Inspection Report Summary
Most inspections found no deficiencies, and many complaint investigations were unsubstantiated, indicating generally consistent compliance with regulations. The most recent report from October 24, 2025, cited one minor deficiency related to staff writing medication start dates on prescription labels, which posed a potential health and safety risk. Earlier reports included some more serious issues, such as a civil penalty issued in October 2024 for repeated violations involving medication assistance, care planning, and food handler certifications, as well as a substantiated complaint in May 2025 for failing to provide adequate dental care support to a resident. Several investigations found immediate health and safety risks related to staffing levels and timely medical attention, but these were isolated and did not result in license suspensions or fines beyond the one civil penalty. Overall, the facility’s recent inspections show some improvement, with fewer deficiencies noted in the latest annual review compared to prior years.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 91
Capacity: 125
Deficiencies: 1
Oct 24, 2025
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing requirements for the facility.
Findings
The facility was generally compliant with licensing requirements, with pathways clear, equipment and furnishings in working order, and proper storage of medications and supplies. One deficiency was cited related to facility staff writing the start date of medications on prescription labels, which posed a potential health and safety risk.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff were writing the start date of residents' medications on the prescription label, which posed a potential health and safety risk. | Type B |
Report Facts
Capacity: 125
Census: 91
Deficiencies cited: 1
Plan of Correction Due Date: Nov 21, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Gonzalez | Assistant Administrator | Met with Licensing Program Analyst during inspection and exit interview |
| Hannah Rodgers | Licensing Program Analyst | Conducted the inspection and signed the report |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 125
Deficiencies: 0
Jul 8, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that staff were not providing adequate care and supervision of a resident.
Findings
The investigation included staff and resident interviews and record review. All interviewed staff and residents stated that adequate care and supervision were provided. The allegation was deemed unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint alleged inadequate care and supervision by staff. The allegation was found to be unsubstantiated based on the investigation.
Report Facts
Staff interviewed: 5
Residents interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Rico | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Sonia Hernandez | Assisted Living Coordinator | Met with investigator and received the report |
| Aharon Striks | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 125
Deficiencies: 0
May 29, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations of staff neglect resulting in a resident hospitalization and staff over medicating a resident.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff neglect causing hospitalization and over medication claims were unsubstantiated based on interviews, medical record reviews, and medication administration records.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff neglect resulting in hospitalization and staff over medicating a resident. Interviews with residents and staff, as well as medical record reviews, did not support the allegations.
Report Facts
Capacity: 125
Census: 90
Number of residents interviewed: 7
Number of staff interviewed: 6
Number of Medication Technicians interviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melody Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Mary Gonzalez | Assistant Administrator | Met with Licensing Program Analyst during investigation |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 90
Capacity: 125
Deficiencies: 1
May 29, 2025
Visit Reason
The inspection visit was conducted to initiate a case management deficiency investigation regarding discrepancies in the reporting and delayed medical attention following a fall incident involving Resident #1.
Findings
The investigation found discrepancies in the dates of Resident #1's fall and a delay in seeking medical attention after the fall, which posed an immediate health, safety, and personal rights risk to the resident. A Type A deficiency was issued for failure to ensure immediate medical attention.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel did not ensure immediate medical attention for Resident #1 after a fall, posing immediate health, safety, and personal rights risk. | Type A |
Report Facts
Capacity: 125
Census: 90
Plan of Correction Due Date: May 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Gonzalez | Assistant Administrator | Met with Licensing Program Analyst during inspection and informed of deficiency |
| Melody Brown | Licensing Program Analyst | Conducted the inspection and investigation |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 125
Deficiencies: 2
May 20, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-02-13 regarding staff not reappraising a resident as necessary and insufficient staffing to meet resident needs.
