Deficiencies (last 6 years)
Deficiencies (over 6 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% worse than California average
California average: 4 deficiencies/year
Deficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
97% occupied
Based on a March 2026 inspection.
Occupancy rate over time
Inspection Report
Census: 57
Capacity: 59
Deficiencies: 0
Date: Mar 20, 2026
Visit Reason
The unannounced visit was conducted to confirm recent changes to the facility's licensed capacity and to review updated fire clearance and facility sketch documentation.
Findings
The facility was observed to be clean, in good repair, and free of health and safety concerns. The Riverside County Fire Department approved the requested capacity increase from 59 to 64 non-ambulatory residents, including 5 bedridden.
Report Facts
Licensed Capacity: 59
Census: 57
Requested Capacity: 64
Bedridden Capacity: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Valeria Garcia | Executive Director | Met with during inspection and provided facility information |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 59
Deficiencies: 2
Date: Dec 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that staff did not prevent a resident from leaving the facility unsupervised and failed to report the incident to appropriate parties in a timely manner.
Complaint Details
The complaint alleged staff did not prevent a resident from leaving the facility unsupervised and failed to report the incident timely. The complaint was substantiated based on interviews and record reviews showing multiple elopements by the resident, lack of staff intervention, and failure to submit required SOC 341 reports.
Findings
The investigation substantiated that a resident eloped from the facility unsupervised and that staff failed to submit a required SOC 341 report to the Long-Term Care Ombudsman, violating reporting requirements. The facility staff had received training on supervision but failed to intervene during the elopement incident.
Deficiencies (2)
Reporting Requirements 87211(c): The facility failed to properly submit incident reports under SOC 341 Elder Abuse requirements, posing a potential health and safety risk to residents.
CCR 87705(3): Facility staff failed to intervene and redirect a resident at risk for elopement, posing a potential health and safety risk to residents.
Report Facts
Capacity: 59
Census: 51
Deficiency count: 2
Plan of Correction Due Date: 2026
Inspection Report
Complaint Investigation
Census: 51
Capacity: 59
Deficiencies: 0
Date: Oct 23, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff did not ensure residents had adequate sleeping accommodations and that the Facility Administrator was not on the premises for a sufficient number of hours.
Complaint Details
The complaint was unsubstantiated based on interviews, observations, and record reviews. Allegations included inadequate sleeping accommodations and insufficient presence of the Facility Administrator. No evidence was found to support these claims.
Findings
The investigation found no evidence to substantiate the allegations. Observations, staff and resident interviews, and record reviews confirmed that sleeping accommodations were adequate and that the Facility Administrator and Executive Director were regularly present and accessible during weekday hours.
Report Facts
Capacity: 59
Census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Armando Perez | Licensing Program Analyst | Conducted the complaint investigation |
| Valeria Garcia | Executive Director | Interviewed during investigation and received report copy |
| Judine Ramirez | Business Office Manager | Interviewed during investigation and received report copy |
| Tracy Langendoen | Administrator | Facility Administrator named in complaint |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 59
Deficiencies: 0
Date: Oct 17, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that facility staff were abusive to a resident in care due to nonpayment of rent.
Complaint Details
The complaint alleged that staff were abusive to a resident due to nonpayment of rent. The allegation was investigated and found to be unfounded based on interviews and record reviews.
Findings
The investigation found no evidence of staff abuse toward the resident. Interviews with the resident, staff, and witnesses, as well as a review of facility records, revealed no incidents of abuse or eviction proceedings. The allegation was determined to be unfounded and the complaint was dismissed.
Report Facts
Capacity: 59
Census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Armando Perez | Licensing Program Analyst | Conducted the complaint investigation |
| Valeria Garcia | Executive Director | Met with the Licensing Program Analyst during the investigation |
| Tracy Langendoen | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 59
Deficiencies: 1
Date: Oct 17, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility does not have adequate staffing to meet residents' care needs.
Complaint Details
The complaint was substantiated based on interviews and record reviews. The allegation was that the facility lacked adequate staffing to meet residents' care needs, particularly during the night shift. Evidence included incidents of delayed staff response, missed medication administration, and inadequate supervision leading to resident safety risks.
Findings
The investigation substantiated the allegation that the facility was not sufficiently staffed during the night shift from 10 PM to 6 AM, compromising resident safety and supervision. There were documented incidents of delayed staff response to emergencies, a physical altercation between residents without staff intervention, and missed medication administration due to inadequate staffing.
Deficiencies (1)
CCR 87468.2(a)(4) requires care, supervision, and services delivered by sufficient staff to meet residents' individual needs. The facility was not staffed sufficiently at night from 10 PM to 6 AM to meet supervision needs, leading to an altercation that staff did not witness or intervene.
