Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
188% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 7
Date: Sep 18, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety standards, specifically focusing on food handling, storage, and temperature control practices.
Findings
The facility failed to maintain safe food handling practices by not consistently checking and logging temperatures of refrigerators, freezers, and food items served to residents, including milk, gravy, and fish. Temperatures of some refrigerators and freezers were above safe limits, potentially putting residents at risk for food-borne illnesses.
Deficiencies (7)
Failure to ensure temperatures of freezers and refrigerators were checked and logged consistently from 9/3/2025 to 9/18/2025.
Failure to maintain freezer 2 temperature below 0 degrees F; recorded at 10 degrees F.
Failure to maintain fridge 1 temperature below 40 degrees F; recorded at 43 degrees F.
Failure to check and log temperatures of food served during tray line consistently before meals.
Failure to check temperature of gravy before serving and failure to keep gravy on steam table.
Failure to check temperature of milk served to residents; milk temperature recorded at 45 degrees F.
Failure to check temperature of fish before serving to residents.
Report Facts
Residents served milk: 72
Residents served ice cream: 6
Freezer 2 temperature: 10
Fridge 1 temperature: 43
Milk temperature: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide | Mentioned in relation to temperature logging inconsistencies and observations during inspection | |
| Dietary Service Supervisor | Mentioned regarding temperature observations and discrepancies | |
| Registered Dietician Consultant | Provided expert statements on temperature requirements and risks | |
| Director of Nursing | Provided statements on importance of food temperature for resident safety |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 21, 2025
Visit Reason
The inspection was conducted to assess compliance with residents' rights to privacy during personal care activities, specifically focusing on perineal care and changing of incontinence briefs for sampled residents.
Findings
The facility failed to provide adequate privacy during perineal care and diaper changes for two sampled residents, as privacy curtains were not fully closed, leaving residents visible to others. This failure had the potential to cause embarrassment and loss of self-esteem for the residents.
Deficiencies (1)
Failure to provide privacy during perineal care and changing of incontinence briefs for two sampled residents due to privacy curtains not being fully closed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Staff Development | Director of Staff Development | Interviewed regarding privacy curtain policy and resident dignity during care activities. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 12, 2025
Visit Reason
The inspection was conducted based on a complaint investigation regarding failure to implement proper infection control practices, specifically hand hygiene between resident contacts.
Complaint Details
The complaint investigation found that a Certified Nurse Assistant did not wash or sanitize hands after exiting Resident 1's shower room and before touching Resident 2, risking cross contamination. Interviews with staff confirmed the importance of hand hygiene and acknowledged the failure to comply.
Findings
The facility failed to ensure infection control practices were followed when a Certified Nurse Assistant did not perform hand hygiene after exiting one resident's shower room and before touching another resident, posing a risk of cross contamination and infection spread.
Deficiencies (1)
Failure to provide and implement an infection prevention and control program, specifically failure of staff to perform hand hygiene between resident contacts.
Report Facts
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nurse Assistant | Observed failing to perform hand hygiene between resident contacts and interviewed regarding hand hygiene practices. |
| Director of Nursing | Director of Nursing | Interviewed regarding importance of hand hygiene and facility policies. |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control practices and staff compliance. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 9, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to identify and treat a skin rash on a resident prior to discharge.
Complaint Details
The complaint investigation found that Licensed Vocational Nurse (LVN) 1 discharged Resident 1 on 5/29/2025 without conducting a skin check, resulting in a missed diagnosis of a skin rash. Family member reported discovering bleeding scabs after discharge. The deficiency was substantiated based on interviews and record reviews.
Findings
The facility failed to conduct a required skin check on Resident 1 prior to discharge, resulting in delayed treatment of a widespread skin rash. Interviews and record reviews confirmed the omission and the potential for physical decline.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, specifically failure to conduct a skin check prior to discharge.
Report Facts
Residents affected: 1
Dates related to Resident 1: Nov 21, 2023
Dates related to Resident 1: Jan 12, 2024
Date of discharge: May 29, 2025
Date of interviews: Jul 7, 2025
Date of interviews: Jul 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | LVN | Signed discharge plan of care but did not conduct skin check prior to Resident 1's discharge. |
| Registered Nurse 1 | RN | Stated skin checks should be conducted and documented prior to discharge. |
| Registered Nurse 2 | RN | Assessed Resident 1 at home on 5/30/2025 and observed rash. |
| Administrator | ADM | Confirmed policy that licensed staff must complete skin checks prior to discharge. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide a timely x-ray service for a resident as ordered by the physician.
