Deficiencies (last 7 years)
Deficiencies (over 7 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
87% occupied
Based on a January 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 505
Capacity: 582
Deficiencies: 0
Date: Jan 6, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff financially abused a resident in care.
Complaint Details
The complaint alleged that a resident attempted to withdraw a substantial amount of cash to give to a friend believed to be a caregiver at the facility. The investigation revealed the resident was independent, had no cognitive impairment, and preferred to travel with cash. The complaint was found to be unfounded.
Findings
The investigation found the complaint to be unfounded after reviewing records, conducting interviews with staff, residents, and outside sources, and assessing the resident's cognitive and financial status. The allegation was dismissed as false and without reasonable basis.
Report Facts
Capacity: 582
Census: 505
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arian Golbakhsh | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tyre Richards | Residential Administrator | Met with the Licensing Program Analyst during the investigation |
| Brooke Harris | Administrator | Facility administrator named in the report |
| Sabel Martinez | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 505
Capacity: 582
Deficiencies: 0
Date: Jan 6, 2026
Visit Reason
The inspection was conducted as an unannounced complaint investigation following an allegation received on 2025-10-22 that a private caregiver was clocking in for shifts without being physically present at the facility.
Complaint Details
The complaint alleged lack of supervision and that a private caregiver was clocking in for shifts without being physically present for approximately three weeks. The complaint was investigated and found to be unfounded.
Findings
The investigation found no evidence supporting the allegation. Records review and staff interviews revealed no matches to the caregiver named in the complaint, and the complaint was determined to be unfounded and dismissed.
Report Facts
Capacity: 582
Census: 505
Complaint received date: Oct 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arian Golbakhsh | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Tyre Richards | Residential Administrator | Facility representative met during the investigation and exit interview |
| Sabel Martinez | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 505
Capacity: 582
Deficiencies: 0
Date: Jan 6, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff financially abused a resident in care.
Complaint Details
The complaint alleged that a resident tried to withdraw a substantial amount of cash to give to a friend believed to be a caregiver at the facility. The investigation revealed the resident was independent, had no cognitive impairment, and preferred to travel with cash. The complaint was found to be unfounded.
Findings
The investigation found the complaint to be unfounded after reviewing records, conducting interviews with staff, residents, and outside sources, and assessing the resident's cognitive and financial status. The allegation was dismissed as false and without reasonable basis.
Report Facts
Capacity: 582
Census: 505
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arian Golbakhsh | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Tyre Richards | Residential Administrator | Met with the evaluator during the investigation and received the report |
| Brooke Harris | Administrator | Facility administrator named in the report |
| Sabel Martinez | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 505
Capacity: 582
Deficiencies: 0
Date: Jan 6, 2026
Visit Reason
The inspection was conducted as an unannounced complaint investigation following an allegation received on 2025-10-22 that a private caregiver was clocking in for shifts without being physically present at the facility.
Complaint Details
The complaint alleged lack of supervision and that a private caregiver was clocking in for shifts without being physically present for approximately three weeks. The complaint was investigated and found to be unfounded.
Findings
The investigation found no evidence to support the allegation. Records review and staff interviews revealed no matches to the caregiver named in the complaint, and the complaint was determined to be unfounded and dismissed.
Report Facts
Capacity: 582
Census: 505
Complaint received date: Oct 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arian Golbakhsh | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Tyre Richards | Residential Administrator | Facility representative met during the investigation and exit interview |
| Sabel Martinez | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Census: 506
Capacity: 582
Deficiencies: 0
Date: Dec 22, 2025
Visit Reason
An unannounced Case Management visit was conducted to follow up on an incident reported to Community Care Licensing involving an Independent Living Resident who sustained a head and shoulder injury and was hospitalized.
