Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance. The most recent report from September 4, 2025, was a complaint investigation that found no deficiencies and did not substantiate the allegation about air conditioning issues. Earlier reports showed isolated deficiencies, including a substantiated failure in April 2025 to provide authorized representatives with copies of residents' files within the required timeframe, and past issues with the air conditioning system in 2022 and 2024 that were eventually resolved. There were also medication documentation and chemical storage deficiencies cited in November 2023, but no fines or enforcement actions were listed in the available reports. Overall, the facility’s compliance appears to have improved over time, with recent investigations showing no deficiencies.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 101
Capacity: 137
Deficiencies: 0
Sep 4, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not ensure the air conditioner was working properly, resulting in the facility not being kept at a comfortable temperature.
Findings
The investigation included facility inspection, staff and resident interviews, and document review. The allegation was found to be unsubstantiated as the HVAC system was maintained quarterly, temperatures in common areas and resident rooms were within comfortable ranges, and no evidence supported the claim of malfunctioning air conditioning.
Complaint Details
The complaint alleged that staff did not ensure the air conditioner was working properly, causing uncomfortable temperatures. The investigation found no preponderance of evidence to substantiate the allegation, and it was determined to be unsubstantiated.
Report Facts
Temperature measurement: 74.3
Temperature measurement: 73.6
Temperature measurement: 72.1
Temperature measurement: 75.3
Temperature measurement: 73.2
Temperature measurement: 74.3
Temperature measurement: 75.6
Temperature measurement: 75.5
Temperature measurement: 76.4
Temperature measurement: 77
Temperature measurement: 76.6
Temperature measurement: 77.3
Temperature measurement: 70.7
Temperature measurement: 75.2
Temperature measurement: 73
Temperature measurement: 76.1
Temperature measurement: 76.6
Temperature measurement: 73.7
Temperature measurement: 73.2
Temperature measurement: 74.3
Temperature measurement: 71.6
Capacity: 137
Census: 101
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul Gozon | Executive Director | Met with Licensing Program Analyst during the investigation and participated in exit interview |
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 137
Deficiencies: 0
Jul 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not ensuring all staff were criminally record cleared before working on the floor.
Findings
The investigation included interviews with the Executive Director and Business Office Director, review of staff files and schedules, and found that all 10 staff files reviewed had the required criminal and medical clearances. There was insufficient evidence to substantiate the allegation, and no deficiencies were cited.
Complaint Details
The complaint alleged that applicants were hired and scheduled before passing live scan and medical testing. Interviews and record reviews did not support this allegation, resulting in an unsubstantiated finding.
Report Facts
Staff files reviewed: 10
Capacity: 137
Census: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul Gozon | Executive Director | Interviewed during complaint investigation |
| Deborah Lee | Licensing Program Analyst | Conducted the complaint investigation |
| Raul Pereira | Business Office Director | Interviewed during complaint investigation |
Inspection Report
Census: 103
Capacity: 137
Deficiencies: 0
Jun 26, 2025
Visit Reason
An unannounced Case Management Visit was conducted to deliver an Immediate Exclusion Letter for a staff member due to conduct inimical.
Findings
No deficiencies were observed or cited during the visit. An Immediate Exclusion Letter was delivered to exclude Daniel Castro from contact with clients and presence at the facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul Gozon | Executive Director | Met with Licensing Program Analyst during the visit and involved in the delivery of the Immediate Exclusion Letter. |
| Wendy Gibbs | Licensing Program Analyst | Conducted the unannounced Case Management Visit and delivered the Immediate Exclusion Letter. |
| Daniel Castro | Staff member who was immediately excluded due to conduct inimical. |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 137
Deficiencies: 1
Apr 30, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations including failure to provide authorized representatives copies of residents' files, staff neglect causing a resident wound, double diapering residents, and leaving residents in soiled diapers.
Findings
The investigation substantiated the allegation that staff failed to provide authorized representatives copies of residents' files within two business days as required by regulation. The other allegations regarding staff neglect causing wounds, double diapering residents, and leaving residents in soiled diapers were unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited during the visit.
