Inspection Report Summary
Most inspections of this facility found no deficiencies, including the most recent report dated September 18, 2025, which was perfect with no issues cited. Several complaint investigations were unsubstantiated, showing that many allegations did not have supporting evidence. However, some substantiated deficiencies have occurred, primarily related to medication management errors, inadequate supervision leading to resident assaults, failure to notify responsible parties of incidents, and occasional issues with resident rights and environment comfort. The facility has shown some improvement over time, with recent annual inspections clean and no new medication or safety deficiencies reported. Older reports included more serious findings such as a resident being stabbed, medication mismanagement, and lapses in supervision, but these have not recurred in the latest inspections.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 55
Capacity: 112
Deficiencies: 0
Sep 18, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff were inappropriately locking facility doors.
Findings
The investigation found no evidence that facility staff were inappropriately locking doors. Interviews and video review confirmed that doors were accessible to residents, and the allegation was unsubstantiated.
Complaint Details
The complaint alleged that staff were inappropriately locking facility doors. The allegation was found to be unsubstantiated based on interviews and video evidence.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Kathryn Nevin | Facility Designated Administrator | Met with Licensing Program Analyst during the investigation and provided information. |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 112
Deficiencies: 0
Sep 4, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that a resident felt pressured to sign a payment plan.
Findings
The investigation found that the resident was aware of their financial obligations and signed the payment plan despite concerns about their ability to pay. Interviews with involved parties indicated no evidence of coercion. The allegation was determined to be unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint alleged that a resident felt pressured to sign a payment plan. After investigation, including interviews with the resident, Executive Director, Business Office Manager, and Regional Director, the allegation was found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Amount owed by resident: 9743.02
Monthly base charge: 2695
Additional monthly payment: 300
Late fees waived: 1000
Facility capacity: 112
Facility census: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathryn Nevin | Executive Director | Met with Licensing Program Analyst and involved in payment plan meeting. |
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation. |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on report. |
Inspection Report
Annual Inspection
Census: 89
Capacity: 112
Deficiencies: 0
Jun 30, 2025
Visit Reason
Unannounced annual visit conducted on 06/30/2025 by Licensing Program Analyst Charlie Yang to evaluate compliance with licensing requirements at Country Club Manor facility.
Findings
The facility was toured including living areas, kitchen, medication room, bedrooms, restrooms, laundry, and exterior grounds. All areas and supplies were found to be sufficient, in good repair, and in compliance. No deficiencies were observed or cited during this annual visit.
Report Facts
Residents under hospice care: 3
Residents diagnosed with dementia: 37
Residents receiving home health agency services: 4
Bedridden residents under hospice care: 1
Facility capacity: 112
Current census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the inspection and interview with facility staff. |
| Kathryn Nevin | Facility Designated Administrator | Met during inspection; holds administrator certificate number 6077502740. |
| Jennie Tello | Business Office Manager | Briefly interviewed during the inspection. |
Inspection Report
Annual Inspection
Capacity: 6
Deficiencies: 0
Feb 18, 2025
Visit Reason
An unannounced required annual inspection was conducted to evaluate the facility's compliance and status during ongoing renovations.
Findings
The facility was unoccupied due to renovations, which were superficial and did not alter the structure. No deficiencies were issued during the inspection, and the facility had operating utilities and required furniture.
Report Facts
Licensed capacity: 6
Hospice waiver capacity: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janette Romero | Licensing Program Analyst | Conducted the inspection visit |
| Mirjana Bujosevic | Licensee / Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 112
Deficiencies: 3
Dec 6, 2024
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 08/05/2024 regarding multiple allegations including failure to notify responsible parties of incidents, lack of supervision leading to resident assaults, and failure to protect residents from physical attacks.
Findings
The investigation substantiated that the facility failed to notify the responsible party of an incident, did not provide adequate supervision resulting in multiple assaults between residents, and failed to implement an effective plan to protect residents from further attacks. One allegation regarding staff training on dementia care was found unsubstantiated.
Complaint Details
The complaint investigation was substantiated based on evidence that the facility failed to notify the responsible party of a stabbing incident, failed to provide adequate supervision resulting in multiple assaults, and failed to implement a protective plan. The responsible party was notified late by the Ombudsman, and the facility's Executive Director admitted to insufficient monitoring. The allegation that staff were not trained to care for residents with dementia was unsubstantiated.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility did not notify the responsible party of an incident involving a resident being stabbed with a fork. | Type B |
| Due to lack of supervision, a resident was assaulted multiple times by another resident while in care. | Type A |
| Facility did not put a plan in place to protect a resident from being physically attacked by another resident. | Type A |
Report Facts
Capacity: 112
Census: 63
Deficiency POC Due Date: Jan 6, 2025
Deficiency POC Due Date: Dec 7, 2024
Stop and Watch communications: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Josef Dunham | Executive Director | Interviewed regarding supervision and monitoring failures |
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephen Richardson | Licensing Program Manager | Oversaw the investigation and signed the report |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 112
Deficiencies: 2
Aug 2, 2024
Visit Reason
An unannounced case management visit was conducted following an incident where resident R2 stabbed resident R1 in the face with a fork during dinner on 07/24/24. The visit aimed to review incident reporting and compliance with regulations.
