Inspection Report Summary
Most inspections found no deficiencies, including the most recent report from September 19, 2025, which was a complaint investigation that found the complaint about visitor restrictions to be unfounded. Earlier reports showed some isolated issues, such as a technical violation for water temperature in January 2025 and substantiated complaints in late 2022 related to inadequate supervision leading to resident elopements and lack of hot water affecting bathing and laundry services. Several complaint investigations about falls and supervision were unsubstantiated, and there were no fines or enforcement actions listed in the available reports. The facility appears to have addressed many prior concerns, as recent inspections show improvement with fewer deficiencies. Minor issues like food service staffing were noted in 2022 but did not recur in later reports.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
92% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 114
Capacity: 124
Deficiencies: 0
Sep 19, 2025
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that staff placed restrictions on a resident's right to have visitors and did not provide privacy during visits.
Findings
The investigation found that the resident's Power of Attorney had valid authority to restrict visitors due to distress caused to the resident, and the complaint was determined to be unfounded.
Complaint Details
The complaint alleged that staff restricted Resident #1's visitors and did not provide privacy during visits on September 10 and 11, 2025. The resident had passed away before the investigation. Interviews and document reviews confirmed that the Power of Attorney had authorized visitor restrictions due to distress caused by certain visitors. The complaint was found to be unfounded.
Report Facts
Estimated Days of Completion: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon Lopez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Jasmine Barajas | Health Services Director | Facility staff who assisted during the investigation visit |
Inspection Report
Annual Inspection
Census: 107
Capacity: 124
Deficiencies: 1
Jan 9, 2025
Visit Reason
The inspection was an unannounced Required/Annual Inspection conducted to evaluate the facility's compliance with regulations.
Findings
The facility was found to be in compliance with no deficiencies cited. Observations included operable safety systems, adequate food supplies, proper medication storage, and well-maintained resident rooms and common areas. A technical violation was issued for water temperature exceeding the allowed range.
Deficiencies (1)
| Description |
|---|
| Water temperature tested between 105.0-123.6 degrees Fahrenheit; a Technical Violation was issued on this date. |
Report Facts
Food supply duration: 2
Food supply duration: 7
Fire extinguisher service date: Aug 15, 2024
Resident files reviewed: 10
Staff files reviewed: 9
Residents interviewed: 10
Staff interviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Kornmann | Executive Director | Met with LPAs during inspection and named in the report |
| Linda Robbins | Sales Manager | Met with LPAs and discussed purpose of inspection |
| Claudia Gutierrez | Licensing Program Analyst | Conducted inspection and signed report |
| Eboni Bentley | Licensing Program Analyst | Conducted inspection |
| Armando J Lucero | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 124
Deficiencies: 0
Mar 22, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 07/08/2022 alleging that a resident suffered a fall resulting in serious injuries due to lack of care and supervision.
Findings
The investigation found that Resident #1 had multiple falls, including one on July 5, 2022, which resulted in serious injuries. Staff took appropriate steps to assist and call 911. The allegation of neglect or lack of supervision was deemed unsubstantiated due to insufficient evidence that staff caused or contributed to the fall.
Complaint Details
The complaint was investigated through interviews with the administrator, six staff members, witnesses, and review of facility documentation. The allegation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violation occurred.
Report Facts
Facility capacity: 124
Census: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Kornmann | Administrator | Met with Licensing Program Analyst and involved in complaint investigation |
| Michelle Reed | Licensing Program Analyst | Conducted the complaint investigation |
| Sheila Santos | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 124
Deficiencies: 0
Mar 20, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 08/03/2022 alleging that a resident suffered a fall resulting in serious injuries due to lack of care and supervision.
Findings
The investigation found that Resident #1, who was a fall risk, sustained a fall resulting in a hematoma and broken clavicle. However, there was insufficient evidence to substantiate neglect or lack of supervision by facility staff. The allegation was deemed unsubstantiated.
Complaint Details
The complaint was investigated through interviews with the administrator, six staff members, and witnesses, as well as review of facility documentation. The allegation of neglect or lack of supervision was unsubstantiated due to lack of definitive supporting evidence.