Complaint Details
The complaint investigation was triggered by allegations that staff did not provide authorized representatives copies of residents' rental agreements and visitor logs, a resident sustained a wound due to staff neglect, residents were double diapered, and residents were left in soiled diapers. The allegation regarding failure to provide records was substantiated, while the others were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide copies of residents' files to authorized representatives within two business days as required by CCR 87468.2(a)(19). | Type B |
Report Facts
Capacity: 137
Census: 114
Deficiency count: 1
Plan of Correction Due Date: May 10, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raul Pereira | Business Office Manager | Met with Licensing Program Analyst during exit interview and delivery of findings |
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Jill Tucker | Administrator | Facility Administrator mentioned in report header |
Inspection Report
Complaint Investigation
Capacity: 137
Deficiencies: 0
Jan 30, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2024-10-16 regarding allegations of staff not providing authorized representatives copies of residents' files, resident wounds due to staff neglect, double diapering residents, and residents being left in soiled diapers.
Findings
The investigation reviewed multiple documents, interviewed staff and residents, and found no preponderance of evidence to substantiate any of the allegations. All allegations were determined to be unsubstantiated, and no deficiencies were cited during the visit.
Complaint Details
The complaint included allegations that staff failed to provide authorized representatives with copies of residents' files, a resident sustained a wound due to staff neglect, residents were double diapered, and residents were left in soiled diapers. The investigation included document reviews, staff and resident interviews, and found no evidence to support the allegations. The complaint was unsubstantiated.
Report Facts
Facility capacity: 137
Staff interviewed: 12
Residents interviewed: 9
Complaint received date: Oct 16, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul Gozon | Executive Director | Met with during the investigation and exit interview |
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Jill Tucker | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Capacity: 137
Deficiencies: 0
Sep 6, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-12-14 regarding multiple allegations against the facility.
Findings
The investigation reviewed multiple allegations including safeguarding residents' personal items, documentation and reporting of incidents, provision of activities, medication management, safeguarding confidential information, provision of utensils, and staff communication with residents. The investigation found no preponderance of evidence to support the allegations and determined them to be unsubstantiated. No deficiencies were cited during the visit.
Complaint Details
The complaint included allegations that staff did not safeguard residents' personal items, failed to document or report incidents to residents' authorized persons, did not provide activities, mismanaged medication, failed to safeguard confidential information, did not provide utensils, and were unable to communicate with residents. The investigation found these allegations unsubstantiated due to lack of evidence.
Report Facts
Capacity: 137
Residents interviewed: 6
Staff interviewed: 9
Dates of incidents reported: 8
Medication records reviewed: 6
Staff training modules: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Cecille Bernabe | Assistant Executive Director/Memory Care Director | Interviewed during investigation and exit interview |
| Raul Pereira | Office Business Director | Interviewed during investigation and exit interview |
| Paul Gozon | Executive Director | Interviewed during investigation |
| Jill Tucker | Administrator | Named as facility administrator |
Inspection Report
Annual Inspection
Census: 115
Capacity: 137
Deficiencies: 0
Aug 2, 2024
Visit Reason
The visit was an unannounced required 1-year inspection to evaluate the facility's compliance with licensing regulations for serving non-ambulatory elderly adults.
Findings
The facility was found to be clean, well-maintained, and in good repair with no deficiencies observed or cited. Resident rooms, common areas, kitchen, safety equipment, medication storage, files, and infection control measures were all compliant with regulatory standards.
Report Facts
Resident apartments inspected: 12
Residents' MARs reviewed: 10
Staff files reviewed: 8
Resident files reviewed: 12
Fire extinguishers last serviced: Sep 12, 2023
Last annual fire inspection: Oct 10, 2023
Last emergency drill: Jun 16, 2024
Perishable food supply: 3
Nonperishable food supply: 7
Licensed capacity: 137
Current census: 115
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raul Pereira | Business Office Manager | Met with Licensing Program Analysts during inspection and participated in exit interview |
| Cecille Bernabe | Assistant Executive Director | Met with Licensing Program Analysts during inspection and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 137
Deficiencies: 0
Jul 17, 2024
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation that the facility HVAC system was in disrepair.
Findings
The investigation included facility tour, temperature measurements, staff and resident interviews, and document review. The HVAC system was found to be functioning with thermostats set within comfortable ranges, and maintenance was documented. Some residents had difficulty operating thermostats, but no deficiencies were observed or cited. The allegation was unsubstantiated due to lack of evidence.