Findings
The facility responded appropriately by arranging prompt medical care for the resident. No licensing or regulatory concerns were identified during interviews and file review, and no deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stefanie Thune-Barnes | Executive Director | Met with during the visit and discussed the purpose of the visit. |
| Brooke Patterson | Health Services Administrator | Met with during the visit and discussed the purpose of the visit. |
| Shila Jurado | Director of Residential Health | Joined later during the visit. |
| Tyre Richards | Residential Administrator | Joined later during the visit and participated in exit interview. |
| Arian Golbakhsh | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
Inspection Report
Complaint Investigation
Census: 506
Capacity: 582
Deficiencies: 0
Date: Dec 22, 2025
Visit Reason
The visit was an unannounced Case Management inspection conducted to follow up on an incident reported involving an Independent Living Resident who sustained multiple rib fractures after a series of falls.
Complaint Details
The complaint involved an incident reported on 11/12/25 regarding a resident who had bruising and multiple rib fractures from falls. The investigation found the facility responded immediately and arranged proper medical care. The complaint was not substantiated with any deficiencies.
Findings
The facility responded promptly and appropriately to the incident by arranging medical care for the resident. No violations or deficiencies were observed during the visit.
Report Facts
Incident report date: Nov 12, 2025
Incident date: Nov 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stefanie Thune-Barnes | Executive Director | Met during inspection and discussed visit purpose |
| Brooke Patterson | Health Services Administrator | Met during inspection and discussed visit purpose |
| Shila Jurado | Director of Residential Health | Met during inspection |
| Tyre Richards | Residential Administrator | Met during inspection and received exit interview |
| Arian Golbakhsh | Licensing Program Analyst | Conducted the inspection visit |
| Sabel Martinez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 506
Capacity: 582
Deficiencies: 0
Date: Dec 22, 2025
Visit Reason
The visit was an unannounced Case Management inspection conducted to follow up on an incident reported involving an Independent Living Resident who sustained multiple rib fractures after a series of falls.
Complaint Details
The visit was triggered by an incident report received on 2025-11-12 regarding a resident who had multiple falls and bruising, resulting in rib fractures. The complaint was investigated and found to be unsubstantiated as the facility responded properly.
Findings
The facility responded promptly and appropriately to the incident by arranging medical care for the resident. No violations or deficiencies were observed during the visit.
Report Facts
Incident report date: Nov 12, 2025
Incident date: Nov 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stefanie Thune-Barnes | Executive Director | Met during the inspection and discussed the purpose of the visit |
| Brooke Patterson | Health Services Administrator | Met during the inspection and discussed the purpose of the visit |
| Shila Jurado | Director of Residential Health | Joined during the visit |
| Tyre Richards | Residential Administrator | Joined during the visit and participated in exit interview |
Inspection Report
Census: 506
Capacity: 582
Deficiencies: 0
Date: Dec 22, 2025
Visit Reason
An unannounced Case Management visit was conducted to follow up on an incident reported to Community Care Licensing involving an Independent Living Resident who sustained a head and shoulder injury and was hospitalized.
Findings
The facility responded appropriately to the incident by arranging prompt medical care. No licensing or regulatory concerns were identified during interviews and file review, and no deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stefanie Thune-Barnes | Executive Director | Met with during the visit and discussed the purpose of the visit. |
| Brooke Patterson | Health Services Administrator | Met with during the visit and discussed the purpose of the visit. |
| Shila Jurado | Director of Residential Health | Joined the visit later. |
| Tyre Richards | Residential Administrator | Joined the visit later and participated in the exit interview. |
| Arian Golbakhsh | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
Inspection Report
Census: 506
Capacity: 582
Deficiencies: 0
Date: Dec 22, 2025
Visit Reason
An unannounced Case Management visit was conducted to follow up on an incident reported to Community Care Licensing involving a memory care resident who sustained a head injury after a fall.
Complaint Details
The visit was triggered by an incident report regarding a fall and injury of a memory care resident. The resident was hospitalized and treated but later passed away from their hospice diagnosis. No substantiation status was provided.
Findings
No health and safety concerns were observed during the visit, and no deficiencies were cited. The resident involved in the incident had passed away shortly after due to their hospice diagnosis, and a full determination regarding the case management visit was not completed due to time constraints.