Report Facts
Capacity: 59
Census: 52
Night shift staff count: 3
Night shift staff count: 4
Residents on night shift: 54
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Armando Perez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Valeria Garcia | Executive Director | Interviewed during the investigation and recipient of the exit interview |
| Liliana Moreno | Administrator | Met with during the investigation |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 59
Deficiencies: 0
Date: Sep 30, 2025
Visit Reason
The visit was an unannounced Case Management inspection conducted regarding a complaint report number 18-AS-20250303133359.
Complaint Details
The visit was triggered by a complaint report number 18-AS-20250303133359. No deficiencies were found and no health or safety concerns were observed.
Findings
The Licensing Program Analyst conducted a health, safety, and welfare check of residents and did not observe any health and safety concerns. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Valeria Garcia | Executive Director | Met with during the inspection and informed of the visit purpose. |
| Seo Jeon | Licensing Program Analyst | Conducted the unannounced inspection visit. |
| Rikesha Stamps | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 59
Deficiencies: 2
Date: Sep 22, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not prevent a physical altercation between residents and did not respond to residents' calls for assistance.
Complaint Details
The complaint was substantiated. Staff did not prevent a physical altercation between residents and did not respond to residents' calls for assistance on August 1, 2025. The investigation included interviews and record reviews confirming insufficient night staffing and supervision.
Findings
The investigation substantiated that staff failed to prevent a physical altercation between two residents and did not respond to calls for assistance, resulting in injuries and medical transport for both residents. The facility was found to be insufficiently staffed during the night shift, contributing to the lack of supervision and response.
Deficiencies (2)
CCR 87468.2(a)(4) requires care, supervision, and services sufficient to meet residents' individual needs. The facility was not staffed sufficiently at night to meet supervision needs, leading to an altercation staff did not witness or intervene.
CCR 87415(a) requires night supervision staff to be familiar with emergency procedures to assist residents. Staff failed to assist during an emergency involving a physical altercation, resulting in injuries to both residents.
Report Facts
Capacity: 59
Census: 53
Staffing: 3
Staffing: 4
Plan of Correction Due Date: Oct 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Armando Perez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Valeria Garcia | Executive Director | Interviewed during investigation and received report copy |
| Liliana Moreno | Administrator | Interviewed during investigation and received report copy |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 59
Deficiencies: 2
Date: Aug 29, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff did not prevent resident-to-resident altercations and failed to properly report incidents involving residents.
Complaint Details
The complaint was substantiated. Allegations included failure to prevent resident altercations and failure to properly report incidents to the Long Term Care Ombudsman Program. The facility was found to have not cross-reported six incidents and had inadequate staffing levels affecting resident supervision.
Findings
The investigation substantiated that staff did not report six resident altercation incidents to the Long Term Care Ombudsman Program as required and that staffing levels were insufficient to prevent resident altercations, posing a potential health and safety risk.
Deficiencies (2)
CCR 87411(a): Facility personnel were not sufficient in numbers and competent to provide necessary services and supervision, posing an immediate health and safety risk to residents.
CCR 87211(c): Six incidents meeting LTCO reporting requirements were not cross-reported by facility staff, posing a potential health, safety, and personal rights risk to residents.
Report Facts
Incidents not reported to LTCO: 6
Facility capacity: 59
Resident census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Armando Perez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Valeria Garcia | Executive Director | Facility representative interviewed regarding allegations and findings |
| Liliana Morano | Administrator | Facility representative interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 59
Deficiencies: 1
Date: Aug 25, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not administer prescribed medications to residents in care, specifically due to occasional lack of Medical Technician (MedTech) coverage on weekends.
Complaint Details
The complaint alleged that staff did not administer prescribed medications due to lack of MedTech coverage on weekends. The allegation was substantiated after investigation, confirming two occasions of missed medication administration.
Findings
The investigation found inconsistencies in MedTech scheduling with 16 instances of missing coverage, confirming two occasions where medications were not administered to residents. The complaint was substantiated based on interviews and record reviews.
Deficiencies (1)
CCR 87465(a)(4) requires the licensee to assist residents with self-administered medications as needed. Medication was not administered as prescribed on two occasions, posing a potential health, safety, or personal rights risk to residents.
Report Facts
Instances of missing MedTech coverage: 16
Shifts with confirmed MedTech coverage: 14
Residents not receiving scheduled medications: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Armando Perez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Valeria Garcia | Executive Director | Facility representative interviewed during investigation |
| Tracy Langendoen | Administrator | Named in relation to medication administration deficiency |
Inspection Report
Census: 54
Capacity: 55
Deficiencies: 0
Date: Aug 14, 2025
Visit Reason
The Licensing Program Analyst conducted an unannounced visit to confirm recent changes to the facility's licensed capacity and to review updated fire clearance and facility sketch documents.
