revera | Administrator | Facility administrator involved in interviews and findings. |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 180
Deficiencies: 1
Date: Oct 28, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations including refusal to issue a refund, medication errors, failure to provide meals, failure to follow modified diet, unspecified additional fees, failure to provide shower assistance, and insufficient testing equipment.
Complaint Details
The complaint investigation was triggered by allegations including refusal to issue refund, medication errors, failure to provide meals, failure to follow modified diet, unspecified additional fees, failure to provide shower assistance, and insufficient testing equipment. The medication error complaint was substantiated; the refund complaint was unsubstantiated; and the other allegations were unfounded.
Findings
The investigation found the refund allegation unsubstantiated with no deficiencies cited. However, the medication error allegation was substantiated with deficiencies cited related to incorrect medication administration on two occasions. Other allegations regarding meals, diet, fees, shower assistance, and testing equipment were found to be unfounded with no deficiencies cited.
Deficiencies (1)
The facility did not ensure that the correct medication was administered to resident R1 on 5-27-21 and 9-26-21, resulting in wrong medication and dosage being given.
Report Facts
Capacity: 180
Census: 122
Deficiency Type: 1
Plan of Correction Due Date: Oct 28, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennell Revera | Executive Director / Facility Administrator | Met with Licensing Program Analysts during complaint investigations and exit interviews |
| Tirzah Hubbard | Licensing Program Analyst | Conducted complaint investigation and signed report |
| Stephen Richardson | Licensing Program Manager | Oversaw complaint investigation |
| Charlie Yang | Licensing Program Analyst | Assisted in conducting complaint investigation |
Inspection Report
Annual Inspection
Census: 122
Capacity: 180
Deficiencies: 0
Date: Aug 10, 2021
Visit Reason
The visit was an unannounced Required Annual 1 Year inspection conducted to evaluate compliance with licensing regulations.
Findings
The facility was found to be in good condition with no deficiencies observed. The physical plant, kitchen, courtyard, and safety equipment were all in compliance with regulations, and infection control measures for Covid-19 were in place.
Report Facts
Hospice residents: 3
Home Health residents: 5
Covid-19 positive residents: 2
Covid-19 positive staff: 3
Fully vaccinated residents: 115
Fully vaccinated staff: 110
Partially vaccinated staff: 3
Facility temperature: 75
Hot water temperature: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennell Revera | Administrator | Met with Licensing Program Analyst during inspection |
| Tirzah Hubbard | Licensing Program Analyst | Conducted the inspection and observed compliance |
| Stephen Richardson | Licensing Program Manager | Named in report header and narrative |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 180
Deficiencies: 0
Date: Jul 23, 2021
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations including staff not meeting resident needs, resident left in soiled diapers, and resident room was malodorous.
Complaint Details
Complaint was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found the allegations to be unsubstantiated with no deficiencies observed or cited. Interviews and document reviews indicated that care needs were addressed appropriately and no foul odors were detected in the resident's room.
Report Facts
Capacity: 180
Census: 139
Assessments conducted: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Cal Mendiola | Resident Services Director | Met with evaluator during investigation |
| Janelle Rivera | Facility Designated Administrator | Met with evaluator during investigation |
| Stephenie Doub | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 113
Capacity: 180
Deficiencies: 1
Date: Nov 17, 2020
Visit Reason
The visit was an unannounced virtual case management inspection conducted due to COVID-19 precautionary measures.
Findings
The facility was found to have deficiencies related to the absence of an administrator, facility manager, or designated substitute on the premises during the virtual visit, posing a potential health risk to residents.
Deficiencies (1)
No staff was able to conduct a virtual visit at 0815 hours on 11/17/2020, violating the requirement for an administrator, facility manager, or designated substitute to be on premises 24 hours per day.
Report Facts
Capacity: 180
Census: 113
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Smith | Executive Director | Spoke with Licensing Program Analyst during virtual visit and exit interview |
| Suong Teh | Licensing Program Analyst | Conducted the virtual visit and authored the report |
| Krystall Moore | Licensing Program Manager | Supervisor overseeing the inspection |
| Stephen Richardson | Licensing Program Manager | Attempted to contact facility during virtual visit |
Inspection Report
Capacity: 180
Deficiencies: 0
Date: Nov 12, 2020
Visit Reason
The purpose of this office meeting is to discuss the COVID outbreak at the facility.
Findings
The facility discussed infection control measures including assigning an Infectious Control Lead, co-horting plan, and visitation restrictions. No deficiencies were cited at this time.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Smith | Executive Director | Facility Executive Director present during the meeting. |
| Krystall Moore | Regional Manager | Regional Manager present during the meeting and Licensing Program Manager. |
| Myra Cunana | Program Clinical Consultant Supervisor | Present during the meeting. |
| Stephen Richardson | Licensing Program Manager | Present during the meeting. |
| Suong Teh | Licensing Program Analyst | Present during the meeting. |
| Isabele Miller | Department of Public Health nurse | Present during the meeting. |
| Marcos Santos | Vice President of Clinical Operation | Present during the meeting. |
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