Report Facts
Capacity: 582
Census: 506
Incident report date: Sep 5, 2025
Incident date: Sep 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stefanie Thune-Barnes | Executive Director | Met during the inspection and discussed the purpose of the visit |
| Brooke Patterson | Health Services Administrator | Met during the inspection and discussed the purpose of the visit |
| Shila Jurado | Director of Residential Health | Joined the inspection visit |
| Tyre Richards | Residential Administrator | Joined the inspection visit and received exit interview |
| Arian Golbakhsh | Licensing Program Analyst | Conducted the unannounced Case Management visit |
Inspection Report
Census: 506
Capacity: 582
Deficiencies: 0
Date: Dec 22, 2025
Visit Reason
An unannounced Case Management visit was conducted to follow up on an incident reported involving a memory care resident who had small sores behind their knee due to a splint from a prior injury.
Findings
During the visit, no health or safety concerns were observed and no deficiencies were cited. The Licensing Program Analyst was unable to complete a determination due to time constraints, and additional visits may be necessary.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stefanie Thune-Barnes | Executive Director | Met with during the visit |
| Brooke Patterson | Health Services Administrator | Met with during the visit |
| Shila Jurado | Director of Residential Health | Met with during the visit |
| Tyre Richards | Residential Administrator | Met with during the visit and received exit interview |
| Arian Golbakhsh | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Sabel Martinez | Licensing Program Manager | Named in report |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 22, 2025
Visit Reason
The inspection was conducted to assess compliance with care plan development and review requirements following a resident fall incident.
Findings
The facility failed to update the care plan for a resident who experienced a fall, which had the potential to cause subsequent falls or injuries. Interviews and record reviews confirmed the lack of documented new interventions after the resident's return from the hospital.
Deficiencies (1)
F 0657: The facility failed to develop and revise the complete care plan within 7 days of the comprehensive assessment for a resident who fell, resulting in potential risk for subsequent falls and injuries.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse (LN) 1 | Supervising nurse on duty when Resident 1 sustained a fall and provided assessment details. | |
| Interim Director of Nursing (IDON) | Provided information on lack of documented interventions and care plan update after resident's fall. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 14, 2025
Visit Reason
The investigation was conducted due to a complaint regarding a medication error involving Resident 1, who received medication via the wrong route, posing a risk to their health and safety.
Complaint Details
The complaint investigation substantiated that Resident 1 was administered medication by the wrong route, resulting in choking and emergency response. The attending physician confirmed the resident was tube fed and should not have received oral medications.
Findings
The facility failed to keep Resident 1 safe from medication errors by administering medication orally instead of via the ordered G-Tube route, causing the resident to choke. The Licensed Nurse did not verify the resident's identity or follow medication administration policies, violating the facility's procedures.
Deficiencies (1)
F0760: The facility failed to ensure residents are free from significant medication errors. Resident 1 was given crushed medications by mouth instead of via G-Tube, causing choking and requiring emergency intervention.
Report Facts
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Licensed Nurse | Named in medication error finding for administering medication by the wrong route |
| Director of Nursing | Director of Nursing | Provided statements regarding medication administration policies and incident details |
| Medication Nurse 1 | Medication Nurse | Observed passing medications and described medication administration policy |
| Resident 1's attending physician | Physician | Interviewed regarding the medication error incident and resident's feeding status |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Aug 8, 2025
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including medication self-administration assessments, advance directives documentation, psychotropic medication consent, transfer/discharge notifications, pressure ulcer care, nutritional monitoring and weight loss interventions, medication administration errors, medication storage, food palatability and temperature, food storage safety, quality assurance implementation, and infection control practices.
Deficiencies (12)
F 0554: The facility failed to assess a resident's ability to self-administer medications, risking overmedication and safety.
F 0578: The facility failed to provide written and follow-up initiation of advance directives for a resident, risking honoring resident wishes.
F 0605: The facility failed to ensure informed consent was signed by the responsible party before administering psychotropic medications.
F 0628: The facility failed to notify a resident or representative of transfer/discharge and bed hold rights after hospitalization.
F 0686: The facility failed to provide weekly wound assessments and accurate staging for a resident's pressure injuries.