Findings
The investigation found that Resident #1 sustained an ankle fracture and subsequent fall, but there was insufficient evidence to substantiate that staff neglect caused the resident's death. The allegations that staff did not reappraise the resident as necessary and that the facility lacked sufficient staff were both unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was triggered by allegations that staff did not reappraise a resident as necessary and that the facility did not have enough staff to meet resident needs. The investigation included file reviews and interviews and concluded the allegations were unsubstantiated due to insufficient evidence to prove violations.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Observation of the Resident - The licensee failed to ensure residents were regularly observed for changes in physical, mental, emotional, and social functioning, posing immediate health and safety risks. | Type A |
| Personnel Requirements - Facility personnel were not sufficient in numbers and competence to meet resident needs, posing immediate health and safety risks. | Type A |
Report Facts
Capacity: 125
Census: 89
Deficiencies cited: 2
Plan of Correction Due Date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melody Brown | Licensing Program Analyst | Conducted the complaint investigation and met with Assistant Administrator to discuss findings |
| Mary Gonzalez | Assistant Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Aharon Striks | Administrator | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 125
Deficiencies: 1
May 20, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not ensure that a resident received medical and dental services.
Findings
The investigation found that a resident (R1) had not received dental care since moving into the facility in 2017 due to lack of assistance and a plan to encourage routine dental care. The allegation was substantiated based on interviews, record reviews, and evidence that R1's mental health condition impaired self-advocacy and the facility failed to provide adequate support for dental care.
Complaint Details
The complaint was substantiated. The allegation that staff did not ensure a resident received medical and dental services was validated by evidence including interviews with the resident, public guardian, staff, and record reviews.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop and implement a plan for incidental medical and dental care that encourages routine dental care and provides assistance appropriate to the resident's needs. | Type B |
Report Facts
Census: 89
Total Capacity: 125
Plan of Correction Due Date: May 27, 2025
Resident's first dental appointment date: Jan 23, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melody Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Mary Gonzalez | Assistant Administrator | Facility representative met during investigation and exit interview |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 90
Capacity: 125
Deficiencies: 7
Oct 29, 2024
Visit Reason
The inspection was an unannounced required comprehensive annual inspection conducted to evaluate the facility's compliance with regulations.
Findings
The facility was found to have multiple deficiencies including lack of physician orders for half bed rails for two residents, expired food handler certifications for two kitchen staff, incomplete resident medical and care plans, and failure to assist residents with medications as required. A civil penalty was issued for repeated violations within 12 months.
Severity Breakdown
Type A: 2
Type B: 5
Deficiencies (7)
| Description | Severity |
|---|---|
| Staff did not assist Resident #1 and Resident #4 with their medications as ordered. | Type A |
| Resident #2 Physician Report was incomplete, missing required physician signature date. | Type A |
| Two kitchen staff (Staff #6 and Staff #7) had expired food handler certifications. | Type B |
| Resident #3 did not have a completed Pre-Admission Appraisal. | Type B |
| Residents #1, #2, and #5 did not have required Preplacement Needs and Services Plan/Care Plan. | Type B |
| Resident #5 Admission Agreement was not signed by Licensee/Administrator/Designee. | Type B |
| Residents #5 and #6 had half bed rails without written physician orders indicating need for mobility assistance. | Type B |
Report Facts
Civil penalty amount: 1000
Number of residents present: 90
Total licensed capacity: 125
Number of kitchen staff with expired certification: 2
Number of residents with missing care plans: 3
Number of residents with half bed rails without physician orders: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Gonzalez | Assistant Administrator | Met with Licensing Program Analyst during inspection and discussed findings |
| Melody Brown | Licensing Program Analyst | Conducted the inspection and authored the report |
| Efren Malagon | Licensing Program Manager | Supervisor of Licensing Program Analyst and named in report |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 125
Deficiencies: 0
Oct 21, 2024
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging staff financial abuse of residents in care.
Findings
The investigation found the allegation of financial abuse to be unsubstantiated after interviews with residents and review of evidence. No deficiencies were cited during the visit.
Complaint Details
The complaint alleged staff were financially abusing residents. Interviews with 5 residents, including Resident #1, denied any financial abuse or staff managing their finances. The allegation was found unsubstantiated.
Report Facts
Residents interviewed denying abuse: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beena Singh | Licensing Program Analyst | Conducted the complaint investigation and found the allegation unsubstantiated |
| Paola Guerrero | Licensing Program Analyst | Assisted in conducting the unannounced visit for the complaint investigation |
| Maria Gonzalez | Administrator Assistant | Met with investigators during the visit and received the exit interview |
| Aharon Striks | Administrator | Facility administrator named in the report |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 125
Deficiencies: 1
Sep 22, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted on 09/22/2024 following a complaint received on 11/22/2023 alleging hazards on facility grounds, inadequate supervision resulting in injury, untimely assistance to residents, and medication administration issues.
