Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance with regulations. However, some complaint investigations substantiated issues related to medication mismanagement, resident dignity violations, and facility maintenance concerns, including medication errors that led to hospitalization and staff altercations posing safety risks. The facility also received citations for failing to maintain safe accommodations during repairs and for medication refill lapses resulting in missed doses. The most recent report from March 4, 2025, found a deficiency involving medication mismanagement that caused resident hospitalization. While there is no clear overall trend, recent reports show some serious issues alongside many unsubstantiated complaints and isolated deficiencies.
An unannounced visit was conducted to investigate a complaint alleging that staff did not give resident medication as prescribed.
Findings
The investigation found that facility staff mismanaged Resident 1's medication, resulting in hospitalization. Medication orders were incorrectly entered into the facility's system, and the facility failed to verify the pharmacy's entry, leading to medication errors.
Complaint Details
The complaint alleging staff did not give resident medication as prescribed was substantiated based on interviews and records reviewed. The preponderance of evidence standard was met.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
The licensee failed to assist residents with self-administered medications as needed, resulting in medication mismanagement and hospitalization of a resident.
Type B
Report Facts
Facility capacity: 140Census: 96Deficiency count: 1Plan of Correction due date: 10
Employees Mentioned
Name
Title
Context
Vicky Torres
Administrator
Interviewed regarding medication management and facility operations
Janette Romero
Licensing Program Analyst
Conducted the complaint investigation visit
Carolina Campos
Health Services Associate
Reported supervisors are required to approve new medication orders
The visit was an unannounced complaint investigation triggered by an allegation that facility staff did not seek timely medical care for a resident.
Findings
The investigation found that staff immediately contacted the resident's Power of Attorney (POA) after observing an injury, and followed the POA's instruction not to seek emergency medical services initially. Medical personnel were contacted later when the resident's condition worsened, and the resident was transported to the hospital. The allegation was unsubstantiated due to insufficient evidence to prove a violation.
Complaint Details
The complaint alleged that staff failed to transport a resident to the hospital in a timely manner after an injury was observed. The investigation determined that staff followed the POA's directive, causing a delay in emergency services. The allegation was unsubstantiated.
Report Facts
Capacity: 140Census: 107
Employees Mentioned
Name
Title
Context
Armando Perez
Licensing Program Analyst
Conducted the complaint investigation
Megan Snell
Connections for Living Director
Met with Licensing Program Analyst during investigation and exit interview
Unannounced complaint investigation visit conducted due to allegations including inadequate supervision of residents, staff leaving a resident on the floor for an extended period, and failure to administer medications as prescribed.
Findings
The investigation found the allegations of inadequate supervision, medication administration issues, and leaving a resident on the floor unsubstantiated. However, the allegation of staff engaging in physical and verbal altercations in the presence of residents was substantiated, posing a potential health and safety risk.
Complaint Details
The complaint investigation was triggered by allegations received on 04/29/2024. The allegation that staff engage in physical and verbal altercations in the presence of residents was substantiated. Other allegations regarding supervision, medication administration, and leaving a resident on the floor were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not being met as evidenced by facility staff having two different altercations with themselves, posing a potential health and safety risk to residents in care.
Type B
Report Facts
Capacity: 140Census: 111Plan of Correction Due Date: Dec 17, 2024
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-10-20 regarding multiple allegations about resident care and facility practices.
Findings
The investigation found three allegations unsubstantiated related to residents being left in soiled diapers, not treated with dignity, and toileting needs not met. However, three other allegations were substantiated: resident's hygiene needs were not met, staff did not notify the responsible party of a resident's change in condition, and staff did not safeguard resident's personal belongings. Deficiencies were cited accordingly.
Complaint Details
The complaint investigation addressed allegations including residents left in soiled diapers, lack of dignity and respect, unmet toileting needs, unmet hygiene needs, failure to notify responsible party of change in condition, and failure to safeguard personal belongings. The investigation concluded three allegations unsubstantiated and three substantiated.
Severity Breakdown
Type A: 1Type B: 2
Deficiencies (3)
Description
Severity
Resident had facial hair and untrimmed nails, posing an immediate health and safety risk.
Type A
Staff failed to notify responsible party when resident lost a tooth, posing a potential health and safety risk.
Type B
Facility failed to complete a personal property inventory for resident, posing a potential health and safety risk.