F 0692: The facility failed to monitor and intervene for severe unplanned weight loss, risking resident health and well-being.
F 0760: The facility failed to administer a resident's blood pressure medication as ordered, risking health and well-being.
F 0761: The facility failed to properly store medications and nutritional supplements, including expired items and unsecured medications at bedside.
F 0804: The facility failed to ensure food was palatable, flavorful, and served at preferred temperatures, risking decreased intake and weight loss.
F 0812: The facility failed to label and date food items and remove expired food from refrigerators, risking foodborne illness.
F 0867: The facility's Quality Assurance committee failed to implement corrective action plans for nutrition-related deficiencies identified in the prior survey.
F 0880: The facility failed to implement infection control standards by leaving a used syringe unsecured and not sanitizing blood pressure cuffs between residents.
Report Facts
Weight loss: 24.4
Weight loss percentage: 14.77
Medication count: 11
Medication administration errors: 1
Expired medication dates: 3
Facility census: 50
Temperature drop: 21.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Interviewed regarding medication storage and self-administration assessment for Resident 78. |
| LN 2 | Licensed Nurse | Observed missing medication administration and improper sanitizing of blood pressure cuffs. |
| LN 3 | Licensed Nurse | Conducted medication room observations and interviews about expired medications. |
| LN 4 | Licensed Nurse | Interviewed about transfer/discharge notifications and used syringe disposal. |
| ADON | Assistant Director of Nursing | Interviewed about medication administration, infection control, and medication storage. |
| DM 1 | Dietary Manager | Interviewed about food palatability, temperature, and resident food preferences. |
| IP | Infection Preventionist | Interviewed about infection control practices including syringe disposal and medication storage. |
| RNA 1 | Restorative Nursing Assistant | Interviewed about resident weights and weight loss monitoring. |
| SSC | Social Service Coordinator | Interviewed about advance directives documentation. |
| Medical Director | Medical Director | Interviewed about expectations for weight loss interventions. |
| Resident 7's RP | Responsible Party | Interviewed about informed consent for psychotropic medications. |
Inspection Report
Annual Inspection
Census: 482
Capacity: 582
Deficiencies: 1
Date: 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)
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
Date: 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
Deficiencies: 1
Date: Nov 14, 2024
Visit Reason
The inspection was conducted due to a complaint or allegation regarding medication administration errors at the facility.
Complaint Details
The investigation was complaint-related, focusing on medication administration errors. The deficiency was substantiated with evidence that the medication was not given but was documented as administered.
Findings
The facility failed to ensure proper medication administration for one resident when a prescribed medication for overactive bladder was not administered as ordered. The medication was documented as given but was not available or administered, posing potential harm to the resident.
Deficiencies (1)
F 0760: The facility failed to ensure residents were free from significant medication errors. One resident did not receive the prescribed Oxybutynin Chloride medication as ordered, and the medication was incorrectly documented as administered.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse (LN) 1 | Observed medication pass and admitted to not administering the medication but documenting it as given. | |
| Director of Staff Development (DSD) | Interviewed regarding medication administration procedures and documentation. | |
| Director of Nursing (DON) | Interviewed regarding procedures for medication availability and notification to physicians. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 24, 2024
Visit Reason
An unannounced visit was made in response to a report of a Covid-19 outbreak at the facility.
Findings
The facility failed to ensure staff followed infection control precautions as staff were observed not wearing face masks during a Covid-19 outbreak. This failure had the potential for the spread of infection to residents, staff, and visitors.
Deficiencies (1)
F 0880: The facility failed to provide and implement an infection prevention and control program. Staff were observed not wearing surgical masks during a Covid-19 outbreak, increasing the risk of infection spread.
