Inspection Report Summary
Most inspections found deficiencies related to documentation, medication management, and resident privacy, with issues such as missing admission agreements, incomplete staff health records, improper storage of supplies, and surveillance cameras in residents’ bedrooms. Several complaint investigations were unsubstantiated, though one substantiated complaint noted incomplete staff training records. The facility was fined $3,600 in March 2025 for failing to correct prior deficiencies by the due date. The most recent report from October 15, 2025, cited a deficiency for denying access to resident records during a complaint investigation. While the facility has had ongoing challenges, the pattern of deficiencies has remained fairly consistent without clear improvement or worsening over time.
Deficiencies per Year
8
6
4
2
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 1
Oct 15, 2025
Visit Reason
The visit was an unannounced case management inspection related to deficiencies and a complaint investigation (56-AS-20251008092142). Licensing Program Analysts requested resident files and reports related to the complaint but were denied access.
Findings
A Type B deficiency was cited for failure to provide access to resident records, including admission agreements, physician's reports, and resident registry, which poses a potential health, safety, and personal rights risk to persons in care.
Complaint Details
The visit was triggered by a complaint investigation (56-AS-20251008092142). Staff stated they did not have access to resident files requested by Licensing Program Analysts.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide access to resident files containing admissions agreements, physician's reports, and resident registry during the visit. | Type B |
Report Facts
Capacity: 6
Census: 6
Deficiency count: 1
Plan of Correction Due Date: Oct 29, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heilala Poloa | Staff | Met with Licensing Program Analysts during inspection and stated lack of access to resident files |
| Magda Malcore | Licensing Program Analyst | Conducted the inspection and signed the report |
| Eldin Serrano | Licensing Program Analyst | Conducted the inspection |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Plan of Correction
Census: 6
Capacity: 6
Deficiencies: 4
Mar 19, 2025
Visit Reason
Unannounced Plan of Correction (POC) visit to verify correction of previously cited deficiencies from a 02/12/2025 inspection.
Findings
Several deficiencies cited on 02/12/2025 remained uncorrected, including failure to provide a statement of understanding of regulation, missing signed admission agreement for resident #1, storage of supplies in a resident's private bathroom closet, and presence of surveillance cameras in all residents' bedrooms. Civil penalties of $3600 were assessed for failure to correct deficiencies by the due date.
Deficiencies (4)
| Description |
|---|
| Statement of understanding of regulation cited [87465(d)(3)] was not provided. |
| Copy of resident #1 signed admission agreement was not provided. |
| Facility supplies and equipment were stored in resident’s private bathroom closet. |
| Surveillance cameras were still mounted in all residents’ bedrooms. |
Report Facts
Civil penalties assessed: 3600
Daily civil penalty accrual: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Baddeley | Administrator/Licensee | Named in relation to deficiencies and appeal rights |
| Heilala Poloa | Caregiver | Met with Licensing Program Analysts during visit |
| Magda Malcore | Licensing Program Analyst | Conducted the Plan of Correction visit |
| Eldin Serrano | Licensing Program Analyst | Conducted the Plan of Correction visit |
| Karen Clemons | Licensing Program Manager | Named in report |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 6
Feb 12, 2025
Visit Reason
Licensing Program Analyst conducted an unannounced required comprehensive annual inspection of the Residential Care Facility for Elderly (RCFE).
Findings
The inspection found multiple deficiencies including failure to maintain medication administration logs, incomplete physical health records for staff, improper storage of facility supplies in a resident's closet, missing signatures on resident admission agreements, and presence of cameras in resident bedrooms, all posing potential health, safety, or personal rights risks.
Deficiencies (6)
| Description |
|---|
| Facility did not maintain a medication administration record/log. |
| Staff physical health records for S1, S2, and S3 were incomplete or missing. |
| Facility supplies were stored in a resident's private closet. |
| Fill-in staff was not familiar with medication record management. |
| Authorized persons' signatures were missing on Resident #1's admission agreement documents. |
| Cameras were mounted on the walls of residents' bedrooms. |
Report Facts
Capacity: 6
Census: 6
POC Due Date: Mar 10, 2025
Resident files reviewed: 3
Staff files reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Baddeley | Administrator/Director | Met with Licensing Program Analyst during inspection |
| Carmen Enriquez | Caregiver | Met with Licensing Program Analyst during inspection and received copies of reports |
| Karen Clemons | Licensing Program Manager | Supervisor and named in report |
| Magda Malcore | Licensing Program Analyst | Conducted inspection and authored report |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 4
Jan 24, 2024
Visit Reason
The visit was an unannounced required annual inspection conducted by Licensing Program Analysts to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be operating within its approved capacity and in generally safe and clean conditions. However, multiple deficiencies were cited related to incomplete Infection Control Plan, storage of expired and altered label medications, failure to maintain PRN medication logs, and an incomplete Emergency Disaster Plan.
Severity Breakdown
Type B: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Incomplete Infection Control Plan posing potential health, safety or personal rights risk to persons in care. | Type B |
| Storage of expired medication and acceptance of medication with altered labels posing potential health, safety or personal rights risk to persons in care. | Type B |
| Failure to maintain a log for two different PRN medications for two different residents posing potential health, safety or personal rights risk. | Type B |
| Incomplete Emergency Disaster Plan posing potential health, safety or personal rights risk to persons in care. | Type B |
Report Facts
Capacity: 6
Census: 6
Plan of Correction Due Date: Feb 2, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Baddeley | Licensee | Facility administrator and licensee met during inspection and named in findings |
| Michelle Echeverria | Licensing Program Analyst | Conducted inspection and authored report |
| Nedra Brown | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 1
May 8, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including uncleared staff working at the facility, inadequate staff training, and incomplete staff records.
Findings
The investigation found the allegations regarding uncleared staff and inadequate training to be unsubstantiated, but substantiated that the facility staff records were incomplete, specifically lacking proof of CPR training and tuberculosis tests for employees.
Complaint Details
The complaint investigation was based on allegations of uncleared staff working at the facility, inadequate staff training, and incomplete staff records. The first two allegations were found unsubstantiated, while the third was substantiated due to missing CPR training and TB test documentation for employees.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure all employees' files have proof of first aid training and tuberculosis tests, posing potential health, safety, and personal rights violations to persons in care. | Type B |
Report Facts
Employees without CPR training proof: 5
Employees without TB test proof: 6
Total employees: 6
Census: 6
Total capacity: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Baddeley | Licensee | Met during the investigation and involved in interviews regarding allegations. |
| Rayshaun Nickolas | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Karen Clemons | Licensing Program Manager | Oversaw the complaint investigation. |
| Shirley Becks | Caregiver | Interviewed during the investigation. |
| Christina Espinoza | Caregiver | Interviewed during the investigation. |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 0
Feb 14, 2022
Visit Reason
An unannounced required annual inspection was conducted with an emphasis on infection control due to the COVID-19 pandemic.
Findings
The facility was found to be in compliance with regulatory requirements, including infection control measures, operational standards, and safety protocols. No deficiencies were cited during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Baddeley | Administrator | Interviewed regarding infection control measures and facility operations. |
| Stephanie Williams | Licensing Program Analyst | Conducted the inspection and observations. |
| Efren Malagon | Licensing Program Manager | Named in the report as Licensing Program Manager. |
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