Type B
Report Facts
Capacity: 140Census: 111Deficiencies cited: 3Plan of Correction Due Date: Dec 4, 2024Plan of Correction Due Date: Dec 17, 2024
Employees Mentioned
Name
Title
Context
Joseph Alejandre
Licensing Program Analyst
Conducted the complaint investigation and authored the report
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including failure to refill resident's medication, unqualified staff handling medication, serving cold meals, facility disrepair, staff neglect leading to a resident's fall, and unresponsiveness of the administrator to a resident's responsible party.
Findings
The investigation substantiated the allegation that staff failed to refill a resident's medication, resulting in missed doses and posing an immediate health and safety risk. The allegation that staff handling medication were unqualified was found to be unfounded. Other allegations regarding cold meals, facility disrepair, staff neglect, and administrator unresponsiveness were unsubstantiated based on interviews, documentation, and observations.
Complaint Details
The complaint investigation was substantiated for failure to refill resident's medication. The allegation that staff handling medication were not qualified was unfounded. Allegations regarding cold meals, facility disrepair, staff neglect leading to a resident's fall, and administrator unresponsiveness were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Licensee failed to ensure resident was assisted with medication administration; resident missed five doses of medications as they were not refilled.
An unannounced case management visit was conducted in conjunction with complaint investigation 18-AS-20240429160126 regarding alleged staff misconduct.
Findings
The investigation revealed that Staff 1 placed their hand over a resident's mouth and told the resident to 'Shut up,' constituting humiliation and intimidation. Staff 1 was terminated from employment. The resident was observed to be clean and well cared for during the visit.
Complaint Details
Complaint investigation 18-AS-20240429160126 substantiated the allegation that Staff 1 humiliated and intimidated a resident by covering the resident's mouth and telling them to 'Shut up.'
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Licensee failed to ensure residents are free from humiliation and intimidation; Staff 1 covered the resident's mouth and told the resident to 'Shut up,' posing an immediate health and safety risk.
Type A
Report Facts
Census: 111Total Capacity: 140Deficiency Count: 1
Employees Mentioned
Name
Title
Context
Vicky Torres
Administrator
Facility administrator met during inspection
Kimberly Lyman
Licensing Program Analyst
Conducted the complaint investigation and inspection
Joseph Alejandre
Licensing Program Analyst
Conducted the complaint investigation and inspection
Alisa Ortiz
Licensing Program Manager
Named as Licensing Program Manager overseeing the inspection
The inspection was an unannounced complaint investigation visit triggered by allegations received on 05/10/2024 regarding staffing sufficiency, staff behavior towards residents, and discouragement of incident reporting.
Findings
The investigation found that staffing levels and qualifications were appropriate, staff denied yelling at residents or discouraging incident reporting, and residents confirmed being treated well. The allegations were deemed unsubstantiated due to lack of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included insufficient staff numbers and qualifications, staff yelling at residents, and discouragement of incident reporting. Interviews and documentation review did not corroborate these claims.
Report Facts
Capacity: 140
Employees Mentioned
Name
Title
Context
Kimberly Lyman
Evaluator / Licensing Program Analyst
Conducted the complaint investigation
Joseph Alejandre
Licensing Program Analyst
Assisted in conducting the complaint investigation
Vicky Torres
Administrator
Facility administrator named in the report
Alisa Ortiz
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
Lanea Palmer
Facility staff member met during the investigation
An unannounced visit was made to the facility to deliver amended complaint findings for two complaint control numbers: 18-AS-20231013143500 and 18-AS-20230918160404.
Findings
The Licensing Program Analyst met with the Executive Director to explain the purpose of the visit and conducted an exit interview. A copy of the report was provided to the Executive Director.
Complaint Details
The visit was related to amended complaint findings for complaint control numbers 18-AS-20231013143500 and 18-AS-20230918160404.
Employees Mentioned
Name
Title
Context
Vicky Torres
Executive Director
Met with Licensing Program Analyst during the visit and received the report.
Javina George
Licensing Program Analyst
Conducted the unannounced visit and delivered amended complaint findings.
An unannounced complaint investigation visit was conducted in response to a complaint received on 2024-04-15 alleging that staff did not prevent a resident from pushing another resident.
Findings
The investigation revealed that on 2024-04-13, a resident was pushed by another resident resulting in a fall and head injury. Both residents denied the altercation and staff confirmed presence during the incident. The allegation was deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that staff did not prevent a resident from pushing another resident. The allegation was investigated and found unsubstantiated, meaning there was not a preponderance of evidence to prove the violation occurred.