Report Facts
Residents infected with Covid-19: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse (LN 1) | Observed not wearing a surgical mask during the visit. | |
| Certified Nursing Assistant (CNA 1) | Observed not wearing a mask and interviewed about mask use. | |
| Certified Nursing Assistant (CNA 2) | Observed not wearing a mask and interviewed about mask use. | |
| Infection Preventionist (IP) | Interviewed regarding infection control and Covid-19 precautions. | |
| Director of Nursing (DON) | Interviewed regarding facility policy on mask use during Covid-19 outbreak. |
Inspection Report
Routine
Census: 50
Capacity: 97
Deficiencies: 14
Date: Jun 7, 2024
Visit Reason
Routine inspection to evaluate compliance with healthcare facility regulations including resident care, medication administration, food safety, infection control, and equipment maintenance.
Findings
The facility had multiple deficiencies including failure to maintain comfortable room temperatures, medication administration errors, failure to implement physician orders, inadequate food safety and sanitation practices, improper food storage and handling, failure to follow dietary recommendations, and lapses in infection control and equipment maintenance.
Deficiencies (14)
F 0584: The facility failed to maintain Resident 216's room temperature within the comfortable range of 71°F to 81°F, with a recorded temperature of 88°F.
F 0658: The facility failed to ensure safe medication administration when Licensed Nurse 31 administered medications prepared by another nurse, risking unsafe medication delivery to Resident 500.
F 0684: The facility failed to implement physician orders and notify physicians for Residents 61, 45, and 55 when physical therapy, daily weights, and wound treatment were refused or not provided.
F 0755: The facility failed to ensure accurate medication procedures for Residents 314, 315, 316, and 61, including lack of parameters for PRN pain meds, untimely medication administration, and unavailable prescribed supplements.
F 0759: The facility had a medication error rate of 6.67% with two errors out of 30 opportunities, including failure to administer prescribed medications to Residents 61 and 501.
F 0761: The facility failed to ensure medication carts were securely locked when unattended, risking unauthorized access to medications.
F 0802: The facility failed to ensure kitchen staff received adequate training in food sanitation and safety, with improper sanitizer testing, incorrect cooling procedures, and lack of qualified in-service trainers.
F 0803: The facility failed to develop an emergency menu with appropriate food and water supplies to meet nutritional and therapeutic needs of residents during emergencies.
F 0804: The facility failed to ensure food was served palatably and at safe temperatures, with residents reporting dry, tough, and unappealing meals.
F 0805: The facility failed to follow dietary recommendations for Resident 60 by not providing finger foods in the prescribed form, risking decreased intake and weight loss.
F 0812: The facility failed to maintain food safety and sanitation in dietary services, including unclean ice machines, improper air gap installations, dirty refrigerator gaskets, worn cutting boards, and uncovered food during transport.
F 0813: The facility failed to implement its policy for safe storage and handling of outside food brought by family, including storing expired unlabeled orange juice in the nursing station refrigerator.
F 0880: The facility failed to ensure staff performed hand hygiene before entering Resident 1's room, risking cross contamination and infection.
F 0908: The facility failed to maintain kitchen equipment in safe operating condition, including torn refrigerator door gaskets and a damaged ice machine with mold and calcium deposits.
Report Facts
Medication error rate: 6.67
Facility census: 50
Total licensed capacity: 97
Room temperature: 88
Desired room temperature: 79
Medication administration opportunities: 30
Medication errors: 2
Sanitizer test reading: 300
Sanitizer test reading: 200
Emergency food supply: 873
Water supply: 346.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 31 | Licensed Nurse | Named in medication administration error involving Resident 500. |
| Licensed Nurse 2 | Licensed Nurse | Named in medication administration error involving Resident 500. |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration, infection control, and outside food policies. |
| Dietary Supervisor | Dietary Supervisor | Interviewed regarding food safety, sanitation, and dietary concerns. |
| Food and Beverage Director | Food and Beverage Director | Interviewed regarding food quality and kitchen sanitation. |
| Registered Dietitian | Registered Dietitian | Conducted nutritional evaluations and interviewed regarding dietary issues. |
| Director of Staff Development | Director of Staff Development | Interviewed regarding staff training and outside food policy. |
| Medical Records Staff | Medical Records Staff | Observed failing to perform hand hygiene before entering Resident 1's room. |
| Director of Plant Operations | Director of Plant Operations | Interviewed regarding kitchen equipment maintenance and air gap issues. |
Inspection Report
Complaint Investigation
Capacity: 582
Deficiencies: 0
Date: 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.