Findings
The facility was observed to be clean, in good repair, and compliant with food supply and medication storage requirements. No health or safety concerns were noted during the visit.
Report Facts
Licensed Capacity: 55
Requested Capacity: 59
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Valeria Garcia | Executive Director | Met during inspection and confirmed facility details |
| Armando Perez | Licensing Program Analyst | Conducted the unannounced inspection visit |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 55
Deficiencies: 1
Date: Jul 29, 2025
Visit Reason
The inspection was an unannounced visit to investigate a complaint received on 2022-12-23 regarding facility staff not regularly providing observations of residents' physical changes.
Complaint Details
The complaint was substantiated based on evidence that staff failed to document changes in Resident 1's condition, leading to worsening of a pressure injury. The preponderance of evidence standard was met.
Findings
The investigation found that staff did not document written observations of Resident 1's condition changes, despite following the care plan. The allegation was substantiated due to lack of proper reporting and documentation, which resulted in a stage 3 wound posing immediate health and safety risks.
Deficiencies (1)
CCR 87463(1)(E) requires reappraisals for significant changes in condition. The Administrator did not comply as staff failed to properly report, observe, and document changes in Resident 1's condition, resulting in a stage 3 wound and immediate health risk.
Report Facts
Capacity: 55
Census: 54
Deficiency count: 1
Plan of Correction Due Date: Due date for plan of correction is 2025-08-12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lavette Farlow | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Valeria Garcia | Administrator | Facility administrator informed of the investigation and findings |
| Jessenia Rubalcaba | Activity Director | Greeted the Licensing Program Analyst upon arrival |
Inspection Report
Annual Inspection
Census: 54
Capacity: 55
Deficiencies: 4
Date: Jul 22, 2025
Visit Reason
The inspection was an unannounced required annual inspection to evaluate compliance with licensing requirements.
Findings
The facility was generally clean and in good repair with adequate facilities and safety measures. However, deficiencies were found in personnel and resident records, including missing admission agreements, medical consent forms, personal rights notifications, and incomplete employee health screenings. A technical violation was noted for incomplete emergency drill records.
Deficiencies (4)
CCR 87412(a) Personnel Records: Two out of eight staff files were missing required health screening and TB test documentation, posing a potential health and safety risk.
CCR 87507(c) Admission Agreements: Two out of eight resident records were missing signed and dated admission agreements, posing a potential health and safety risk.
Emergency drill records were missing the time conducted and did not appear to include all staff, constituting a technical violation.
Two out of eight client files were missing the admission agreement, medical consent form, and personal rights notification.
Report Facts
Resident records reviewed: 8
Employee records reviewed: 8
Staff files missing health screening and TB test: 3
Resident files missing admission agreement, medical consent, and personal rights: 2
Fire extinguisher last serviced: Sep 5, 2024
Last fire drill date: Jul 9, 2025
Inspection Report
Complaint Investigation
Census: 53
Capacity: 55
Deficiencies: 1
Date: Apr 18, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident developed a Stage 3 pressure injury due to neglect.
Complaint Details
The complaint was substantiated based on evidence that staff neglected proper wound care for resident R1, leading to worsening of the pressure injury. An immediate civil penalty of $500 was assessed with potential for additional penalties.
Findings
The investigation found that staff failed to properly care for the resident's wound, which worsened from a Stage 2 to a Stage 3 pressure injury. The facility did not maintain proper documentation or a plan of care for the resident's wound condition as it deteriorated.
Deficiencies (1)
CCR 87466 The licensee shall ensure residents are regularly observed for changes in physical, mental, emotional, and social conditions and document such changes. The licensee failed to comply as staff did not properly care for R1's wound, resulting in a Stage 3 wound that posed immediate health and safety risks.
Report Facts
Civil penalty amount: 500
Capacity: 55
Census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lavette Farlow | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Liliana Moreno | Med-Tech Supervisor/Administrator | Met with the evaluator during the investigation |
Inspection Report
Census: 52
Capacity: 55
Deficiencies: 1
Date: Apr 3, 2025
Visit Reason
Licensing Program Analyst conducted a case management visit to the facility for the purpose of issuing deficiencies related to an incident involving two clients.
Findings
The facility failed to report an incident involving inappropriate touching between two clients to the Community Care Licensing Division within the required seven days. This violation poses a potential health and safety risk to clients in care.