Findings
The investigation found the first three allegations regarding hazards on facility grounds, supervision, and timely assistance to be unsubstantiated based on interviews and observations. However, the allegation that staff did not ensure residents were administered medications as prescribed was substantiated, with evidence of multiple missed medications and incomplete medication records for Resident #1.
Complaint Details
The complaint investigation was triggered by allegations that the licensee did not ensure facility grounds were free from hazards, staff did not adequately supervise residents resulting in injury, staff did not provide timely assistance, and staff did not ensure residents were administered medications as prescribed. The first three allegations were unsubstantiated, while the medication administration allegation was substantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87465 Incidental Medical and Dental Care (a)(4) - Licensee failed to assist residents with self-administered medications as prescribed, evidenced by multiple missed medications and incomplete medication administration records for Resident #1. | Type A |
Report Facts
Census: 84
Total Capacity: 125
Deficiencies cited: 1
Civil penalty amount: 250
Daily penalty amount: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melody Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Mary Gonzalez | Assistant Administrator | Facility representative met during investigation and exit interview |
| Marco Navarro | Medical Technician/Caregiver | Met during investigation and exit interview |
| Aharon Striks | Administrator | Facility administrator named in report |
| Staff #8 | Witnessed resident fall and assisted in care on 09/08/2023 | |
| Staff #9 | Assisted Staff #8 with resident care and called paramedics on 09/08/2023 | |
| Staff #1 | Reported on medication administration issues and provided MAR documentation | |
| Staff #3 | Reported concerns about medication record entries |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 125
Deficiencies: 0
Aug 6, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 02/23/2021 regarding a resident fall due to hallway obstructions, inappropriate meal assistance, and staff using inappropriate language with residents.
Findings
The investigation included interviews with staff and residents and review of documents. The allegations were found to be unsubstantiated due to insufficient preponderance of evidence to prove the violations occurred. The facility had taken steps such as in-service training and communication improvements related to meal service.
Complaint Details
The complaint alleged that a resident sustained a fall due to obstructions in the hallway, staff did not appropriately assist residents with meals, and staff used inappropriate language with residents. The investigation found no substantiation for these allegations.
Report Facts
Staff interviewed: 8
Residents interviewed: 10
Complaint received date: Feb 23, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yolanda Delgado | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Aharon Striks | Administrator | Facility administrator involved in discussion with resident regarding meal assistance allegation |
| Mary Gonzalez | Person met with during the investigation | |
| Jazmond D Harris | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 125
Deficiencies: 0
Apr 15, 2024
Visit Reason
The inspection was an unannounced visit to investigate a complaint alleging that staff spoke to residents in an inappropriate manner.
Findings
The investigation found that residents denied any inappropriate manner of staff communication, and staff also denied yelling at residents. The allegation was deemed unsubstantiated, and no deficiencies were cited.
Complaint Details
The complaint alleged that staff spoke to residents in an inappropriate manner. After interviews with residents and staff, the allegation was found unsubstantiated due to lack of evidence.
Report Facts
Capacity: 125
Census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Gardner | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Maria Gonzales | Administrator Assistant | Met with the Licensing Program Analyst during the investigation and received the report |
Inspection Report
Follow-Up
Census: 87
Capacity: 125
Deficiencies: 1
Apr 15, 2024
Visit Reason
The visit was an unannounced follow-up case management inspection to review a self-reported incident regarding Resident R1 that occurred on 12/29/2023.
Findings
The investigation found that Resident R1 was not given their medication from 12/28/2023 around 1 PM to 12/29/2023 around 2 PM despite thirteen attempts by staff to contact R1. The facility failed to ensure R1 was assisted with medication during this time, resulting in one deficiency cited under Title 22, Division 6 of the California Code of Regulations.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assist Resident R1 with self-administered medication as required, posing an immediate health, safety, or personal rights risk. | Type A |
Report Facts
Deficiencies cited: 1
Attempts to contact resident: 13
Capacity: 125
Census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Gardner | Licensing Program Analyst | Conducted the inspection and investigation |
| Maria Gonzalez | Administrator Assistant | Met with Licensing Program Analyst during inspection and discussed findings |
| Efren Malagon | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Follow-Up
Census: 88
Capacity: 125
Deficiencies: 0
Jan 10, 2024
Visit Reason
The visit was conducted as an unannounced case management follow-up on a self-reported incident involving Resident R1 that occurred on 2023-12-29.