Report Facts
Complaint Control Number: 18Complaint Control Number: 20240415154217
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-05-07 regarding food safety protocols, falsification of medical documentation, incident reporting, medication administration without physician permission, and resident reassessment.
Findings
The investigation found no preponderance of evidence to substantiate any of the allegations. The kitchen was clean and followed food safety protocols, medical documentation was accurate, incidents were properly reported, medications were only crushed with physician orders, and residents were reassessed as required.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not following food safety protocols, falsifying medical documentation, not reporting incidents, administering crushed medications without physician permission, and not reassessing residents as necessary. None of these allegations were substantiated based on the evidence gathered.
Report Facts
Facility capacity: 140Census: 117Food safety inspection score: 96Number of resident files reviewed: 6Number of staff interviewed: 5Number of kitchen staff interviewed: 4Number of residents interviewed: 6Number of residents with physician orders for crushed medication: 9
Employees Mentioned
Name
Title
Context
Joseph Alejandre
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Kimberly Lyman
Licensing Program Analyst
Assisted in the complaint investigation visit
Vicky Torres
Executive Director
Facility administrator met during the investigation and provided information
The inspection was an unannounced required annual inspection conducted by the Licensing Program Analyst to assess compliance with state regulations.
Findings
The facility was observed to be clean, well-maintained, and in good repair with no deficiencies cited. Records and files were reviewed with some noted issues in document organization, but no regulatory violations were found.
An unannounced case management visit was conducted in conjunction with a complaint investigation related to facility conditions and resident safety.
Findings
The facility failed to ensure that resident R1 was provided safe and healthful accommodations while a substantial repair was being done in the living room. The resident remained in their room despite the damage and repair work, and the responsible party refused to move the resident to another room.
Complaint Details
The visit was triggered by complaint visit 18-AS-20211215084528. The complaint was investigated through interviews, record reviews, and observations. The citation was issued based on these findings.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Licensee failed to ensure R1 was provided safe and healthful accommodations. R1 remained in the resident's room while a substantial repair was being done.
Type B
Report Facts
Capacity: 140Census: 117Plan of Correction Due Date: Dec 3, 2024
Employees Mentioned
Name
Title
Context
Kimberly Lyman
Licensing Program Analyst
Conducted the complaint investigation and signed the report
Joseph Alejandre
Licensing Program Analyst
Conducted the complaint investigation
Vicky Torres
Administrator
Facility administrator met with inspectors during the visit
Unannounced complaint investigation visit conducted due to allegations regarding disrepair of a resident's ceiling and electricity issues.
Findings
The investigation substantiated the allegations that a resident's ceiling had leaks and the electricity was in disrepair due to water in light switches causing breaker issues. The ceiling was observed repaired during the visit, but the facility failed to maintain a safe and healthful environment initially.
Complaint Details
Complaint was substantiated. The investigation was triggered by allegations of disrepair in a resident's ceiling and electricity. The facility had ongoing issues with leaks and electrical safety hazards. Citations were issued accordingly.
Severity Breakdown
Type B: 2
Deficiencies (2)
Description
Severity
Facility failed to maintain a clean, safe, sanitary, and good repair environment; ongoing ceiling leaks in Resident 1's room posed health and safety risks.
Type B
Facility failed to maintain premises in a state of good repair and safe environment; water inside light sockets in Resident 1's room posed health and safety risks.
Type B
Report Facts
Capacity: 140Census: 117Deficiency count: 2Plan of Correction Due Date: Dec 3, 2024
Employees Mentioned
Name
Title
Context
Kimberly Lyman
Licensing Program Analyst
Conducted the complaint investigation and cited deficiencies
Joseph Alejandre
Licensing Program Analyst
Assisted in conducting the complaint investigation
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff were not ensuring that a resident was adequately fed while in care.
Findings
The investigation included a review of meal tracking forms and staff interviews, which revealed the resident was on a meal plan and was provided meals, preferring to eat in their room. The allegation was found to be unsubstantiated due to lack of evidence.
Complaint Details
The complaint was unsubstantiated as the investigation did not find sufficient evidence to prove the alleged violation occurred.
Report Facts
Capacity: 140Census: 117
Employees Mentioned
Name
Title
Context
Kimberly Lyman
Evaluator / Licensing Program Analyst
Conducted the complaint investigation
Joseph Alejandre
Licensing Program Analyst
Assisted in conducting the complaint investigation
Lori Spencer
Administrator
Facility administrator present during the investigation
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-06-21 regarding meal service timeliness, food quality, and adequacy of food availability at the facility.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Observations and interviews with residents, staff, and kitchen personnel indicated meals were served timely, food was not overcooked, and adequate food and snacks were available to residents.