Complaint Details
The complaint investigation found that the STAT x-ray ordered on 6/6/2025 for Resident 1 was not performed timely due to the radiology technician's failure to inform staff that the x-ray was not completed. The resident was reported combative and uncooperative. The facility staff did not receive timely notification, delaying necessary care.
Findings
The facility failed to ensure that Resident 1 received a STAT x-ray of the left hand in a timely manner as ordered on 6/6/2025. The radiology technician did not perform the x-ray due to the resident being combative and did not inform the facility staff, resulting in delayed care.
Deficiencies (1)
Failure to provide timely, approved x-ray services or have an agreement with an approved provider to obtain them, resulting in delayed care for Resident 1.
Report Facts
Date of x-ray order: Jun 6, 2025
Date of inspection: Jun 9, 2025
Timeframe for STAT x-ray: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding failure to follow up on x-ray results and facility procedures |
| RN 1 | Registered Nurse | Interviewed about placing the x-ray order and assisting the radiology technician |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 1, 2025
Visit Reason
The inspection was conducted following a complaint investigation into verbal abuse between residents and a failure to report the abuse timely, as well as an elopement incident involving a cognitively impaired resident who left the secured unit unsupervised.
Complaint Details
The complaint investigation was substantiated. Resident 23 verbally abused Resident 47 using racial slurs and profanity on 4/29/2025. The facility failed to report the incident timely to the administrator and appropriate authorities. Resident 3 eloped from the secured unit on 4/24/2025 at 7:06 PM due to failure of staff to lock doors, monitor the resident every 15 minutes, and supervise the secured unit exit. Immediate jeopardy was identified and removed after corrective actions.
Findings
The facility failed to protect Resident 47 from verbal abuse by Resident 23, who used racial slurs and profanity. The facility also failed to timely report the verbal abuse incident. Additionally, the facility failed to prevent Resident 3, who was at risk for elopement, from leaving the secured unit due to inadequate supervision, unlocked doors, and failure to monitor the resident every 15 minutes as required.
Deficiencies (3)
Failed to ensure Resident 47 was free from verbal abuse by Resident 23, including use of racial slurs and profanity.
Failed to timely report verbal abuse involving Resident 47 within two hours as required by facility policy.
Failed to prevent Resident 3's elopement from the secured unit due to unlocked doors, lack of supervision, and failure to monitor every 15 minutes.
Report Facts
Residents affected: 1
Residents affected: 1
Residents in secured unit: 48
Staff trained: 7
Staff trained: 14
Staff trained: 36
Staff trained: 20
Staff trained: 4
Staff trained: 7
Staff trained: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 6 | Certified Nursing Assistant | Named in Resident 3 elopement incident for failing to lock secured unit door and ensure resident did not follow |
| CNA 7 | Certified Nursing Assistant | Responsible for monitoring Resident 3 every 15 minutes but failed to document whereabouts during elopement |
| CNA 8 | Certified Nursing Assistant | Witnessed verbal abuse incident between Resident 23 and Resident 47 |
| CNA 9 | Certified Nursing Assistant | Witnessed verbal abuse incident and intervened; admitted failure to report incident timely |
| Administrator (ADM) | Administrator | Interviewed regarding verbal abuse incident and failure to report |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding verbal abuse incident and failure to report; responsible for staff education on elopement policy |
| Registered Nurse Supervisor (RNS 1) | Registered Nurse Supervisor | Contacted hospitals and police to locate Resident 3 after elopement |
| Director of Staff Development (DSD) | Director of Staff Development | Provided in-service training on elopement policy to staff |
| LVN 4 | Licensed Vocational Nurse | Person in charge of secured unit during Resident 3 elopement |
| Medical Director | Medical Director | Assisted in developing Immediate Jeopardy removal plan |
Inspection Report
Routine
Deficiencies: 11
Date: May 1, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, abuse prevention, care planning, infection control, safety, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy during care, failure to prevent verbal abuse and timely report it, inaccurate resident assessment data, failure to implement care plans to prevent aspiration, lack of communication aids for non-English speaking residents, failure to prevent resident elopement resulting in immediate jeopardy, inadequate staff knowledge of abuse recognition and reporting, improper food storage and handling, failure to maintain infection control protocols, and insufficient resident room space.
