Most inspections found deficiencies related primarily to staff training and medication administration, food safety, and timely resident refunds, with several complaint investigations unsubstantiated. The most recent report from July 29, 2025, substantiated that an unqualified adult assisted residents with medications without current training or proper criminal clearance, resulting in two deficiencies. Earlier reports cited issues such as hot water temperature exceeding limits, lack of first aid training among staff, improper food storage posing health risks, and a delayed refund to a resident, but no fines or license actions were listed in the available reports. Several complaint investigations, including allegations of staff substance use and inadequate food service, were unsubstantiated. The facility’s record shows ongoing attention to compliance, with some improvements noted when the most recent report confirmed medication administration issues but no new broader safety violations.
The inspection was an unannounced complaint investigation triggered by allegations including an unqualified adult providing residents' medications and staff not providing resident's medication as prescribed.
Findings
The investigation substantiated the allegation that an unqualified adult (staff S3) assisted residents with medications without current required medication training and proper criminal record clearance. Another allegation regarding staff not providing medication as prescribed was unsubstantiated due to lack of evidence.
Complaint Details
The complaint investigation was substantiated for the allegation that an unqualified adult provided residents' medications, with evidence showing lack of current medication training and criminal record clearance for staff S3. The allegation that staff did not provide resident's medication as prescribed was unsubstantiated due to insufficient evidence.
Severity Breakdown
Type A: 2
Deficiencies (2)
Description
Severity
Employees assisting residents with self-administration of medication did not meet training requirements; staff S3 last completed required medication training on 11/11/2023 and 11/12/2023, which is out of compliance.
Type A
Criminal record clearance requirements were not met; staff S3 was not associated with the facility and had separated fingerprint clearance from related agencies, violating regulation 87355(e)(2)(3).
Type A
Report Facts
Facility capacity: 75Medication training hours: 24Medication training last completed: Nov 12, 2023Plan of Correction due date: Jul 30, 2025
Employees Mentioned
Name
Title
Context
Kelly Ording
Administrator
Met with Licensing Program Analyst during investigation and provided information about staff S3
Dina Alviso
Licensing Program Analyst
Conducted the complaint investigation
Tamra Richmond
Business Office Manager
Met with Licensing Program Analyst during investigation
Bethany Moellers
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
The inspection was an annual required unannounced visit conducted to evaluate compliance with licensing regulations and facility operations.
Findings
The facility was generally compliant with regulations including infection control, emergency plans, medication storage, and resident activities. One deficiency was cited for hot water temperature exceeding the regulatory maximum.
Deficiencies (1)
Description
Hot water temperature at a resident bathroom sink was 122.9 degrees Fahrenheit, exceeding the regulatory maximum of 120 degrees Fahrenheit.
Report Facts
Hot water temperature: 122.9Deficiency citation: 1Hospice waiver capacity: 10
Employees Mentioned
Name
Title
Context
Jose Acumabig
Administrator
Named as facility administrator, not present during inspection
Tamra Richmond
Business Office Manager
Met with Licensing Program Analyst during inspection and exit interview
Shaianne Chantavong
Activity Director
Met with Licensing Program Analyst to review activity calendars
The inspection was a continued annual inspection conducted on 02/13/2024 as part of the annual visit started on 01/24/2024, to evaluate compliance with regulatory requirements including infection control, emergency plans, and staff training.
Findings
The facility was found to have required infection control and emergency plans, sufficient supplies, and complete resident and staff files. However, six out of eight direct care staff lacked required first aid training, resulting in a cited deficiency.
Deficiencies (1)
Description
Six (6) out of eight (8) direct care staff did not have first aid training as required by Personnel Requirements - General Section 87411(c)(1).
Report Facts
Staff without first aid training: 6Total direct care staff: 8Facility capacity: 45Hospice waiver limit: 10Fire clearance capacity: 75
Employees Mentioned
Name
Title
Context
Jose Acumabig
Administrator
Named as facility administrator; was not available to meet with Licensing Program Analyst.
Tamra Richmond
Business Office Manager
Met with Licensing Program Analyst during inspection.
The inspection was a Required - 1 Year unannounced routine visit to evaluate the facility's compliance and operations.
Findings
The facility was found to have a required infection control plan, renovated resident units except two vacant ones, and properly serviced fire extinguishers. The facility applied for and was approved to increase capacity from 45 to 75 residents. No deficiencies were cited during this inspection.
Report Facts
Capacity increase approval: 75
Employees Mentioned
Name
Title
Context
Jose Acumabig
Administrator
Met with Licensing Program Analyst during inspection and participated in exit interview
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2023-07-28 alleging that staff were consuming alcohol and marijuana during their shifts.
Findings
The investigation found no evidence to substantiate the allegation. Staff interviews and record reviews did not support that any staff consumed alcohol or marijuana while on shift. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleging staff consumption of alcohol and marijuana during shifts was investigated and found unsubstantiated due to insufficient evidence.
Report Facts
Facility capacity: 45
Employees Mentioned
Name
Title
Context
Jose Acumabig
Administrator
Met with during the investigation and named in the report
The inspection was a required 1-Year unannounced visit focused on infection control procedures and practices at the facility.