Complaint Details
The complaint alleged that the facility had a broken air conditioning and heating system for about two years. The investigation found no preponderance of evidence to prove the alleged violation(s) occurred, and the allegation was unsubstantiated.
Report Facts
Room temperatures measured: 74.3
Room temperatures measured: 74.8
Room temperatures measured: 73.2
Room temperatures measured: 76.7
Room temperatures measured: 77.3
Room temperatures measured: 75.3
Room temperatures measured: 70.6
Room temperatures measured: 74
Room temperatures measured: 74.4
Room temperatures measured: 71.9
Room temperatures measured: 74.3
Room temperatures measured: 71.4
Room temperatures measured: 76.6
Room temperatures measured: 77.5
Room temperatures measured: 75.3
Room temperatures measured: 72.2
Room temperatures measured: 77
Room temperatures measured: 74.3
Room temperatures measured: 74.3
Room temperatures measured: 78.6
Work orders related to air conditioning: 21
Work orders requesting thermostat adjustment: 10
Resident complaints about air conditioning: 7
Residents interviewed: 10
Residents reporting no issues with air conditioning: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit |
| Cecille Bernabe | Assistant Executive Director | Participated in exit interview and investigation |
| Raul Pereira | Business Office Director | Participated in exit interview and investigation |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 137
Deficiencies: 0
Mar 19, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that facility staff do not store cleaning chemicals locked and inaccessible to residents in care.
Findings
The investigation found that all cleaning chemicals were stored securely in locked cabinets and inaccessible to residents. Staff confirmed they received training on chemical storage, and residents reported not seeing cleaning chemicals left out. No evidence was found to support the allegation, and no deficiencies were cited.
Complaint Details
The complaint alleged that cleaning products were left out or stored in unsecured cabinets accessible to residents in the memory care unit. The allegation was unsubstantiated due to lack of evidence.
Report Facts
Staff trained on chemical safety: 7
Residents interviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul Gozon | Executive Director | Met with Licensing Program Analyst during the investigation and participated in exit interview. |
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 137
Deficiencies: 0
Feb 10, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation of neglect/lack of supervision resulting in severe injury.
Findings
The investigation found no preponderance of evidence to substantiate the allegation. Medical records showed Resident #1 did not sustain a fracture from the alleged fall, and the facility had implemented preventative measures following the incident.
Complaint Details
The allegation was that neglect or lack of supervision resulted in severe injury to Resident #1. The investigation included medical record reviews, interviews with staff, residents, and witnesses, and found the allegation to be unsubstantiated.
Report Facts
Residents non-ambulatory: 5
Residents receiving hospice care: 16
Complaint received date: Aug 23, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Kathryn O'Brien | Lifestyle Director | Facility staff member met during the investigation and recipient of exit interview |
Inspection Report
Annual Inspection
Census: 119
Capacity: 137
Deficiencies: 2
Nov 18, 2023
Visit Reason
An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations for the facility serving non-ambulatory elderly adults.
Findings
The facility was found to be sanitary, appropriately furnished, and compliant with infection control practices. However, deficiencies were cited related to medication documentation and storage of cleaning agents accessible to memory care residents.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff did not document when giving prescribed medications, posing a potential health, safety, or personal rights risk to persons in care. | Type B |
| Cleaning agents were not stored inaccessible to residents with dementia, posing an immediate health, safety, or personal rights risk. | Type A |
Report Facts
Rooms inspected: 12
Residents' service files reviewed: 6
Staff personnel files reviewed: 6
Medication Administration Records reviewed: 6
Fire/Disaster Drills date: Sep 6, 2023
Annual fire clearance date: Sep 30, 2023
Plan of Correction Due Date: Dec 1, 2023
Plan of Correction Due Date: Nov 20, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul Gozon | Executive Director | Met with Licensing Program Analyst during inspection and named in findings related to medication documentation and cleaning agent storage |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Eva M Alvarez | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 137
Deficiencies: 0
Jun 30, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff were not providing a safe environment for residents in care.
Findings
The investigation found that a single verbal altercation occurred between residents regarding seating in the dining area, which was resolved. Staff and other residents denied ongoing safety concerns. The allegation was determined to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that staff were not providing a safe environment for residents. Interviews with staff, residents, and review of documentation revealed a single verbal altercation between residents, with no further incidents. The allegation was unsubstantiated.