Findings
During the visit, staff were interviewed and documents related to the incident were reviewed. No deficiencies or citations were issued.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Gardner | Licensing Program Analyst | Conducted the unannounced case management visit and investigation. |
| Maria Gonzales | Administrator Assistant | Met with Licensing Program Analyst during the visit and received the report. |
| Efren Malagon | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Annual Inspection
Census: 87
Capacity: 125
Deficiencies: 0
Oct 25, 2023
Visit Reason
The visit was an unannounced required comprehensive annual inspection of the Residential Care Facility for Elderly (RCFE).
Findings
The facility was found to be operating within approved capacity and in safe, clean, and good repair conditions. No deficiencies were cited during the inspection, and all regulatory requirements including physical plant, food service, care and supervision, and record reviews were satisfactorily met.
Report Facts
Resident files reviewed: 6
Staff files reviewed: 6
Water temperature: 119.9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paola Guerrero | Licensing Program Analyst | Conducted the inspection and authored the report |
| Mary Gonzalez | Assistant Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Aharon Striks | Administrator | Facility administrator named in the report |
| Efren Malagon | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 125
Deficiencies: 1
Oct 16, 2023
Visit Reason
This was an unannounced complaint investigation visit triggered by a complaint alleging that a resident's restroom does not accommodate wheelchair access.
Findings
The investigation substantiated the complaint that Resident R1's bedroom bathroom door was too small to allow access, preventing R1 from using the bathroom in their bedroom. The facility failed to provide a bedroom with adequate bathroom access, instead providing a portable commode outside the bathroom door, which did not meet R1's basic bathroom needs. One deficiency was cited related to insufficient accommodations for the resident's bathroom needs.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation. The allegation that the resident's restroom does not accommodate wheelchair access was found valid.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide a bedroom with accommodations for Resident R1's basic bathroom needs, including sufficient room to accommodate wheelchair access. | Type B |
Report Facts
Deficiencies cited: 1
Plan of Correction due date: Oct 17, 2023
Facility capacity: 125
Facility census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Gardner | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Maria Gonzalez | Administrator Assistant | Met with Licensing Program Analyst during the investigation and received the report. |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 125
Deficiencies: 0
Jul 18, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2023-03-27 regarding staff safeguarding residents' personal items, funds, medication management, dignity and respect, facility conditions, illegal eviction, and retaliation against residents for complaining.
Findings
The investigation included a facility tour, document review, and interviews with staff and residents. All allegations were found to be unsubstantiated due to insufficient evidence. Residents and staff denied the allegations, and no deficiencies were cited during the visit.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not safeguarding residents' personal items and funds, mismanaging medication, disrespecting residents, improper facility conditions, illegal eviction, and retaliation. Interviews and document reviews did not support these claims.
Report Facts
Capacity: 125
Census: 89
Complaint received date: Mar 27, 2023
Visit start time: 1200
Visit end time: 1305
Eviction notice date: Feb 23, 2023
Pest control treatment dates: Array
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Gardner | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Efren Malagon | Licensing Program Manager | Oversaw the complaint investigation |
| Maria Gonzalez | Administrator Assistant | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Aharon Striks | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 125
Deficiencies: 0
May 15, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff failed to supervise residents, did not safeguard residents' personal property, and did not treat residents with dignity or respect.
Findings
The investigation found that the allegations were unsubstantiated. Interviews with residents and staff revealed disputes between two residents but no evidence of staff neglect or mistreatment. No deficiencies were cited during the visit.
Complaint Details
The complaint involved allegations of staff failing to supervise residents, not safeguarding personal property, and not treating residents with dignity or respect. The investigation found no preponderance of evidence to substantiate these allegations.
