Inspection Report
Annual Inspection
Census: 482
Capacity: 582
Deficiencies: 1
Feb 13, 2025
Visit Reason
The inspection was an unannounced continuation of a required annual inspection to evaluate compliance with licensing regulations at the facility.
Findings
The facility was found to be clean, sanitary, and in good repair with all safety and health requirements met. No deficiencies were cited, but one technical violation was issued regarding the need to add three more stairwell evacuation chairs.
Deficiencies (1)
| Description |
|---|
| Technical Violation regarding adding three more stairwell evacuation chairs; the facility currently has sixteen chairs. |
Report Facts
Residents present: 482
Total licensed capacity: 582
Non-ambulatory residents: 119
Residents under hospice care: 6
Stairwell evacuation chairs present: 16
Additional stairwell evacuation chairs needed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection and issued the report |
| Shila Jurado | Director of Residential Health | Facility representative met during inspection and exit interview |
Inspection Report
Annual Inspection
Census: 482
Capacity: 582
Deficiencies: 0
Jan 21, 2025
Visit Reason
An unannounced visit was conducted to perform a Required Annual Inspection of the facility.
Findings
No deficiencies were cited during the visit. Due to time constraints, a return visit is needed to complete the annual inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced annual inspection visit. |
| Shila Jurado | Director of Residential Health | Met with the Licensing Program Analyst during the inspection. |
Inspection Report
Complaint Investigation
Capacity: 582
Deficiencies: 0
Mar 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the provider made material misrepresentations about accepted healthcare and changes to the Continuing Care Contracts that were not previously approved by residents or the Continuing Care Contracts Bureau.
Findings
The investigation found that the provider's contract required residents to enroll in Medicare Parts A and B and reserved the right to reject Medicare Advantage HMO policies. The Department concluded the allegation was unsubstantiated after reviewing contracts, interviewing involved parties, and examining documentation.
Complaint Details
The complaint alleged that the provider made material misrepresentations about accepted healthcare and unauthorized changes to Continuing Care Contracts. The allegation was found to be unsubstantiated.
Report Facts
Facility capacity: 582
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Walden | Evaluator | Conducted the complaint investigation |
| Kimberly Finch-Dominy | Administrator / Executive Director | Interviewed during the investigation |
| Allison Nakatomi | Licensing Program Manager | Named in report |
Inspection Report
Annual Inspection
Census: 485
Capacity: 582
Deficiencies: 0
Jan 11, 2024
Visit Reason
An unannounced required one-year inspection was conducted to ensure substantial compliance with Title 22 regulations at the facility.
Findings
The facility was found to be in substantial compliance with regulations, with clean and sufficient linens, sanitary bathrooms, proper safety equipment, compliant medication storage and administration, and adequate staffing. No deficiencies were issued at the time of the visit.
Report Facts
Residents served: 582
Non-ambulatory residents: 227
Dementia residents: 27
Hospice waiver residents: 20
Food supply days - perishable: 2
Food supply days - nonperishable: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Finch-Dominy | Executive Director | Met during inspection and exit interview |
| Shila Jurado | Director of Residential Continuing Care | Met during inspection and granted entry |
| Amy Rodgers | Licensing Program Analyst | Conducted the inspection |
| Denise Powell | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 503
Capacity: 582
Deficiencies: 0
Nov 27, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 07/17/2023 alleging staff drinking while on duty.
Findings
The investigation found no preponderance of evidence to prove the alleged violation occurred; therefore, the allegation was unsubstantiated.
Complaint Details
The complaint alleged staff were drinking while on duty. Interviews and record reviews did not corroborate the allegation. The complaint was unsubstantiated.
Report Facts
Capacity: 582
Census: 503
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Brooke Harris | Administrator | Met with during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 458
Capacity: 582
Deficiencies: 0
Oct 25, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of neglect or lack of supervision resulting in a resident sustaining injury.