Report Facts
Capacity: 137
Census: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Camille Bughaw | LVN, Memory Support Director | Interviewed regarding the allegation and investigation findings |
| Jeremiah Randle | Licensing Program Analyst | Conducted the complaint investigation visit |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 116
Capacity: 137
Deficiencies: 0
Nov 14, 2022
Visit Reason
Licensing Program Analyst Jeremiah Randle conducted an unannounced visit to the facility for the purpose of the required annual inspection.
Findings
The facility was inspected thoroughly including resident rooms, bathrooms, medication storage, staff and resident files, fire safety, food service, and hygiene supplies. No deficiencies or citations were observed during the inspection.
Report Facts
Residents on hospice: 9
Bedridden residents: 6
Assisted Living units: 54
Memory Care units: 55
Staff files reviewed: 7
Bathrooms inspected for water temperature: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeremiah Randle | Licensing Program Analyst | Conducted the inspection visit |
| Michele Johnson | Administrator | Met with Licensing Program Analyst during inspection and assisted with the visit |
| Stephanie Cifuentes | Licensing Program Manager | Named in report header and narrative |
Inspection Report
Follow-Up
Census: 117
Capacity: 137
Deficiencies: 1
Sep 6, 2022
Visit Reason
The visit was a Plan of Correction (POC) unannounced follow-up to verify correction of a previously substantiated complaint regarding the facility's air conditioning system being in disrepair.
Findings
The facility's main air conditioning unit remained unrepaired and not fully operational, affecting multiple resident rooms and common areas. The facility had purchased and rented portable A/C units to mitigate heat issues while awaiting bids to replace the main A/C unit.
Complaint Details
The visit followed a substantiated complaint from 04/08/22 regarding the facility's air conditioning being in disrepair and not working in several resident rooms for over two months.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87303(b) A comfortable temperature for residents shall be maintained at all times. This was not met as evidence by; based on the observations and interviews the facility had A/C not completely operational and still remains unrepaired. This poses a potential risk for persons in care. | Type B |
Report Facts
Census: 117
Total Capacity: 137
Portable A/C units purchased/rented: 20
Portable A/C units purchased arriving next day: 10
Portable A/C units requested to purchase: 30
Rooms without A/C on 1st floor: 12
Rooms without A/C on 2nd floor: 12
Current temperature: 82.4
POC Due Date: Sep 20, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michele Johnson | Executive Director | Interviewed during inspection and involved in exit interview |
| Ana Soto | Licensing Program Analyst | Conducted the inspection and signed the report |
| Janae Hammond | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 137
Deficiencies: 1
Apr 8, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that the facility was not maintained at a comfortable temperature and that the facility's A/C was in disrepair.
Findings
The investigation found that while some residents felt the temperature could be cooler, the common areas were maintained at a comfortable temperature. However, the allegation that the A/C was in disrepair was substantiated, with the A/C not working in certain resident rooms for over two months. The facility was actively trying to repair the A/C and provided personal fans to affected residents.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Ana Soto. The allegation that the facility was not maintained at a comfortable temperature was unsubstantiated, but the allegation that the facility's A/C was in disrepair was substantiated. The facility had been trying to repair the A/C for over two months and provided personal fans to affected residents. The investigation included interviews with staff and residents, tours of the facility, and review of repair invoices.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87303(b) A comfortable temperature for residents shall be maintained at all times. This was not met as evidenced by; based on the observations and interviews the facility had A/C not completely operational. This poses a potential risk for persons in care. | Type A |
Report Facts
Capacity: 137
Census: 95
Deficiency count: 1
Plan of Correction Due Date: May 8, 2022
Duration A/C not working: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Soto | Licensing Program Analyst | Conducted the complaint investigation |
| Camile Bughaw | Director of Memory Care Unit | Interviewed during the investigation and participated in exit interview |
| Jill Tucker | Administrator | Facility administrator named in the report |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 95
Capacity: 137
Deficiencies: 0
Feb 28, 2022
Visit Reason
An unannounced Case Management visit was conducted to serve an Order to Licensee/Facility of Immediate Exclusion from Facility for Staff #1 due to violation of client’s personal rights.