Report Facts
Complaint received date: Aug 3, 2022
Investigation visit time: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Reed | Licensing Program Analyst | Conducted the complaint investigation and met with the administrator |
| Jennifer Kornmann | Administrator | Facility administrator interviewed during investigation |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 124
Deficiencies: 0
Mar 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 08/11/2022 alleging that a resident sustained multiple falls due to lack of supervision.
Findings
The investigation included interviews with staff and review of resident records. It was determined that the allegation was unsubstantiated as there was not a preponderance of evidence to prove the falls were due to lack of supervision.
Complaint Details
The complaint alleged that Resident #1 sustained multiple falls while in care due to lack of supervision. The investigation found the allegation unsubstantiated.
Report Facts
Complaint received date: Aug 11, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Reed | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jennifer Kornmann | Administrator | Facility administrator met during investigation and recipient of report |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 124
Deficiencies: 0
Feb 24, 2023
Visit Reason
An unannounced complaint investigation was conducted to investigate the allegation that staff did not provide the resident's authorized representative with all records.
Findings
The investigation found that the facility did not have progress notes for the first two months of the resident's stay, but all available progress notes were provided to the authorized representative. The allegation was deemed unfounded and dismissed.
Complaint Details
The complaint alleged that staff did not provide Resident 1's authorized representative with all progress notes for the first two months. The allegation was investigated and found to be unfounded.
Report Facts
Capacity: 124
Census: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Program Analyst | Conducted the complaint investigation |
| Jennifer Kornmann | Executive Director | Interviewed during the investigation and named in findings |
| Sheila Santos | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 124
Deficiencies: 3
Nov 1, 2022
Visit Reason
An unannounced complaint investigation visit was conducted following allegations that the facility did not have hot water, residents were not being bathed, and residents' laundry services were not being met while in care.
Findings
The investigation found that out of 9 rooms, 6 did not have hot water meeting regulation guidelines. End of shift reports and staff interviews confirmed that six residents did not receive showers and laundry services were not completed due to lack of hot water. The allegations were substantiated and posed immediate health and safety risks.
Complaint Details
The complaint was substantiated based on water temperature measurements, interviews, and record reviews. The complaint control number is 22-AS-20220823133542. The complaint was received on 08/23/2022 and investigated with an unannounced visit on 11/01/2022.
Severity Breakdown
Type A: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Maintenance and Operation-Faucets used by residents for personal care did not deliver hot water within the required temperature range of 105 to 120 degrees F. | Type A |
| Basic services including personal assistance with bathing were not provided as six residents did not receive showers due to no warm or hot water. | Type A |
| Facilities with washing machines did not have adequate supplies available and equipment maintained in good repair, resulting in laundry services not being completed due to no hot water. | Type A |
Report Facts
Rooms without compliant hot water: 6
Residents not bathed: 6
Facility capacity: 124
Facility census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Reed | Licensing Program Analyst | Conducted the complaint investigation and made the unannounced visit. |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Jennifer Kornmann | Administrator | Facility Administrator met during the investigation and named in findings. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 124
Deficiencies: 0
Nov 1, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that a resident wandered away from the facility twice due to lack of supervision.
Findings
The complaint was investigated through interviews with staff, the administrator, and witnesses. The investigation found the complaint to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis.
Complaint Details
The complaint alleged that a resident wandered away from the facility twice due to lack of supervision. No dates or times were provided, and it was unknown if these incidents were related to prior citations for elopements. The complaint was found to be unfounded.
Report Facts
Capacity: 124
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Reed | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Jennifer Kornmann | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 124
Deficiencies: 0
Nov 1, 2022
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 07/11/2022 regarding lack of supervision resulting in a resident suffering a fall and injury.
Findings
The investigation found no supporting evidence of neglect or lack of supervision by facility staff that caused or contributed to the resident's fall. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged lack of supervision resulting in a resident falling and sustaining injury. The investigation included interviews and record reviews. The allegation was unsubstantiated due to insufficient evidence to prove the violation occurred.