Deficiencies (11)
Failure to provide privacy during assistance with personal care and treatment procedures for two sampled residents.
Failure to ensure one resident was free from verbal abuse and failure to timely report the verbal abuse incident.
Failure to enter a diagnosis of schizophrenia in the Minimum Data Set for one resident.
Failure to implement the plan of care to prevent aspiration and choking for one resident.
Failure to provide a communication board for a resident who spoke primarily Mandarin.
Failure to prevent elopement of a cognitively impaired resident from the secured unit, resulting in immediate jeopardy.
Failure to ensure Certified Nurse Assistants knew how to recognize verbal abuse and implement the facility's abuse policy.
Failure to ensure expired dry food items were not kept in storage and improper ice handling practices by kitchen staff.
Failure to maintain infection prevention and control program by not wearing appropriate PPE while providing care to a resident on Enhanced Barrier Precautions.
Failure to provide rooms with at least 80 square feet per resident in multiple occupancy rooms.
Failure to ensure gnats were not present inside the kitchen area.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Expired food items: 2
Residents affected: 97
Rooms: 27
Residents per room: 2
Residents per room: 3
Gnats observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 6 | Certified Nursing Assistant | Named in Resident 3 elopement incident for failing to close secured unit door. |
| CNA 7 | Certified Nursing Assistant | Responsible for monitoring Resident 3 every 15 minutes but failed to document. |
| CNA 8 | Certified Nursing Assistant | Observed in verbal abuse incident and recalled Resident 23's behavior history. |
| CNA 9 | Certified Nursing Assistant | Observed verbal abuse incident and failed to report it timely. |
| CNA 14 | Certified Nursing Assistant | Observed privacy curtain not fully closed during care of Resident 45. |
| Dietary Aide 1 | Dietary Aide | Observed touching ice and trash can with bare hands during meal prep. |
| Dietary Manager | Dietary Manager | Observed expired food items in kitchen and discussed gnat infestation. |
| Infection Preventionist | Infection Preventionist | Discussed PPE requirements for residents on Enhanced Barrier Precautions. |
| Administrator | Administrator | Involved in immediate jeopardy removal plan and verbal abuse incident response. |
| Director of Nursing | Director of Nursing | Involved in immediate jeopardy removal plan and verbal abuse incident response. |
| Director of Staff Development | Director of Staff Development | Provided staff training on abuse recognition and elopement prevention. |
| Registered Nurse Supervisor RNS 1 | Registered Nurse Supervisor | Involved in locating eloped resident and staff education. |
| Licensed Vocational Nurse LVN 4 | Licensed Vocational Nurse | Person in charge of secured unit during elopement incident. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of abuse involving Resident 1 to the appropriate authorities as required by policy and regulations.
Complaint Details
The complaint investigation found that the facility did not report an alleged abuse incident involving Resident 1 within the required two-hour timeframe to the California Department of Public Health, the Ombudsman, and local law enforcement. Staff interviews revealed lack of knowledge about abuse reporting requirements and delays in reporting the incident.
Findings
The facility failed to report an allegation of abuse for Resident 1 to the California Department of Public Health, the Ombudsman, and local law enforcement within two hours, resulting in delayed notification and potential risk of abuse. Additionally, two staff members did not understand the facility's abuse reporting policies, which could contribute to further risk of resident abuse.
Deficiencies (2)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failure to ensure staff understood the facility's policies and procedures regarding abuse reporting, including knowledge of the Abuse Coordinator and required reporting agencies.