Deficiencies (1)
CCR 87211(a)(1)(D): A written report was not submitted to the licensing agency within seven days of an incident threatening the welfare, safety, or health of a resident. The facility administration did not comply with this requirement in one incident involving two clients.
Report Facts
Census: 52
Total Capacity: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Valeria Garcia | Executive Director | Named in relation to the incident and facility administration |
| Armando Perez | Licensing Program Analyst | Conducted the inspection and issued deficiencies |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 55
Deficiencies: 0
Date: Apr 3, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that a staff member threatened a resident.
Complaint Details
The complaint alleged that Staff 1 verbally threatened residents by stating they would be evicted if they did not follow the rules. Interviews and observations did not find evidence supporting the allegation. The allegation was unsubstantiated.
Findings
The investigation included observations, interviews, and record reviews. The allegation was deemed unsubstantiated due to insufficient evidence to prove the alleged violation.
Report Facts
Capacity: 55
Census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Armando Perez | Licensing Program Analyst | Conducted the complaint investigation |
| Valeria Garcia | Executive Director | Interviewed during the investigation |
| Tracy Langendoen | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 55
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
The visit was conducted as an unannounced complaint investigation regarding an allegation that the facility did not have a qualified administrator with a valid certificate.
Complaint Details
The complaint alleged that the facility did not have a qualified administrator as they did not possess a valid administrator certificate. The investigation found the allegation to be unfounded.
Findings
The allegation was investigated through observations, interviews, and records review. It was found that the administrator held a valid certificate that was posted in the facility and renewal documents had been submitted. The complaint was determined to be unfounded.
Report Facts
Capacity: 55
Census: 46
Inspection Report
Annual Inspection
Census: 50
Capacity: 55
Deficiencies: 1
Date: Jul 26, 2024
Visit Reason
The Licensing Program Analyst conducted an unannounced required annual inspection of the facility.
Findings
The facility was generally operating within license conditions with safe and clean physical plant conditions. However, missing call buttons and lack of a signal system device in one building were noted as deficiencies. Medication storage and records were compliant.
Deficiencies (1)
CCR 87303(i) requires facilities to have signal systems meeting specified criteria. One out of four buildings lacked a signal system, with missing call buttons in multiple resident bedrooms and no signal device set up for building two, posing a potential health and safety risk.
Report Facts
Residents receiving hospice services: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Martinez | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Diana Ramirez | Onsite Administrator | Met with Licensing Program Analyst during inspection and responsible for facility operations. |
| Tracy Langendoen | Administrator/Director | Facility Administrator with active certificate. |
Inspection Report
Census: 53
Capacity: 55
Deficiencies: 1
Date: Jan 25, 2024
Visit Reason
An unannounced visit was conducted by Licensing Program Analyst Janira Arreola for a separate unrelated matter involving case management and deficiencies.
Findings
The facility did not have resident records readily available for licensing review, posing a potential health, safety, or personal rights risk. No immediate health or safety concerns were observed during the visit.
Deficiencies (1)
CCR 87506(a): The licensee failed to maintain a record for each resident in the facility or a central administrative location readily available to licensing staff. The facility did not have the file for resident R1 available for licensing review, posing a potential health, safety, or personal rights risk.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judine Ramirez | Medical Technician | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 55
Deficiencies: 0
Date: Jan 23, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff were not ensuring that a resident had access to a phone while in care.
Complaint Details
The complaint alleged that facility staff were not ensuring that a bedridden resident had access to a phone. The investigation included interviews with staff and the resident, observations of telephone availability, and follow-up calls. The allegation was found unsubstantiated.
Findings
The allegation was investigated through observation, interviews, and record review. It was found that telephones are accessible to every resident, including bedridden residents who can request use of administrative staff cellphones. The allegation was deemed unsubstantiated due to insufficient evidence.
Report Facts
Facility Capacity: 55
Resident Census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Ashlee Theus | Business Office Manager | Interviewed regarding resident telephone access |
| Diana Ramirez | Executive Director | Provided information about resident telephone access |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 55
Deficiencies: 0
Date: Sep 13, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 08/20/2020 regarding resident falls, pressure ulcers, unexplained bruising, lack of water provision, hygiene supplies, and staff meeting residents' needs.
Complaint Details
The complaint investigation addressed multiple allegations including residents falling, pressure ulcers, unexplained bruising, lack of water, insufficient hygiene supplies, and inadequate staffing. All allegations were found unsubstantiated with no preponderance of evidence to prove violations.
Findings
All allegations investigated were found to be unsubstantiated due to lack of evidence or witnesses. Facility staff interviews, file reviews, client interviews, and observations confirmed no violations or deficiencies related to the complaints.