Complaint Details
The complaint investigation addressed allegations that the facility was not serving meals in a timely manner, was overcooking residents' food, was serving food that was not of quality, and did not ensure an adequate amount of food was available to residents. All allegations were deemed unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 140Census: 117Residents interviewed during breakfast: 6Residents interviewed during lunch: 6Residents observed having breakfast: 12Residents observed having lunch: 31Residents interviewed about food quality: 12Kitchen staff interviewed: 3Staff interviewed about meal service: 4Days food deliveries arrive: 3
Employees Mentioned
Name
Title
Context
Joseph Alejandre
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Kimberly Lyman
Licensing Program Analyst
Assisted in the complaint investigation visit
Vicky Torres
Executive Director
Met with LPAs during investigation and provided information
Sheila Santos
Licensing Program Manager
Named as Licensing Program Manager on the report
Lori Spencer
Administrator
Facility administrator named in the report
Executive Chef
Provided information about food quality and kitchen operations
An unannounced complaint investigation was conducted in response to a complaint received on 08/13/2024 regarding Personal Rights at Citrus Place facility.
Findings
The allegation was investigated through interviews, record reviews, and observations, and was determined to be unfounded as the resident in question does not reside at the facility and there were no health and safety concerns observed.
Complaint Details
The complaint was related to Personal Rights. The allegation was found to be unfounded, meaning it was without merit or false and could not have happened.
The inspection was a required annual unannounced visit conducted to evaluate compliance with licensing requirements for the residential care facility for the elderly.
Findings
The facility was found to be in compliance with no deficiencies cited. Observations included infection control measures for COVID-19 positive residents, clean and well-maintained physical plant, adequate food service, proper medication management, and disaster preparedness with recent fire drill documentation.
Report Facts
COVID-19 positive residents: 8Residents medication lists reviewed: 5Last fire drill date: Dec 22, 2023
Employees Mentioned
Name
Title
Context
Lori Spencer
Administrator
Met with Licensing Program Analyst during the visit and received the report
The visit was an unannounced complaint investigation conducted to investigate allegations that staff did not maintain a comfortable temperature at all times for residents in care.
Findings
The investigation found that the facility had experienced air conditioning issues earlier in the month but had taken steps to ensure residents were kept comfortable using fans and portable air conditioning units. At the time of the visit, temperatures were comfortable, no residents complained or experienced heat-related symptoms, and there was a plan to repair the air conditioning system. Therefore, the allegation was unsubstantiated.
Complaint Details
The complaint alleged that on 7/11/2023 the facility lobby, kitchen, and dining area were 90 degrees and that management stated the air conditioning system was "too costly" to fix, with staff using fans to cool the dining room. The allegation was found unsubstantiated after investigation.
The inspection visit was conducted to investigate a complaint alleging that the facility was not conducting fire drills.
Findings
The investigation found that the last fire drill was conducted on 2023-05-31, confirmed by the Maintenance Director, and therefore the allegation was unsubstantiated.
Complaint Details
The complaint alleged that the facility was not conducting fire drills. The allegation was found to be unsubstantiated after review and interviews.
An unannounced visit was conducted to amend the finding of one allegation from October 22, 2021, related to a complaint.
Findings
The visit was focused on addressing a previous allegation from a complaint dated October 22, 2021. No additional findings or deficiencies are explicitly stated in the report.
Complaint Details
The visit was related to complaint #18-AS-20210818134318 and involved amending the finding of one allegation from October 22, 2021.
Employees Mentioned
Name
Title
Context
Stephanie Torres
Licensing Program Analyst
Conducted the unannounced visit to amend the finding of one allegation.
An unannounced annual inspection was conducted with an emphasis on infection control to evaluate the facility's compliance with Community Care Licensing guidelines.
Findings
The inspection found no deficiencies. The facility demonstrated sufficient infection control measures including adequate hand hygiene supplies, cleaning provisions, proper PPE use, and a designated infection control lead. The facility also has plans for COVID-19 testing, isolation, and monitoring.
Report Facts
Capacity: 140Census: 110
Employees Mentioned
Name
Title
Context
Lori Spencer
Executive Director
Met with Licensing Program Analyst during inspection
Stephanie Torres
Licensing Program Analyst
Conducted the inspection visit
Loading inspection reports...
Need Help?
Let us help you or a loved one find the perfect senior home.