Findings
The facility failed to notify the responsible party and primary care physician of resident R1 despite documentation indicating otherwise, posing a potential threat to resident safety. Additionally, resident R2's annual reappraisal was overdue. Deficiencies were cited related to false claims in documentation and failure to conduct timely reappraisals.
Complaint Details
The visit was complaint-related due to an incident where R2 stabbed R1 with a fork. The complaint was substantiated by findings that the facility failed to properly notify responsible parties and physicians as required.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility did not notify the responsible party and primary care physician of R1 despite documentation indicating they had been notified, posing a potential threat to resident safety. | Type B |
| Failure to conduct a required reappraisal for resident R2 by the due date, despite a diagnosis of dementia. | Type A |
Report Facts
Capacity: 112
Census: 65
Deficiencies cited: 2
Plan of Correction Due Dates: Type A deficiency due 08/03/2024; Type B deficiency due 08/16/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stephen Richardson | Licensing Program Manager | Supervisor for the inspection |
| Josef Dunham | Administrator/Director | Facility Administrator interviewed during inspection |
Inspection Report
Annual Inspection
Census: 63
Capacity: 112
Deficiencies: 0
Jul 5, 2024
Visit Reason
An unannounced annual required inspection was conducted to ensure compliance with Title 22 regulations.
Findings
The facility was found to be in compliance with no health or safety concerns observed. Resident rooms and common areas were clean and well-maintained, staff files and resident files were current, and medications and hazardous materials were properly secured.
Report Facts
Resident files reviewed: 6
Staff files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Josef Dunham | Administrator | Met with Licensing Program Analyst during inspection and noted to have an active administrator certificate |
| Christina Valerio | Licensing Program Analyst | Conducted the annual inspection |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 112
Deficiencies: 1
Jun 25, 2024
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff were not providing residents with a comfortable environment.
Findings
The investigation found that one resident with vision impairment was unable to effectively use the single emergency pull chord in a shared room, resulting in frequent loud calls for assistance that disturbed other residents. This behavior caused discomfort and agitation among nearby residents, interfering with their daily activities and sleep.
Complaint Details
The complaint was substantiated based on the preponderance of evidence. The allegation that staff were not providing residents with a comfortable environment was found valid.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents in all residential care facilities for the elderly shall have safe, healthful and comfortable accommodations, furnishings and equipment. The facility was found deficient as residents infringed on the personal rights of nearby residents daily, making them uncomfortable in their living spaces and environment, posing an immediate threat to health, safety, and personal rights. | Type A |
Report Facts
Census: 67
Total Capacity: 112
Frequency of resident outbursts: 8
Plan of Correction Due Date: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Josef Dunham | Facility Designated Administrator | Named in relation to the complaint investigation and plan of correction |
| Sarah Nichols | Resident Services Director | Interviewed during the complaint investigation |
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Liza King | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 112
Deficiencies: 0
Mar 14, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations including staff mismanaging resident's medication, refusal to provide proper bedding, and untimely assistance to residents.
Findings
The investigation found that the facility was following physician's orders for medication administration, housekeeping and laundry services were adequate, and staff responded appropriately to resident pull cord alerts. The allegations were determined to be unsubstantiated with no deficiencies observed or cited.
Complaint Details
Complaint allegations were found to be unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Report Facts
Medication audit reviewed: 26
Capacity: 112
Census: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Liza King | Licensing Program Manager | Named in report as Licensing Program Manager |
| Sarah Nichols | Facility designated representative met during investigation | |
| Josef Dunham | Administrator | Facility designated Administrator who was unavailable during the visit |
Inspection Report
Annual Inspection
Capacity: 6
Deficiencies: 0
Mar 1, 2024
Visit Reason
The inspection was an unannounced annual visit conducted to evaluate the facility's compliance and licensing status.
Findings
No deficiencies were cited during the visit. The facility was undergoing extensive remodeling with no residents present at the time. Required signs and appropriate furnishings were observed throughout the facility.
Report Facts
Annual Dues Paid Date: Feb 24, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Shaw Ross | Licensing Program Analyst | Conducted the annual inspection visit. |
| Mirjana Bujosevic | Administrator / Licensee | Met with Licensing Program Analyst during the visit and provided information about the facility. |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 112
Deficiencies: 0
Dec 11, 2023
Visit Reason
This was an unannounced complaint investigation visit triggered by a complaint received on 2023-11-06 alleging that staff did not meet a resident's hygiene needs.
Findings
Based on interviews with residents and staff, record reviews, and observations, the allegation that staff did not meet a resident's hygiene needs was determined to be unsubstantiated. No deficiencies were cited during this visit.
Complaint Details
The complaint alleged that staff did not meet a resident's hygiene needs. The investigation included interviews with five residents and eight staff members, and review of resident R6's records and daily notes. The allegation was found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 112
Census: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Josef Dunham | Administrator | Facility administrator met during the investigation |
| Stephen Richardson | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 112
Deficiencies: 0
Nov 27, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations including untimely medication ordering, lack of glove use during food preparation, inadequate food service, and mismanagement of narcotic medication.