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.
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.
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
Complaint Investigation
Census: 60
Deficiencies: 1
Date: Mar 7, 2024
Visit Reason
The inspection was conducted following a complaint received on 1/26/24 regarding missed medication administration for a group of residents on 1/14/24.
Complaint Details
Complaint received on 1/26/24 about missed medications on 1/14/24. Investigation confirmed missed doses for multiple residents. The complaint was substantiated.
Findings
The facility failed to ensure that 3 of 3 residents received medications as ordered by their physicians, resulting in missed doses of critical cardiac and other medications. The failure posed potential harm to residents and was linked to staffing shortages and communication issues.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to physician orders when staff did not administer medications to treat chronic conditions for 3 residents. Missed medications included cardiac drugs and others critical to resident health.
Report Facts
Residents affected: 3
Resident census: 60
Missed medication dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding staffing and medication administration failures | |
| Administrator | Interviewed regarding incident and corrective actions | |
| Director of Staff Development | Interviewed regarding staff education on medication administration |
Inspection Report
Annual Inspection
Census: 485
Capacity: 582
Deficiencies: 0
Date: 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
Date: 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.
Complaint Details
The complaint alleged staff were drinking while on duty. Interviews and record reviews did not corroborate the allegation. The complaint was unsubstantiated.
Findings
The investigation found no preponderance of evidence to prove the alleged violation occurred; therefore, the allegation 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
Date: 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.
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.
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.
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
Date: 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.
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.
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.
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
Date: 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
Deficiencies: 1
Date: Jul 24, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision to a resident at high risk for falls and failure to comply with facility policy to thoroughly investigate a fall.
Complaint Details
The complaint investigation found that Resident 1, identified as high risk for falls, fell on 6/30/23. The bed alarm was in use but not confirmed to be working correctly. The facility's interdisciplinary team did not document concerns about the incomplete fall investigation or the initial room placement. The investigation concluded the facility failed to adequately supervise and investigate the fall.
Findings
The facility failed to provide adequate supervision to Resident 1, who was at high risk for falls, resulting in an unwitnessed fall and fractured rib. The facility also failed to complete a thorough fall investigation and did not ensure the bed alarm was properly set or audible at the time of the fall.
Deficiencies (1)
F 0689: The facility failed to provide adequate supervision to a resident at high risk for falls and did not comply with policy to thoroughly investigate a fall. Resident 1 had an unwitnessed fall, fractured a rib, and the fall investigation report was incomplete.
Report Facts
Fall Risk Assessment date: Jun 24, 2023
Fall date: Jun 30, 2023
Brief Interview for Mental Status (BIMS) score: 10
Inspection Report
Routine
Deficiencies: 8
Date: Jun 8, 2023
Visit Reason
Routine inspection of Casa DE Las Campanas nursing home to assess compliance with regulatory requirements including medication administration, resident care, nutrition, and food safety.
Findings
The facility failed to ensure proper implementation of medication self-administration policies, physician notification of significant weight loss, care plan adherence for weight monitoring, medication administration per physician orders, controlled medication accountability, pharmacist medication regimen review after falls, nutritional assessments and preferences, meal substitutions, and proper food labeling and expiration date monitoring.
Deficiencies (8)
F 0554: Facility failed to ensure Resident 2 had physician orders, care plan, and interdisciplinary team assessment for safe self-administration of medications kept at bedside.
F 0580: Facility failed to notify physician regarding significant weight loss for Resident 203, risking delayed treatment.
F 0656: Facility failed to implement a complete care plan for Resident 203's weight monitoring, resulting in missed weekly weights.
F 0658: Facility failed to clarify physician orders for Resident 23, administering medications by mouth instead of via G-Tube as ordered.
F 0755: Facility failed to ensure controlled medications were fully accounted for; two oxycodone tablets for Resident 8 were not documented as administered.
F 0756: Facility failed to request medication regimen review after multiple falls for Resident 28 and pharmacist did not identify medication-related fall risks.