Findings
The investigation determined that Staff #1 violated California Code of Regulations Title 22 regarding client’s personal rights, resulting in an immediate exclusion order. A health and safety inspection was also conducted, reviewing the physical plant and food supply.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Tucker | Administrator | Met with Licensing Program Analyst and acknowledged the Immediate Exclusion order. |
| Lourdes Montoya | Licensing Program Analyst | Conducted the unannounced Case Management visit and served the Immediate Exclusion order. |
| Angela J Kendrick | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Annual Inspection
Census: 88
Capacity: 137
Deficiencies: 1
Aug 19, 2021
Visit Reason
An unannounced annual required visit was conducted with a primary focus on Infection Control measures using the new CARE Inspection Tool.
Findings
The facility was found to be sanitary, appropriately furnished, and compliant with infection control practices. One deficiency was cited regarding water temperature in the Memory Care building not meeting Title 22 regulations. No other deficiencies were cited during this inspection.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Water temperature did not meet Title 22 regulations between 105 F to 120 F in the Memory Care building. | Type A |
Report Facts
Deficiency due date: Aug 27, 2021
Capacity: 137
Census: 88
PPE supply duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Krieger | Administrator | Met with Licensing Program Analyst during inspection and named in exit interview |
| Jill Tucker | Executive Director | Met with Licensing Program Analyst during inspection |
| Jamie Pyles | Health Service Director | Met with Licensing Program Analyst during inspection |
| Don Senaha | Licensing Program Analyst | Conducted the inspection |
| Eva M Alvarez | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 137
Deficiencies: 0
Jul 20, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to an allegation that resident care needs were not being met.
Findings
The investigation included interviews with residents, staff, and facility directors, as well as records and plant inspections. The Licensing Program Analyst found no evidence to support the allegation, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged that resident care needs were not being met. After investigation, including interviews and records review, the allegation was found to be unsubstantiated.
Report Facts
Capacity: 137
Census: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Don Senaha | Licensing Program Analyst | Conducted the complaint investigation and visits |
| Ana Cardona | Business Office Director | Interviewed during the investigation and exit interview |
| Jamie Pyles | Health Services Director | Interviewed during the complaint investigation |
| Michael Krieger | Administrator | Participated in facetime tele-visit during investigation |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 137
Deficiencies: 0
May 11, 2021
Visit Reason
An unannounced complaint investigation was conducted following allegations received on 2021-02-08 regarding staff hitting residents, residents sustaining injuries while in care, improper medication administration, and failure to ensure residents receive their meals.
Findings
The investigation included interviews with residents, staff, and a witness, as well as review of records and a plant inspection. No evidence was found to substantiate the allegations; medication administration and meal service were found to be compliant, and no staff abuse or resident injury issues were confirmed.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff hitting residents, residents sustaining injuries, improper medication administration, and failure to ensure residents receive meals. Interviews and record reviews found no evidence to support these allegations.
Report Facts
Capacity: 137
Census: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Krieger | Administrator | Met with during investigation and exit interview |
| Don Senaha | Licensing Program Analyst | Conducted complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Conducted subsequent visit to deliver complaint findings |
Inspection Report
Census: 77
Capacity: 137
Deficiencies: 0
May 5, 2021
Visit Reason
The visit was a Case Management - Incident visit conducted virtually due to COVID-19, to gather information regarding unwitnessed falls of a resident on 04/24/2021 and 04/29/2021.
Findings
No deficiencies were found during the visit. Additional information was requested including the resident's physician report, needs and service plan, progress notes, prescription order chart, current medications/treatments, and fall risk plan.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Krieger | Administrator | Met during the visit and participated in the telephonic exit interview. |
| Jamie Pyles | Health Services Director | Provided incident reports and was interviewed during the visit. |
| Don Senaha | Licensing Program Analyst | Conducted the Case Management visit. |
Inspection Report
Census: 79
Capacity: 137
Deficiencies: 0
Nov 13, 2020
Visit Reason
The visit was an unannounced Case Management - Incident report conducted telephonically due to COVID-19 mitigation measures.
Findings
The Licensing Program Analyst was unable to tour the area under construction due to internet issues but reviewed videos showing construction areas safely masked off to prevent resident access. Drywall replacement was underway in the laundry room, break room, and three resident rooms, with affected residents relocated to the second floor.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Don Senaha | Licensing Program Analyst | Initiated the unannounced Case Management - Incident report and conducted the telephonic visit. |
| Matthew Robison | Facility representative who participated in the telephonic visit and provided videos of the construction area. | |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Loading inspection reports...