Findings
The investigation found the allegation unsubstantiated after observations, record reviews, and interviews. Resident 1 was observed without injuries and appeared content. Staffing levels and supervision were deemed adequate, and the injury was documented and treated according to physician orders.
Complaint Details
The complaint alleged neglect or lack of supervision causing a resident to sustain a suspicious laceration. The investigation included interviews with staff and outside agencies, review of records, and direct observation. The allegation was found unsubstantiated as evidence did not support the claim.
Report Facts
Complaint Control Number: 08-AS-20230928085817
Capacity: 582
Census: 458
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ramon Serrano | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Kimberly Finch-Dominy | Administrator / Executive Director | Facility representative met during investigation and exit interview |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Capacity: 582
Deficiencies: 0
Sep 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the licensee did not provide adequate notice for a fee increase to residents.
Findings
The investigation found that the provider did notify residents of the fee increase in compliance with applicable Health & Safety Code requirements. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged inadequate notice of fee increase to residents, violating Health & Safety Code §1771.8(d). After interviews and document review, including letters and memos notifying residents of the increase and implementation dates, the allegation was found unsubstantiated.
Report Facts
Capacity: 582
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Houston | Evaluator | Conducted the complaint investigation |
| Kimberly Finch-Dominy | Administrator | Facility administrator interviewed during investigation |
| Bob Lange | Former Resident Representative | Interviewed complainant |
| Allison Nakatomi | Licensing Program Manager | Named in report signature |
Inspection Report
Follow-Up
Census: 455
Capacity: 582
Deficiencies: 0
Aug 9, 2023
Visit Reason
An unannounced case management visit was conducted to follow up on an incident reported to Community Care Licensing involving a resident found deceased outside the facility grounds.
Findings
The licensee followed the absentee notification plan as necessary, pertinent resident records were collected, and a health and safety check of residents was conducted. No deficiencies were cited during the visit.
Report Facts
Incident report date: Jul 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brooke Harris | Administrator | Met with Licensing Program Analyst during the visit and discussed the purpose of the visit |
| Renita Hall | Licensing Program Analyst | Conducted the unannounced case management visit |
| Denise Powell | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 459
Capacity: 582
Deficiencies: 1
Jun 1, 2023
Visit Reason
The visit was an unannounced Case Management inspection conducted in response to three incident reports self-submitted by the licensee regarding incidents involving three residents who required emergency room visits.
Findings
The licensee failed to submit written reports of the incidents to the licensing agency within the required seven days, resulting in a cited deficiency. A Plan of Correction was jointly developed with the licensee.
Complaint Details
The visit was complaint-related based on three LIC624 Incident Reports involving residents who had emergency room visits due to falls and changes in condition. The deficiency was substantiated as the licensee did not meet reporting requirements.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit a written report to the licensing agency and responsible person within seven days of incidents threatening resident welfare and health for 3 residents. | Type B |
Report Facts
Residents involved: 3
Census: 459
Total Capacity: 582
Plan of Correction Due Date: Jul 1, 2023
Skilled Nursing Care Days: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management visit and cited the deficiency |
| Kimberly Finch-Dominy | Executive Director | Met with Licensing Program Analyst during inspection and involved in exit interview |
| Brooke Harris | Administrator | Met with Licensing Program Analyst during inspection and involved in exit interview |
| Lizzette Tellez | Licensing Program Manager | Supervisor overseeing the inspection and deficiency citation |
Inspection Report
Complaint Investigation
Census: 498
Capacity: 582
Deficiencies: 0
Dec 23, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that the facility did not ensure or arrange transportation services and that meals were not served in a designated dining area.
Findings
The investigation found insufficient evidence to substantiate the allegations. The facility provided various transportation options and maintained active dining services, including designated dining areas and to-go meal options, despite some closures during COVID-19 outbreaks.