Report Facts
Capacity: 55
Census: 54
Caregivers per Villa: 1
Facility visits: 3
Residents per hairbrush: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rayshaun Nickolas | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Diana Molina-Ramirez | Executive Director | Interviewed regarding allegations and facility operations |
| Ashlee Theus | Business Office Manager | Interviewed regarding allegations and facility operations |
| Karen Clemons | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 55
Deficiencies: 1
Date: Sep 6, 2023
Visit Reason
Unannounced complaint investigation visit triggered by a complaint alleging hazardous items accessible to residents and other facility concerns.
Complaint Details
The complaint investigation was substantiated for hazardous items accessible to residents due to unsecured cleaning solutions. Other allegations were unsubstantiated due to lack of evidence or witness corroboration.
Findings
The investigation substantiated the allegation that cleaning solutions were not stored inaccessible to residents. Other allegations including facility disrepair, lack of activities, safeguarding medical equipment, bed accommodations, emergency preparedness, timely resident checks, and staff behavior were found unsubstantiated.
Deficiencies (1)
CCR 87309(a) requires disinfectants and cleaning solutions to be stored where inaccessible to clients. The facility failed to ensure cleaning solutions were stored inaccessible to residents.
Report Facts
Capacity: 55
Census: 54
Plan of Correction Due Date: Sep 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rayshaun Nickolas | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Diana Molina Ramirez | Executive Director | Facility representative met during investigation |
| Kelley Lara | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 55
Deficiencies: 0
Date: Sep 6, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that a resident sustained multiple falls while in care at the facility.
Complaint Details
The complaint alleged that client #1 had three falls within six months. Interviews with staff did not confirm the falls, and the resident was deceased at the time of investigation. The finding was unsubstantiated due to lack of evidence.
Findings
The investigation found no evidence or witnesses to corroborate the allegation of multiple falls by the resident. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 55
Census: 54
Number of falls alleged: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rayshaun Nickolas | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Diana Molina-Ramirez | Executive Director | Met with the Licensing Program Analyst during the investigation |
| Ashlee Theus | Business Office Manager | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 0
Date: Aug 28, 2023
Visit Reason
The visit was an unannounced complaint investigation to follow up on complaint control numbers 18-AS-20220503163805, 18-AS-20200820153416, and 18-AS-20200820154620.
Complaint Details
The complaints under investigation require further investigation and no findings were concluded at this time.
Findings
No deficiencies were cited during this visit. The complaints require further investigation with possible follow-up calls, document requests, and visits before reaching investigative findings.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Molina Ramirez | Executive Director | Met during the visit and participated in the exit interview. |
| Monica Quinones | Wellness Coordinator | Met during the visit and explained the purpose of the visit. |
| Rayshaun Nickolas | Licensing Program Analyst | Conducted the unannounced visit and investigation. |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 0
Date: Aug 28, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the licensee failed to supervise a resident who eloped by jumping out of a window on September 7, 2022.
Complaint Details
The complaint alleged that the licensee failed to supervise a resident who eloped by jumping out of a window. The finding was unsubstantiated due to lack of evidence.
Findings
The investigation found no evidence or witnesses to corroborate the allegation. The facility had sufficient staff on the night of the incident, notified law enforcement promptly, and reported the incident to the Community Care Licensing Division within the regulatory timeframe. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 55
Census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rayshaun Nickolas | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Diana Molina Ramirez | Executive Director | Facility representative met during the investigation |
| Monica Quinones | Wellness Coordinator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 0
Date: Aug 7, 2023
Visit Reason
The visit was an unannounced investigation of multiple complaint control numbers related to the facility.
Complaint Details
The visit was triggered by complaint control numbers 18-AS-20220908145705, 18-AS-20220503163805, 18-AS-20200820153416, and 18-AS-20200820154620. The complaints require further investigation and no substantiation was made at this time.
Findings
No deficiencies were cited during this visit. The complaints require further investigation with possible follow-up calls, document requests, and visits before reaching findings.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Rodriguez | Med Tech | Met with Licensing Program Analyst during the visit and explained the purpose of the visit. |
| Diana Molina Ramirez | Executive Director | Met with Licensing Program Analyst and was present during the visit. |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 1
Date: Jul 31, 2023
Visit Reason
Licensing Program Analyst Jesse Gardner made an unannounced case management visit in reference to complaint number 18-AS-20211213132843 to investigate prior citation and compliance issues.
Complaint Details
Visit was complaint-related referencing complaint number 18-AS-20211213132843. The citation was related to failure to obtain criminal record clearance for Staff One. The plan of correction was cleared.