Report Facts
Capacity: 125
Census: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Gardner | Licensing Program Analyst | Conducted the complaint investigation |
| Efren Malagon | Licensing Program Manager | Oversaw the complaint investigation |
| Maria Gonzalez | Administrator Assistant | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 125
Deficiencies: 0
Feb 15, 2023
Visit Reason
This unannounced visit was conducted to investigate a complaint received on 2021-05-06 alleging that staff did not treat a resident with dignity and respect and that staff stole the resident's personal items.
Findings
The investigation included resident and staff interviews and found that the resident manages their own medical and medication needs with a personal lock on their door. Residents and staff denied observing or knowing about staff stealing or treating residents without dignity. The complaint allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
Complaint allegations were unsubstantiated. Evidence did not support or refute the allegations of staff stealing or treating residents without dignity.
Report Facts
Capacity: 125
Census: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Goldenberg | Licensing Program Analyst | Conducted the complaint investigation |
| Aharon Striks | Administrator | Facility administrator named in the report |
| Mary Gonzales | Administrator | Met with during the investigation |
| Nedra Brown | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 125
Deficiencies: 0
Feb 15, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate an allegation that staff handled a resident in a rough manner.
Findings
The investigation included interviews with residents and staff and found no evidence to support the allegation. The complaint was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff member S1 scratched the bottom of resident C1 during personal care. Five residents and four staff interviewed denied any rough handling. The complaint was found unsubstantiated.
Report Facts
Capacity: 125
Census: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Goldenberg | Licensing Program Analyst | Conducted the complaint investigation |
| Mary Gonzales | Administrator | Facility representative met during the investigation |
| Aharon Striks | Administrator | Named as facility administrator |
| Nedra Brown | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 125
Deficiencies: 0
Feb 2, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2023-01-30 regarding staff treatment of residents, expired food, special diet adherence, and neglect of resident care needs.
Findings
The investigation found no evidence to substantiate any of the four allegations. The staff were found to treat residents with dignity and respect, no expired food was observed, special diet requirements were appropriately managed, and resident care needs were met. No deficiencies were cited during the visit.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was insufficient evidence to prove the alleged violations occurred.
Report Facts
Capacity: 125
Census: 95
Number of allegations: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Gardner | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Efren Malagon | Licensing Program Manager | Oversaw the complaint investigation |
| Maria Gonzalez | Administrator Assistant | Facility representative met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 125
Deficiencies: 0
Feb 2, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff assaulted a resident in care during a facility party.
Findings
The investigation found no evidence to substantiate the allegation of staff assaulting a resident. No deficiencies were cited during the visit.
Complaint Details
The complaint alleged that a staff member assaulted a resident during a facility party. The allegation was deemed unsubstantiated due to lack of evidence.
Report Facts
Capacity: 125
Census: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Gardner | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 125
Deficiencies: 0
Jan 9, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility did not seek medical attention for a resident, did not meet residents' medical needs, did not provide toiletries, and did not ensure residents were fed.
Findings
The investigation included interviews with residents, staff, and an outside party, and a review of documents. The findings were unsubstantiated as there was no preponderance of evidence to prove the alleged violations occurred. Residents reported that medical appointments were not denied but sometimes rescheduled due to transportation availability, hygiene items were provided, and three meals plus snacks were served daily.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to seek medical attention, unmet medical needs, lack of toiletries, and failure to feed residents. Interviews and document reviews did not support these allegations.
Report Facts
Facility capacity: 125
Census: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Mary Gonzalez | Facility representative met during the investigation |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 125
Deficiencies: 0
Jan 6, 2023
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging inadequate supervision and staff scolding of a resident.
Findings
The investigation found that the resident involved was no longer under the facility's care at the time of the alleged incidents, and therefore the allegations were deemed unfounded. No deficiencies were cited during the visit.
Complaint Details
The complaint alleged that staff did not provide adequate supervision to a resident and that staff scolded a resident while in care. The allegations were investigated and found to be unfounded.
Report Facts
Capacity: 125
Census: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Gardner | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Efren Malagon | Licensing Program Manager | Named in report as Licensing Program Manager |
| Maria Gonzalez | Administrator Assistant | Met with Licensing Program Analyst during the investigation |
Inspection Report
Annual Inspection
Census: 125
Capacity: 125
Deficiencies: 0
Aug 31, 2022
Visit Reason
The visit was conducted as a required annual inspection with an emphasis on infection control due to the COVID-19 pandemic.