Report Facts
Residents sampled: 3
Staff sampled: 13
Date of abuse incident: Mar 31, 2025
Date survey completed: Apr 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Witnessed abuse and reported incident; lacked knowledge of Abuse Coordinator |
| CNA 2 | Certified Nursing Assistant | Alleged abuser; denied abuse; suspended pending investigation |
| RN 1 | Registered Nurse | Supervisor on duty during incident; lacked knowledge of abuse reporting requirements |
| LVN 1 | Licensed Vocational Nurse | Received abuse report from CNA 1 |
| DON | Director of Nursing | Received abuse report; acknowledged failure to report to authorities |
| DSD | Director of Staff Development | Provided information on abuse reporting policies and staff training |
Inspection Report
Enforcement
Deficiencies: 1
Date: Dec 4, 2024
Visit Reason
The inspection was conducted due to the facility's failure to ensure that a staff member (previous Director of Staffing Development/Office Assistant) did not work without a valid nursing license while providing care and administering medications to residents.
Findings
The facility failed to follow its policy and procedure regarding licensure and certification of personnel, allowing an unlicensed individual to work in a nursing role and provide direct patient care, including medication administration and monitoring, to nine sampled residents. This posed a potential risk to resident safety. The unlicensed staff member's license was surrendered and expired, but the individual continued to work in a licensed capacity without disclosure to administration.
Deficiencies (1)
Failure to ensure that the Office Assistant did not work without a license to practice nursing while providing care and administering medications to residents.
Report Facts
Residents affected: 9
Staff sampled: 15
Entries in eMAR/eTAR: 15
Medication administration entries: 8
Medication administration entries: 7
Medication administration entries: 8
Calcium dosage: 600
Docusate Sodium dosage: 100
High protein nutrition: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| OA | Director of Staffing Development / Office Assistant | Named in deficiency for working without a nursing license and providing direct patient care including medication administration and monitoring |
| ADM | Administrator | Interviewed regarding the unlicensed OA working as DSD and license status |
| DON | Director of Nursing | Interviewed regarding license expiration alerts and OA's unauthorized care provision |
| PAC | Payroll and Admissions Coordinator | Provided information on OA's work schedule and role |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: May 2, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements for nursing home care, including resident rights, care planning, medication administration, food safety, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy during care, inaccurate resident assessments, failure to revise care plans, inadequate communication competencies among staff, failure to monitor psychotropic medication side effects, medication administration errors, improper food storage and labeling, and insufficient resident room space per regulatory standards.
Deficiencies (11)
Failure to provide privacy and dignity to Resident 59 during gastrostomy tube medication administration, exposing resident's legs and diaper.
Failure to provide information regarding advance directives to Residents 33 and 57 and/or their representatives, despite residents' impaired decision-making capacity.
Inaccurate Minimum Data Set (MDS) assessments for Residents 7 and 8, omitting active diagnoses of schizophrenia, Parkinson's disease, and bipolar disorder.
Failure to revise care plans for Resident 19 regarding use of bilateral floor mats for fall prevention after interdisciplinary team decision to remove mats.
Failure to involve Resident 102 and family in developing post-discharge plan prior to discharge.
Registered Nurse 2 lacked competency to communicate effectively with Resident 33 who spoke Arabic, failing to use communication board.
Failure to monitor and document side effects of psychotropic medication (Seroquel) for Resident 64, including signs of tardive dyskinesia.
Failure to administer scheduled pain medication Tramadol to Resident 55 as ordered, holding medication without physician notification.
Failure to label and date food items in Kitchen 1, including unlabeled oil spray can and frozen waffles, risking foodborne illness.
Failure to properly label and manage food brought in by family and visitors in Refrigerator 1, with inconsistent knowledge among staff about discard timing and responsibilities.