Findings
The facility failed to ensure that Staff One obtained a criminal record clearance prior to employment, posing an immediate health and safety risk. The licensee removed the staff member and cleared the plan of correction.
Deficiencies (1)
CCR 87355(d)(3): Licensee did not ensure Staff One obtained a criminal record clearance prior to beginning work at the facility. This posed an immediate health and safety risk to residents.
Report Facts
Civil penalty amount: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the unannounced case management visit and evaluation. |
| Liliana Moreno | Medical Technician | Met with Licensing Program Analyst during the visit. |
| Joel Esquivel | Supervisor | Named as supervisor in the report. |
Inspection Report
Annual Inspection
Census: 53
Capacity: 55
Deficiencies: 3
Date: Jul 25, 2023
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations at the facility.
Findings
The facility was found to have deficiencies related to infection control, maintenance and operation, and personnel training. Specific issues included blood and feces contamination in a restroom, water damage and leakage in another restroom, and a staff member lacking required CPR/First Aid training.
Deficiencies (3)
CCR 87470(a)(2)(A) Infection control practices were not maintained as blood and feces were observed on the toilet seat in Villa #1, posing a health risk.
CCR 87303(a) The facility was not maintained in good repair due to water damage and leakage in Villa #1's restroom in front of room 102.
CCR 87411(c)(1) Staff #1 did not have required first aid/CPR training, posing a potential health and safety risk to residents.
Report Facts
Capacity: 55
Census: 53
Hospice residents: 18
Bedridden residents: 1
Hospice waiver capacity: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Torres | Activities Director | Observed interacting with residents during inspection |
| Diana Molina Ramirez | Executive Assistant | Facility representative during inspection and recipient of report |
| Staff #1 | Staff member cited for lacking first aid/CPR training |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 55
Deficiencies: 1
Date: Jun 19, 2023
Visit Reason
The investigation was conducted in response to complaints alleging staff did not notify the authorized representative of a resident's room change, failed to meet a resident's hygiene needs, and did not notify the authorized representative of a resident's injuries.
Complaint Details
The complaint investigation involved three allegations: failure to notify the authorized representative of a resident's room change, failure to meet the resident's hygiene needs, and failure to notify the authorized representative of the resident's injuries. The first allegation was unsubstantiated, the second was unfounded, and the third was substantiated.
Findings
The investigation found the allegation regarding failure to notify the authorized representative of a room change was unsubstantiated due to insufficient evidence. The allegation that staff did not meet the resident's hygiene needs was unfounded. The allegation that staff failed to notify the authorized representative of the resident's injuries was substantiated.
Deficiencies (1)
CCR 87468.1(a)(8): The licensee did not ensure the resident's authorized representative was informed of the resident's injury. A narrative report revealed the resident had a blister and notes did not document notification to the representative.
Report Facts
Capacity: 55
Census: 54
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Diana Ramirez | Administrator | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 55
Deficiencies: 1
Date: May 23, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by a complaint received on 2021-10-18 regarding a resident wandering away from the facility.
Complaint Details
The complaint was substantiated based on evidence that a resident exited the facility on 10/12/21 and 10/15/21 without detection due to the lack of an auditory alert device on a door.
Findings
The investigation substantiated that a resident was able to exit the facility undetected due to a door adjacent to the resident's bedroom lacking an auditory alert device. This posed an immediate health and safety risk to residents in care.
Deficiencies (1)
CCR 87705(j): The licensee failed to have an auditory device or staff alert feature to monitor exits, which is required if exiting presents a hazard to any resident. This deficiency was observed as the door lacked a working auditory device to alert staff if opened.
Report Facts
Capacity: 55
Census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation and made findings |
Inspection Report
Census: 55
Capacity: 55
Deficiencies: 2
Date: May 23, 2023
Visit Reason
An unannounced case management visit was conducted to deliver an amended report and assess deficiencies at the facility.
Findings
Two deficiencies were found: call buttons in a resident room were not working, and there were no alternatives to the menu. The facility was issued two citations per Title 22.
Deficiencies (2)
CCR 87555(b)(5): Meals did not consist of an appropriate variety of foods as multiple meal alternatives were not available to residents. This posed a potential personal rights risk.
CCR 8746.2(a)(8): A resident did not have a working call button to alert staff, posing a potential personal rights risk. The call button was fixed and functioning at the time of the visit.
Report Facts
Citations issued: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the unannounced visit and evaluation. |
| Diana Ramirez | Executive Director | Met with Licensing Program Analyst during the visit. |
| Joel Esquivel | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 55
Deficiencies: 0
Date: Dec 8, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that a resident developed multiple pressure injuries while in care and that a resident was being unlawfully evicted.