Findings
The facility was found to have appropriate infection control screening and PPE use, but deficiencies were cited related to improper food storage in the kitchen, posing an immediate health and safety risk. The Administrator agreed with the findings and began corrective actions during the inspection.
Deficiencies (1)
Description
Improper storage of fruit, mayonnaise, open box of beans, and open bags of rice in the kitchen, risking contamination and posing an immediate health and safety risk.
Report Facts
Residents in care: 25Residents receiving hospice care: 1Hospice care waiver capacity: 10Facility capacity: 45Deficiency count: 1Plan of Correction due date: Jan 31, 2023Training proof submission due date: Feb 6, 2023
Employees Mentioned
Name
Title
Context
Jose Acumabig
Administrator
Met with Licensing Program Analyst during inspection and involved in addressing food storage deficiency
The inspection was conducted as a complaint investigation based on allegations that the facility was not following food service safety practices/procedures with food being served to residents and not preventing the spread of COVID-19 or following infection control procedures.
Findings
The allegation regarding food service safety practices was substantiated, with findings that food items were not kept at required temperatures, posing a health and safety risk to residents. The allegation regarding COVID-19 infection control procedures was unsubstantiated due to insufficient evidence. A deficiency citation was issued for the food service violation.
Complaint Details
The complaint investigation was substantiated for the allegation of improper food service safety practices. The allegation regarding failure to prevent the spread of COVID-19 and not following infection control procedures was unsubstantiated due to insufficient evidence.
Deficiencies (1)
Description
Facility is not following food service safety practices/procedures with food being served to residents; food items not kept at required cold or hot temperatures.
Report Facts
Capacity: 45Census: 25Deficiency citation: 1Plan of Correction Due Date: Oct 21, 2022
Employees Mentioned
Name
Title
Context
Jose Acumabig
Administrator
Met with Licensing Program Analyst during inspection and discussed findings
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2022-02-22 alleging the facility was not providing adequate food service.
Findings
The investigation revealed that the resident involved in the complaint was not part of the licensed assisted living facility but resided in an independent living unit, which is outside the Department's jurisdiction. Therefore, the allegation of inadequate food service was found to be unfounded.
Complaint Details
The complaint was regarding inadequate food service. The complaint was investigated and found to be unfounded because the resident was not part of the licensed assisted living facility but an independent living resident.
Report Facts
Facility capacity: 45Census: 23
Employees Mentioned
Name
Title
Context
Jose Acumabig
Administrator
Met with Licensing Program Analyst during complaint investigation
The inspection was a required 1 Year unannounced visit focused on infection control procedures and practices at the facility.
Findings
The facility was found to be in compliance with infection control and pandemic policies, with no deficiencies cited. All safety measures including visitor and staff screening, PPE supply, and fire safety equipment were observed to be adequate.
The inspection was an unannounced complaint investigation conducted in response to multiple allegations received on 09/03/2021 regarding resident acceptance after hospital discharge, illegal eviction, improper billing, and refund issues.
Findings
The investigation found the allegations that the resident was not accepted back after hospital discharge and received an illegal eviction to be unsubstantiated. The allegation of improper billing was unfounded. However, the allegation that a refund was owed to the resident/responsible party was substantiated, with a deficiency cited for failure to provide a timely refund as required by law.
Complaint Details
The complaint investigation addressed allegations including the resident not being accepted back after hospital discharge, illegal eviction, improper care fee billing, and due refund owed. The first two allegations were unsubstantiated, the billing allegation was unfounded, and the refund allegation was substantiated with a deficiency cited.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Failure to provide due refund to the resident/responsible party within the required timeframe as per Health & Safety Code 1569.652(c).
Type B
Report Facts
Capacity: 45Refund amount: 2332.38Additional refund amount: 494.76Plan of Correction due date: Oct 15, 2021
Employees Mentioned
Name
Title
Context
Dina Alviso
Licensing Program Analyst
Conducted complaint inspection and delivered findings
The inspection was a case management visit conducted to obtain more information on some resident incident reports submitted to the Licensing office.
Findings
The Licensing Program Analyst reviewed the incidents with the Health Services Director and obtained additional information and documentation. The incident reports had been reported as required, and no deficiencies were cited during this visit.
Employees Mentioned
Name
Title
Context
Steve Sarine
Administrator
Met with Licensing Program Analyst during case management inspection.
Emil DeGuzman
Health & Wellness Director
Provided additional information and documentation regarding resident incident reports.
The inspection was an unannounced Annual Required inspection focused on the Infection Control procedures and practices of the facility.
Findings
The facility was found to be clean, orderly, and compliant with infection control protocols including screening procedures, PPE availability, and safe medication storage. No deficiencies were found in the areas inspected.
Report Facts
Hospice waiver residents: 5Fire clearance capacity: 45Residents in care: 27
Employees Mentioned
Name
Title
Context
Steve Sarine
Administrator
Met with Licensing Program Analyst during inspection
Dina Alviso
Licensing Program Analyst
Conducted the inspection
Hope DeBenedetti
Licensing Program Manager
Named in report header
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