Report Facts
Complaint Control Number: 22-AS-20220711174604
Capacity: 124
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Reed | Licensing Program Analyst | Conducted the complaint investigation and met with the Administrator |
| Jennifer Kornmann | Administrator | Facility Administrator met during investigation and exit interview |
Inspection Report
Annual Inspection
Census: 84
Capacity: 124
Deficiencies: 0
Oct 24, 2022
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be in good repair with no deficiencies noted. Resident rooms and common areas were clean and safe, fire and safety equipment were operational, and COVID-19 mitigation plans were reviewed and found adequate.
Report Facts
Licensed capacity: 124
Census: 84
Hospice waiver beds: 10
Bedridden residents allowed: 6
Hot water temperature range (Fahrenheit): 105.0-119.8
Fire alarm and carbon monoxide alarm test date: Sep 23, 2022
Food supply minimum days: 2
Food supply minimum days: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Tapia | Licensing Program Analyst | Conducted the inspection and authored the report |
| Leo Serna | Business Office Director | Met with Licensing Program Analyst during inspection |
| Jennifer Kornmann | Executive Director | Facility administrator; participated in exit interview |
Inspection Report
Follow-Up
Census: 82
Capacity: 124
Deficiencies: 1
Aug 23, 2022
Visit Reason
The visit was conducted to follow-up on an elopement incident that occurred at the facility involving Resident #1 who left the facility unsupervised.
Findings
Resident #1 climbed over the side gate and eloped on 08/18/2022 without staff awareness, posing an immediate health and safety risk. The facility was cited for failure to provide adequate care and supervision.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Basic services including care and supervision were not met as Resident #1 eloped by climbing over the side gate and staff were unaware, posing an immediate health and safety risk. | Type A |
Report Facts
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Reed | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Kathleen McCarron | Vice President of Operations | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Sheila Santos | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Capacity: 124
Deficiencies: 1
Aug 8, 2022
Visit Reason
The visit was conducted as a case management visit to discuss an Unusual Incident reported on 08/04/2022 involving a resident elopement from the Memory Care Unit.
Findings
Resident #1 eloped from the facility through delayed egress doors on 08/04/2022, the third such incident involving this resident within a 12-month period. Staff were unaware of the elopement until alerted by the resident's responsible party. The delayed egress doors have a delay in locking, and staff have been trained and reminded to secure doors properly.
Complaint Details
The visit was complaint-related due to an Unusual Incident involving Resident #1 eloping from the Memory Care Unit on 08/04/2022. This was the third elopement incident involving the resident within the past year. Staff were unaware of the elopement until notified by the resident's responsible party. The complaint was substantiated with cited deficiencies.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Care of Person's With Dementia - Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility. This requirement was not met as evidenced by the resident elopements through delayed egress doors. | Type A |
Report Facts
Deficiency Type: 1
Capacity: 124
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Kornmann | Administrator | Named in relation to the incident and exit interview. |
| Michelle Reed | Licensing Program Analyst | Conducted the case management visit and authored the report. |
| Leo Serna | Business Office Manager | Met with Licensing Program Analyst upon arrival. |
| Sheila Santos | Licensing Program Manager | Supervisor named in the report. |
Inspection Report
Census: 78
Capacity: 124
Deficiencies: 0
Jul 12, 2022
Visit Reason
Licensing Program Analyst Michelle Reed conducted an unannounced Case Management visit to follow up on an Exemption Denial for Staff #1.
Findings
Staff #1, previously denied exemption and removed from the facility, was found still working at the facility. The staff member was immediately sent home and is no longer associated with the facility. No citations were issued at this time pending further information.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Kornmann | Administrator | Informed Licensing Program Analyst that Staff #1 was still working at the facility and sent Staff #1 home upon arrival. |
| Michelle Reed | Licensing Program Analyst | Conducted the unannounced Case Management visit and met with the Administrator. |
| Tammy Sampedro | Executive Director | Signed and sent the Confirmation of Removal letter for Staff #1 on 3/28/22. |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 124
Deficiencies: 1
Jul 7, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations regarding facility doors being a hazard and staff not providing adequate food service.