Complaint Details
The complaint was investigated and found to be unfounded because the subject resident was not a resident of the facility. The allegations of pressure injuries and unlawful eviction were dismissed.
Findings
The investigation found that the resident named in the complaint was not and never had been a resident of the facility. Therefore, both allegations were determined to be unfounded and the complaint was dismissed.
Report Facts
Capacity: 55
Census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Crystal Colvin | Licensing Program Analyst | Conducted the complaint investigation |
| Deanna Lewis | LVN | Facility staff interviewed during the investigation |
| Joel Esquivel | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 55
Deficiencies: 1
Date: Oct 4, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility did not contact medical services for a resident after a fall.
Complaint Details
The complaint was substantiated regarding failure to contact medical services after a resident's fall. The allegation that the facility did not provide a safe environment was unsubstantiated.
Findings
The allegation that the facility did not contact medical services for a resident after a fall was substantiated, as staff failed to call 911 despite observing a bump on the resident's head. Another allegation that the facility did not provide a safe environment was unsubstantiated due to evidence of reasonable safety measures taken after a prior fall.
Deficiencies (1)
CCR 87468.2(a)(4): Licensee did not comply with the requirement to provide care, supervision, and services that meet individual needs. NOC shift staff observed a resident with a bump on their head after an unwitnessed fall but did not contact emergency services, posing an immediate health and safety risk.
Report Facts
Capacity: 55
Census: 50
Plan of Correction Due Date: Oct 5, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deanna Lewis | LVN | Interviewed regarding resident fall and facility policies |
| Crystal Colvin | Licensing Program Analyst | Conducted the complaint investigation |
| Joel Esquivel | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Annual Inspection
Census: 52
Capacity: 55
Deficiencies: 0
Date: Aug 30, 2022
Visit Reason
The inspection was an unannounced annual inspection limited to infection control practices at the facility.
Findings
The facility was generally compliant with infection control practices, including COVID-19 symptom screening and staff training. However, the facility lacked an adequate 30-day supply of PPE, specifically surgical and N95 masks, and staff had not been fit tested for N95 masks.
Report Facts
PPE supply duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Ramirez | Executive Director/Administrator | Met with Licensing Program Analyst during inspection and provided information on infection control and PPE. |
| Crystal Colvin | Licensing Program Analyst | Conducted the annual infection control inspection. |
| Joel Esquivel | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 55
Deficiencies: 2
Date: May 23, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by complaint #18-AS-20220520121929.
Complaint Details
The visit was conducted due to complaint #18-AS-20220520121929. Civil penalties totaling $500 were issued for the staff association deficiency.
Findings
Two deficiencies were found: one staff member was not properly associated with the facility, and resident files were not readily available for review, causing a delay.
Deficiencies (2)
CCR 87355(b): Staff member #1 was not associated with the facility, violating criminal record clearance requirements. This poses an immediate safety risk to residents.
CCR 87506(d): Resident records were not readily available upon request, causing a 40-minute delay. This is a potential health, safety, or personal rights risk.
Report Facts
Civil penalty amount: 500
Penalty rate: 100
Penalty duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Diana Ramirez | Administrator | Facility administrator present during inspection and exit interview |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 55
Deficiencies: 1
Date: Dec 28, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 12/13/2021 regarding infection control and staffing issues at the facility.
Complaint Details
The complaint was unsubstantiated. Allegations included unsafe infection control practices and insufficient staffing. The investigation found no evidence supporting these claims.
Findings
The investigation found no evidence to substantiate the allegations that a sick staff member was forced to work or that staffing was insufficient to cover the villas. Staff screening and management coverage were confirmed. However, a deficiency was cited for failure to ensure a staff member obtained a required criminal record clearance prior to employment.
Deficiencies (1)
CCR 87355(d)(3): Licensee did not ensure staff member S1 obtained a criminal record clearance prior to beginning work at the facility. S1 had been working since 08/13/21, posing an immediate health and safety risk to residents.
Report Facts
Capacity: 55
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Tracy Langendoen | Administrator | Facility administrator named in the report |
| Elizabeth Torres | Activities Director | Met with the evaluator during the investigation |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 55
Deficiencies: 3
Date: Oct 21, 2021
Visit Reason
The inspection was conducted unannounced to investigate a complaint (#18-AS-20211018132918) regarding facility deficiencies.
Complaint Details
The visit was triggered by complaint #18-AS-20211018132918. The complaint was investigated and deficiencies were substantiated as described.
Findings
Several deficiencies were observed including a fire safety hazard with a door secured improperly, lack of an emergency intervention plan for residents leaving unannounced, and insufficient staffing in the building where the incident occurred.