Findings
The facility was found to have adequate infection control measures, including sufficient PPE supplies and hand hygiene provisions. No deficiencies were cited during the inspection.
Inspection Report
Complaint Investigation
Census: 97
Capacity: 125
Deficiencies: 1
Aug 16, 2022
Visit Reason
An unannounced visit was conducted to investigate complaint control #56-AS-20220809145821 regarding potential safety issues at the facility.
Findings
The inspection found that cleaning supplies were accessible to residents in care due to an unlocked shower room and an unlocked cabinet, posing an immediate health and safety risk.
Complaint Details
The visit was complaint-related, investigating complaint control #56-AS-20220809145821. The deficiency was substantiated as the cleaning supplies were accessible to residents, posing immediate health and safety risks.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Cleaning supplies were not stored in a locked or inaccessible area, posing immediate health and safety risks to residents. | Type A |
Report Facts
Capacity: 125
Census: 97
Deficiencies cited: 1
Plan of Correction Due Date: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Gonzales | Administrator | Met with Licensing Program Analysts during inspection |
| Bernadette Allen | Licensing Program Analyst | Conducted inspection and issued deficiency |
| Melody Brown | Licensing Program Analyst | Conducted inspection and issued deficiency |
| Karen Clemons | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing inspection |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 125
Deficiencies: 1
Jul 21, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to a complaint received on 07/13/2022 regarding inadequate room temperatures due to air conditioning issues.
Findings
The investigation found that the air conditioning was working but set too low, causing some residents to feel cold and request extra blankets or portable fans. Multiple thermostats were observed set between 73 and 76 degrees Fahrenheit, which is below the required comfortable temperature range.
Complaint Details
The complaint alleging inadequate room temperatures due to air conditioning was substantiated based on interviews and observations.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Maintenance and Operation: A comfortable temperature for residents shall be maintained at all times. The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement was not met as thermostats were set between 73 and 76 degrees F, posing a potential risk to residents. | Type B |
Report Facts
Capacity: 125
Census: 97
Deficiencies cited: 1
Plan of Correction due date: Jul 28, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Semin | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Mary Gonzales | Assistant Administrator | Met with Licensing Program Analyst during investigation |
| Efren Malagon | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 125
Deficiencies: 0
Jun 30, 2022
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility had bed bugs.
Findings
The investigation included a tour of the facility, interviews with staff and residents, and review of documents. No bed bugs were observed during the tour or reported by staff or residents. The allegation was determined to be unsubstantiated due to lack of evidence.
Complaint Details
The complaint alleged the presence of bed bugs in the facility. The investigation found no evidence to substantiate this allegation.
Report Facts
Capacity: 125
Census: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Gonzalez | Administrator | Met with Licensing Program Analyst during the investigation |
| Rayshaun Nickolas | Licensing Program Analyst | Conducted the complaint investigation |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 125
Deficiencies: 0
Feb 23, 2022
Visit Reason
An unannounced case management visit was conducted in conjunction with complaint control number 18-AS-20210903094757 to evaluate the facility's compliance and address the complaint.
Findings
No deficiencies were cited during this visit. The Licensing Program Analyst interviewed residents, care staff, and kitchen staff, and discussed the visit with the assistant administrator.
Complaint Details
Visit was conducted in conjunction with complaint control number 18-AS-20210903094757. No deficiencies were cited, indicating no substantiated issues during this investigation.
Report Facts
Capacity: 125
Census: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Gonzalez | Assistant Administrator | Met with Licensing Program Analyst during the visit |
| Jennifer Semin | Licensing Program Analyst | Conducted the unannounced case management visit |
| Karen Clemons | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 125
Deficiencies: 0
Dec 7, 2021
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2021-09-03 regarding allegations that staff refused to help a resident seek medical help and that a resident's hygiene needs were not being met.