Facility failed to ensure 27 of 37 resident rooms met minimum space requirements of 80 square feet per resident in multiple occupancy rooms.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Unlabeled food items: 6
Resident rooms: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Lacked competency to communicate with Resident 33 in Arabic |
| LVN 4 | Licensed Vocational Nurse | Held Resident 55's pain medication without physician notification |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including communication and medication monitoring |
| SSR | Social Services Representative | Interviewed regarding advance directive and discharge planning deficiencies |
| MDSC | MDS Coordinator | Interviewed regarding inaccurate MDS assessments |
| CNA 1 | Certified Nursing Assistant | Observed Resident 64's tongue thrusting behavior |
| TN | Treatment Nurse | Observed Resident 64's tardive dyskinesia signs |
| LVN 1 | Licensed Vocational Nurse | Reviewed Resident 64's MAR and noted inaccurate documentation |
| LVN 2 | Licensed Vocational Nurse | Interviewed regarding food brought in by family and refrigerator management |
| LVN 3 | Licensed Vocational Nurse | Interviewed regarding food labeling and refrigerator checks |
| RN 1 | Registered Nurse | Interviewed regarding food labeling and discard procedures |
| DM | Dietary Manager | Interviewed regarding food labeling and storage |
| ADM | Administrator | Interviewed regarding food storage policies |
| ADSD | Assistant Director of Staff Development | Interviewed regarding food brought in by family policies |
| CNA 2 | Certified Nursing Assistant | Interviewed regarding resident room space and care |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 24, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to respond appropriately to a resident's call light for assistance.
Complaint Details
Complaint investigation found that Resident 2's call light was turned off by CNA 1 without assistance being offered. Resident reported waiting up to an hour and soiling herself. Staff interviews and Director of Nurses confirmed the failure to respond properly to call lights.
Findings
The facility failed to answer a call light for one of four sampled residents, resulting in the resident waiting up to an hour and soiling herself. Staff interviews confirmed that turning off call lights without checking on residents was unacceptable and contrary to facility policy.
Deficiencies (1)
Facility failed to answer a call light for Resident 2, turning it off without offering assistance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 1 | CNA | Turned off Resident 2's call light without offering assistance. |
| Licensed Vocational Nurse 1 | LVN | Stated it was unacceptable to turn off call lights without seeing what the resident needed. |
| Certified Nursing Assistant 2 | CNA | Described proper procedure of knocking, entering rooms, and addressing resident needs before turning off call lights. |
| Licensed Vocational Nurse 2 | LVN | Stated staff should check on residents when call lights are on to ensure safety. |
| Director of Nurses | DON | Confirmed facility policy requires staff to answer call lights and offer help immediately. |
Inspection Report
Deficiencies: 0
Date: Feb 9, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to a facility survey completed on 2023-02-09.
Findings
No health deficiencies were found during the survey.
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Nov 18, 2021
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements and to evaluate the facility's environment, safety, infection control, and resident care.
Findings
The facility was found deficient in maintaining a homelike environment, ensuring safety to prevent falls, providing appropriate continence care, following safe food storage practices, implementing infection prevention and control, and meeting minimum room size requirements. Several residents' rooms had maintenance issues such as graffiti, chipped paint, and missing caulking. Safety hazards included clutter on floor mats intended to prevent falls. One resident was not placed on a toileting program as indicated by the care plan. Food storage violations included expired items, improper labeling, and personal items stored in food areas. Infection control lapses involved unlabeled urinals and cups in resident bathrooms. The facility requested waivers for 27 resident rooms that did not meet minimum square footage requirements but demonstrated adequate space and care.
Deficiencies (6)
Failed to maintain a homelike environment including graffiti on resident bathroom door, chipped paint, missing caulking, broken floor tiles, and stains on walls.
Failed to ensure a safe environment for a resident at risk for falls by allowing clutter on floor mats intended to prevent injury.
Failed to assess and place a resident on a toileting program as indicated on the care plan.
Failed to follow safe food storage practices including use of expired lemon extract, improper storage of personal items, dented cans stored incorrectly, unlabeled cheese container, and uncovered lettuce.
Failed to implement infection prevention and control program by allowing unlabeled urinals and cups in resident bathrooms and common areas.
Failed to provide resident rooms meeting minimum square footage requirements; requested waivers for 27 rooms.
Report Facts
Residents affected: 14
Residents affected: 1
Residents affected: 1
Residents affected: 9
Resident rooms: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MS | Maintenance Supervisor | Interviewed regarding maintenance issues and graffiti on bathroom door |
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding fall risk and toileting program for residents |
| CNA 1 | Certified Nurse Assistant | Interviewed regarding infection control and unlabeled cups in bathrooms |
| KSUP 1 | Kitchen Supervisor | Interviewed regarding food storage deficiencies |
| DON | Director of Nursing | Interviewed regarding fall risk and safe environment |
| MDS Coordinator | Interviewed regarding toileting program documentation |
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