Deficiencies (3)
CCR 87203 - Fire Safety: A door was secured with two screws preventing it from opening, posing an immediate health and safety risk. This deficiency was corrected during the visit by removing screws and installing a new number code lock.
CCR 87411(a) - Personnel Requirements: Staffing was absent in the area where the incident occurred, posing an immediate health and safety risk to residents.
CCR 87411(d)(3) - Personnel Training: No emergency intervention training was observed for staff regarding actions when a resident leaves the facility unannounced, posing a potential health and safety risk.
Report Facts
Census: 40
Total Capacity: 55
Plan of Correction Due Dates: Due dates for POCs are 10/22/2021, 11/05/2021, and 11/04/2021 as stated for different deficiencies
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Reyna Lacey | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Capacity: 55
Deficiencies: 0
Date: Jul 22, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations of staff sexually abusing a resident and threatening a resident at Citrus Gardens facility.
Complaint Details
The complaint involved allegations that staff sexually abused a resident and threatened a resident. The investigation found no preponderance of evidence to prove the alleged violations occurred, resulting in an unsubstantiated finding.
Findings
The investigation included interviews and record reviews and found the allegations unsubstantiated due to lack of evidence and inconsistent witness accounts. Resident #1 was unable to recall the incident and no injuries were found.
Inspection Report
Complaint Investigation
Census: 39
Capacity: 55
Deficiencies: 0
Date: Jul 20, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted to address allegations including staff yelling at residents, residents not being fed regularly, and staff not wearing masks.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was no preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found all allegations to be unsubstantiated based on interviews with residents and staff, observations, and records review. Staff were observed wearing masks, residents reported being fed regularly, and no inappropriate staff behavior was confirmed.
Report Facts
Capacity: 55
Census: 39
Inspection Report
Complaint Investigation
Census: 29
Capacity: 55
Deficiencies: 0
Date: Jul 15, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2020-11-03 regarding resident care issues including diapering needs, supply adequacy, and timely food service.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included residents' diapering needs not being met, lack of adequate supplies, and untimely food service. Interviews and observations did not support these claims.
Findings
The investigation found all allegations unsubstantiated based on interviews with staff and residents and observations during the visit. Staff and residents denied the allegations and sufficient supplies and timely meals were confirmed.
Report Facts
Capacity: 55
Census: 29
Inspection Report
Annual Inspection
Census: 38
Capacity: 55
Deficiencies: 0
Date: Jul 15, 2021
Visit Reason
The visit was conducted as a required annual inspection with an emphasis on infection control due to the COVID-19 pandemic.
Findings
No apparent health and safety concerns were observed during the inspection. No deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.
Inspection Report
Complaint Investigation
Census: 38
Capacity: 55
Deficiencies: 0
Date: Jul 15, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility did not issue a refund to authorized representatives after residents' deaths.
Complaint Details
The complaint alleged that the facility did not issue refunds to authorized representatives after residents' deaths. The allegation was unsubstantiated after investigation.
Findings
The investigation found that all refunds had been provided to authorized representatives in accordance with regulations. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility Capacity: 55
Resident Census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Williams | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Shannon Hundley | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 55
Deficiencies: 0
Date: Apr 12, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation of an uncleared adult working in the facility.
Complaint Details
The complaint alleged an uncleared adult was working in the facility. The investigation found that Staff #1 had worked at the facility but was not listed on the personnel roster as of 10/20/2020. Background clearance documents were reviewed but it could not be confirmed if all were sent to the Department. The allegation was unsubstantiated.
Findings
The investigation included interviews and records review. The Licensing Program Analyst determined the allegation was unsubstantiated due to insufficient evidence to prove the violation occurred.
Report Facts
Capacity: 55
Census: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Williams | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Shannon Hundley | Facility representative met during investigation | |
| Kelley Lara | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 55
Deficiencies: 1
Date: Apr 12, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the facility did not issue a refund to an authorized representative after a resident's death.
Complaint Details
The complaint was substantiated based on evidence that the facility delayed issuing a refund to the resident's responsible party beyond the required 15 days after removal of the resident's personal property following death.
Findings
The complaint was substantiated as the facility failed to issue a refund within 15 days after the resident's personal property was removed following the resident's death. The refund was delayed due to the facility's accounting department but was eventually issued on 03/16/2021.
Deficiencies (1)
HSC 1569.652(c) requires a refund of fees paid in advance covering the time after a resident's personal property is removed within 15 days. The facility did not meet this requirement as the refund was delayed beyond 15 days after the resident's property removal.
Report Facts
Facility Capacity: 55
Census: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Williams | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Shannon Hundley | Facility representative interviewed during investigation and exit interview |
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