Findings
The investigation included interviews with staff and relevant parties. Staff stated they made all necessary post-surgery appointments and followed discharge instructions, including hygiene care. The resident stated appointments were not timely and hygiene orders were not followed immediately. Documentation showed daily sponge baths were provided per doctor's orders. There was insufficient evidence to substantiate the allegations, so they were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on interviews and documentation; there was no preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 125
Census: 111
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Semin | Licensing Program Analyst | Conducted the complaint investigation visit |
| Mary Gonzalez | Assistant Administrator | Met with Licensing Program Analyst during the investigation |
| Aharon Striks | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 125
Deficiencies: 0
Dec 7, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that a resident was being overmedicated while in care.
Findings
The investigation found that all residents, including the named resident, were given medication according to the physician's orders. Although the allegation may have some validity, there was insufficient evidence to prove a violation, and the complaint was unsubstantiated.
Complaint Details
The complaint alleged that a resident was being overmedicated. The investigation included interviews with staff and relevant parties. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 125
Census: 111
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Semin | Licensing Program Analyst | Conducted the complaint investigation visit |
| Mary Gonzalez | Assistant Administrator | Met with the investigator during the visit |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 125
Deficiencies: 0
Sep 22, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff threatened a resident.
Findings
The investigation included interviews with staff, residents, and the complainant. Staff denied threatening residents, and other residents reported no threats. The complainant felt staff made threats and used a condescending tone. There was insufficient evidence to substantiate the allegation, so it was deemed unsubstantiated.
Complaint Details
The complaint alleged that staff threatened a resident. The investigation found no preponderance of evidence to prove or disprove the allegation, resulting in an unsubstantiated finding.
Report Facts
Capacity: 125
Census: 103
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Semin | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Mary Gonzales | Assistant Administrator | Met with Licensing Program Analyst during investigation |
| Aharon Striks | Administrator | Named as facility administrator |
Inspection Report
Annual Inspection
Census: 91
Capacity: 125
Deficiencies: 0
Aug 24, 2021
Visit Reason
The visit was an unannounced required annual inspection with an emphasis on infection control due to the COVID-19 pandemic.
Findings
The inspection found that the facility had sufficient infection control measures in place, including adequate PPE supplies, hand hygiene, cleaning provisions, and trained staff. No deficiencies were cited during the inspection.
Report Facts
PPE supply duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Goldenberg | Licensing Program Analyst | Conducted the inspection and made observations |
| Mary Gonzales | Assistant Administrator | Facility representative met during inspection |
| Aharon Striks | Administrator | Named as facility administrator |
| Nedra Brown | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 125
Deficiencies: 0
Jun 29, 2021
Visit Reason
The inspection was an unannounced visit to investigate a complaint alleging that staff were administering unauthorized medications to a resident.
Findings
The complaint allegation was found to be unsubstantiated after interviews with residents and staff, and review of records. There was no preponderance of evidence to prove the alleged violation occurred.
Complaint Details
The complaint alleged that on 6/1/2021 a staff member put something green in the eggs of a resident. Interviews with eight residents and three staff members did not support the allegation. The complaint was determined to be unsubstantiated.
Report Facts
Capacity: 125
Census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Goldenberg | Licensing Program Analyst | Conducted the complaint investigation |
| Mary Gonzales | Assistant Administrator | Met with the Licensing Program Analyst during the investigation |
| Nedra Brown | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 125
Deficiencies: 0
Jun 18, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations including inadequate staffing, poor food quality, improper incontinence care, presence of roaches, improper trash disposal, lack of enforcement of community rules, and facility cleanliness.
Findings
The investigation found no substantiated evidence supporting the allegations. Observations and interviews indicated that residents' incontinent care needs were met, food was properly stored and not expired, the facility was clean and free of vermin, trash was properly disposed of, and community rules were enforced with appropriate measures.
Complaint Details
The complaint investigation was unsubstantiated. Despite multiple allegations, there was no preponderance of evidence to prove violations occurred. The report notes that some allegations may have happened or be valid, but were not substantiated by the investigation.
Report Facts
Residents interviewed: 6
Residents receiving incontinent care: 4
Food orders per week: 3
Inspection start time: 930
Inspection end time: 1500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Goldenberg | Licensing Program Analyst | Conducted the complaint investigation |
| Nedra Brown | Licensing Program Manager | Named in report as Licensing Program Manager |
| Aharon Striks | Administrator | Facility administrator involved in discussion of allegations |
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