Findings
The allegation that facility doors are a hazard was deemed unsubstantiated after testing doors and reviewing records. The allegation that staff are not providing adequate food service was substantiated based on interviews, observations, and review of staffing schedules and records, revealing insufficient food service personnel and staff working outside their primary roles.
Complaint Details
The complaint investigation was initiated based on allegations received on 05/18/2022. The allegation regarding facility doors being a hazard was unsubstantiated. The allegation regarding inadequate food service was substantiated. The investigation included interviews with residents and staff, review of facility and staffing records, and observations.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| General Food Service Requirements. The licensee did not employ sufficient food service personnel which poses a potential risk to the health and safety of residents in care. | Type B |
Report Facts
Capacity: 124
Census: 78
Deficiency due date: Jul 28, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jennifer Kornmann | Executive Director | Met with Licensing Program Analyst during the investigation |
| Leo Serna | Business Office Director | Participated in exit interview and received report copy |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 124
Deficiencies: 1
Apr 4, 2022
Visit Reason
The visit was conducted to discuss two unusual incident reports sent to the Department on 3/17/22 and 3/28/22 involving residents wandering from the facility unassisted.
Findings
Residents R1 and R2 wandered from the community without staff supervision despite care plans indicating they cannot leave unassisted and have wandering behaviors. Both residents were found and returned without injuries, but this posed an immediate health and safety risk.
Complaint Details
The investigation was triggered by two unusual incident reports regarding residents wandering unassisted. The complaint was substantiated as deficiencies were cited related to inadequate supervision of residents with wandering behaviors.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Care of Person's With Dementia - Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility. R1 and R2 wandered from the Community without staff supervision. According to records reviewed they cannot leave the facility unassisted and have wandering behaviors. This poses an immediate health and safety risk to residents in care. | Type A |
Report Facts
Capacity: 124
Census: 55
Deficiencies cited: 1
Plan of Correction Due Date: Apr 5, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tammie Sampedro | Administrator | Met with Licensing Program Analyst during inspection and involved in exit interview |
| Michelle Reed | Licensing Program Analyst | Conducted the case management visit and inspection |
| Sheila Santos | Licensing Program Manager | Supervisor named in the report and deficiency section |
Inspection Report
Original Licensing
Capacity: 124
Deficiencies: 0
Nov 22, 2021
Visit Reason
The visit was an announced pre-licensing inspection conducted to evaluate the facility's readiness for licensure following the application received on 2021-07-19.
Findings
The facility was found to be in compliance with regulations, including operational fire safety equipment, clean and operational resident rooms, secured medication rooms, and adequate emergency supplies. The facility meets Title 22 Division 6 of the California Code of Regulations and is ready for licensure.
Report Facts
Capacity: 124
Census: 0
Non-ambulatory beds: 118
Bedridden beds: 6
Hot water temperature: 120
Fire clearance date: Nov 17, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tammie Sampedro | Executive Director | Led the facility tour and was met during the inspection |
| Danielle Morgan | President | Led the facility tour during the inspection |
| Jerome Haley | Licensing Program Analyst | Conducted the inspection and inspected the kitchen and medication room |
| Joseph Alejandre | Licensing Program Analyst | Participated in the announced pre-licensing inspection visit |
| Ryan Aloi | Santa Ana Fire Department Inspector | Approved fire clearance on 2021-11-17 |
Inspection Report
Original Licensing
Capacity: 124
Deficiencies: 0
Nov 4, 2021
Visit Reason
Initial licensing evaluation conducted via telephone call to confirm applicant and administrator understanding of licensing requirements and program policies.
Findings
The applicant and administrator successfully completed the Component II evaluation, demonstrating understanding of facility operation, staff qualifications, program policies, and COVID-19 mitigation plan. No clients were in care at the time of the evaluation.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tammie Sampedro | Administrator | Applicant/administrator participating in licensing evaluation |
| Danielle Morgan | Applicant/administrator participating in licensing evaluation | |
| Jude De La Concepcion | Licensing Program Manager | Named in report header |
| Maria Ejaz | Licensing Program Analyst | Named in report header |
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