Complaint Details
The complaint was unsubstantiated based on interviews, records review, and observations. Allegations included failure to ensure transportation services and failure to serve meals in designated dining areas. Evidence showed the facility had transportation options and dining areas available, with closures only during COVID-19 outbreaks.
Report Facts
Facility capacity: 582
Census: 498
Complaint received date: Oct 21, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Finch-Dominy | Executive Director | Met with during investigation and named in findings |
| Brook Harris | Residential Administrator | Met with during investigation and named in findings |
| Carmen Lopez | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 465
Capacity: 582
Deficiencies: 0
Dec 19, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the licensee did not safeguard a resident from financial abuse.
Findings
The investigation found no preponderance of evidence that financial abuse occurred between the residents. The licensee safeguarded the resident by reporting and investigating the matter. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that Resident #1 was financially abused by Resident #2 around August and September 2021. The investigation included interviews, record reviews, and cognitive assessments, all indicating no financial abuse occurred. The allegation was unsubstantiated.
Report Facts
Capacity: 582
Census: 465
SLUMS Score: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Monica Furguiele | Director of Resident Services | Met with investigator and participated in exit interview |
| Rosalia Gomez | Receptionist | Welcomed and identified the Licensing Program Analyst during the visit |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Staff #1 | Facility Manager | Performed cognitive reassessment of Resident #1 and reported no suspicion of financial abuse |
Inspection Report
Annual Inspection
Census: 567
Capacity: 582
Deficiencies: 0
Jan 4, 2022
Visit Reason
The inspection was an unannounced required 1-year visit to evaluate the facility's compliance with licensing regulations, including infection control measures related to COVID-19.
Findings
The Licensing Program Analyst conducted a tour and observation of the facility, staff, and residents, provided technical assistance on COVID-19 mitigation, and found no deficiencies during this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shila Jurado | Director of Residential Continuing Care | Met with Licensing Program Analyst during the inspection and exit interview. |
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Rebecca Hedgecock | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 567
Capacity: 582
Deficiencies: 0
Jan 4, 2022
Visit Reason
The Department conducted an announced Case Management visit to provide technical assistance and to evaluate the facility's COVID-19 screening, testing, and disinfection processes and the staff’s use of personal protective equipment.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst and Healthcare Associated Infection nurse toured the facility, interacted with staff, and interviewed the director.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shila Jurado | Director of Residential Continuing Care | Met with during the visit and interviewed. |
Inspection Report
Complaint Investigation
Capacity: 582
Deficiencies: 0
May 27, 2021
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 05/12/2021 regarding the facility's compliance with Health & Safety Code section 1771.7 related to the Resident Satisfaction Survey.
Findings
The investigation found that although the facility's 2019 resident satisfaction survey focused more on the dining program, it also included questions about overall satisfaction, sense of safety, needs being met, and willingness to recommend the community. The complaint was determined to be unfounded.
Complaint Details
The complaint alleged failure to comply with H&SC section 1771.7 regarding the Resident Satisfaction Survey. The complaint was investigated and found to be unfounded.
Report Facts
Facility capacity: 582
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christina Hadley | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Allison Nakatomi | Licensing Program Manager | Named in report signature section |
| Chris Burk | Executive Director | Met with during the investigation |
Inspection Report
Census: 491
Capacity: 582
Deficiencies: 0
Dec 14, 2020
Visit Reason
The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, testing surveillance, screening protocols as well as the use of personal protective equipment.
Findings
During the visit, no deficiencies were issued. The team interviewed the Director of Resident Services and conducted a walk-through of the facility, concluding with a debriefing.
Report Facts
Capacity: 582
Census: 491
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shila Jurado | Director of Resident Services | Interviewed during the visit and participated in the walk-through and debriefing |
| Denise Powell | Licensing Program Manager | Conducted the on-site visit |
| Elizar Perez | County of San Diego Nurse Contractor | Participated in the on-site visit |
| Jacqueline Ruegg | Health Facility Evaluator Nurse | Participated in the on-site visit |
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