F 0800: Facility failed to assess food preferences for Residents 11 and 30 and did not offer alternate meals or condiments to Resident 203, contributing to poor food intake.
F 0812: Facility failed to ensure all food items were labeled, dated, and free of expired products, risking foodborne illness and decreased food intake.
Report Facts
Weight loss: 10
Medication doses unaccounted: 2
Medication regimen review months: 8
Expired food items: 5
Expired dry spices: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 24 | Licensed Nurse | Named in medication self-administration observation and interview regarding Resident 2. |
| LN 21 | Licensed Nurse | Named in medication administration observation and interview regarding Resident 23 medication route error. |
| DON | Director of Nursing | Interviewed regarding multiple findings including medication self-administration, weight loss notification, medication order clarifications, and nutrition. |
| RD | Registered Dietician | Interviewed regarding nutritional assessments and food preferences for residents. |
| CP | Consultant Pharmacist | Interviewed regarding medication regimen reviews and fall risk assessments. |
| EC | Executive Chef | Interviewed regarding food labeling and expiration date compliance. |
| DSM | Dietary Services Manager | Interviewed regarding food labeling and expiration date compliance. |
Inspection Report
Complaint Investigation
Census: 459
Capacity: 582
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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.
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
Census: 459
Capacity: 582
Deficiencies: 1
Date: Jun 1, 2023
Visit Reason
An unannounced Case Management visit was conducted in response to three incident reports submitted by the licensee regarding incidents involving residents that required emergency room visits and delayed reporting to the licensing agency.
Findings
The licensee failed to submit written reports of incidents involving three residents to the licensing agency within the required seven days, resulting in a cited deficiency. A Plan of Correction was developed and the deficiency was resolved as of the date of issuance.
Deficiencies (1)
Failure to submit a written report to the licensing agency and the person responsible within seven days of incidents threatening resident welfare and health for 3 of 459 residents.
Report Facts
Residents involved: 3
Census: 459
Total Capacity: 582
Plan of Correction Due Date: Jul 1, 2023
Days of skilled nursing care: 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 | Facility representative involved in the exit interview and Plan of Correction development |
| Brooke Harris | Administrator | Facility representative involved in the exit interview and Plan of Correction development |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 24, 2023
Visit Reason
The inspection was conducted following a complaint regarding a fall incident involving Resident 1, focusing on supervision and investigation of the fall.
Complaint Details
The investigation was complaint-driven, focusing on a fall incident involving Resident 1. The complaint was substantiated as the facility failed to provide adequate supervision and did not conduct a thorough fall investigation.
Findings
The facility failed to provide adequate supervision to a high fall-risk resident and did not comply with its policy to thoroughly investigate the fall. Resident 1 had an unwitnessed fall resulting in unconsciousness, and staff interviews revealed alarms did not sound and no thorough post-fall assessment or investigation was conducted.
Deficiencies (1)
F 0689: The facility failed to ensure adequate supervision to a resident at high risk for falls, resulting in an unwitnessed fall where the resident was unconscious for 30-60 seconds. The facility also failed to comply with its policy to thoroughly investigate the fall and interview all relevant staff.
Report Facts
Fall risk score: 75
Date of fall: Apr 6, 2023
Date of survey completion: May 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding the fall and investigation. | |
| Licensed Nurse 1 (LN 1) | Admitted Resident 1, ordered alarms, placed Resident 1 near nurse station, and involved in post-fall care. | |
| Licensed Nurse 2 (LN 2) | Medication nurse assigned on day of fall, present at nurse station during fall, did not hear alarm or assess resident post-fall. | |
| Certified Nursing Assistant 1 (CNA 1) | Assigned to Resident 1, placed alarm on bed, placed Resident 1 in wheelchair near nurse station without chair alarm, did not inform staff. |
Inspection Report
Complaint Investigation
Census: 498
Capacity: 582
Deficiencies: 0
Date: 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.
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.
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.
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
Date: 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.
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.
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.
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
Date: 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
Date: 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
Date: 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.
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.
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.
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
Date: 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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