Findings
Based on interviews, observations, and record review, the allegations were found to be unsubstantiated with no deficiencies cited. Staff were observed following proper procedures for medication ordering, narcotic counts, hygienic food preparation, and dietary order compliance.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 112
Census: 62
Staff interviewed: 13
Residents interviewed: 10
Medication administration records reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joe Dunham | Administrator | Facility administrator met during the investigation |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 112
Deficiencies: 0
Nov 17, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 11/15/2023 regarding improper sanitation of facility grounds, maintenance of resident rooms, pest control, and addressing changes in a resident's medical condition.
Findings
The investigation found no evidence to support the allegations. Housekeeping and maintenance were observed performing duties, pest control treatments were up to date, and resident care practices including laundry schedules were confirmed. The complaint was deemed unfounded with no deficiencies cited.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false or without reasonable basis. No deficiencies were observed or cited.
Report Facts
Estimated Days of Completion: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Stephen Richardson | Licensing Program Manager | Named in report as Licensing Program Manager |
| Sarah Blane McClain | Resident Care Coordinator | Met with Licensing Program Analyst during investigation |
| Josef Dunham | Administrator | Facility Administrator contacted during investigation |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 112
Deficiencies: 2
Oct 31, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted to address multiple allegations received on 08/31/2023 regarding facility trash bin lids, financial abuse, medication administration by unqualified staff, resident clothing cleanliness, administrator presence, and meal provision.
Findings
The investigation found four allegations unsubstantiated: staff not securing trash bin lids, financial abuse of residents, unqualified staff administering medications, and residents not dressed in clean clothing. Two allegations were substantiated: the facility administrator was not present for a sufficient number of hours, and staff did not ensure residents were eating meals, with meal logs showing discrepancies.
Complaint Details
The complaint investigation was triggered by allegations including unsecured trash bin lids, financial abuse, unqualified medication administration, unclean resident clothing, insufficient administrator presence, and failure to ensure residents ate meals. The investigation involved interviews with residents and staff, observations, and records review. Four allegations were unsubstantiated, and two were substantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Administrator did not ensure presence at facility for sufficient number of hours. | Type B |
| Staff did not ensure residents were provided with three meals per day; meal logs showed discrepancies. | Type B |
Report Facts
Residents interviewed: 10
Residents with no concerns about trash bin lids: 6
Residents unaware of administrator presence: 6
Facility staff denying financial abuse: 5
Med-Tech files reviewed: 3
Meal log discrepancies: 66
Meal log discrepancies: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Romerico Foz | Administrator | Named in substantiated finding for insufficient presence at facility |
| Pang Lee | Licensing Program Analyst | Conducted the complaint investigation |
| Editha Mccullough | Interim Resident Coordinator | Interviewed during investigation |
| Sara Nichols | Resident Care Coordinator | Interviewed during investigation |
| Robert Godfrey | Regional Director | Responsible for handling resident rent checks |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 112
Deficiencies: 0
Oct 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations received on 2023-09-06 regarding staff not adhering to resident care plans, failure to provide medications, staff retaliation, and medication errors.
Findings
The investigation found no evidence to substantiate the allegations that staff failed to adhere to care plans, did not provide medications, or retaliated against residents. The allegation of staff administering the wrong medication was found to be unfounded. Resident interviews, record reviews, and staff interviews supported these conclusions.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred. One prior substantiated medication mismanagement incident was noted from 4/6/2023, but no recent incidents were found. The allegation of staff retaliation was not supported by evidence.
Report Facts
Capacity: 112
Census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Josef Dunham | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 112
Deficiencies: 0
Aug 23, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation that staff behavior poses a risk to residents while in care.
Findings
The investigation found insufficient evidence to support the allegation. Interviews with residents and staff revealed some concerns about alcohol smell on a staff member, but no proof of intoxication or risk to residents was found. The complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff behavior posed a risk to residents. The investigation included interviews with 4 residents and 5 staff members. Two staff reported smelling alcohol on a staff member, who denied intoxication. The allegation was found unsubstantiated due to lack of evidence.
Report Facts
Capacity: 112
Census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Romerico Foz | Administrator | Met with Licensing Program Analyst during the investigation |
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 112
Deficiencies: 0
Aug 8, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that the facility was serving expired food to residents and that staff levels were insufficient to meet resident needs.
Findings
The investigation found the allegations to be unsubstantiated. No expired food was observed during multiple inspections, and interviews with residents and staff indicated that resident needs were being met with adequate staffing levels. No deficiencies were cited.
Complaint Details
The complaint was unsubstantiated based on interviews with nine residents and six caregivers, inspections of food supplies, and review of staffing levels. The Department determined that the allegations of Personal Rights violations were unsubstantiated but noted the complaint could be amended if additional information is received.
Report Facts
Number of residents interviewed: 9
Number of caregivers interviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 112
Deficiencies: 0
Aug 8, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 2023-05-12 regarding inadequate care and supervision, mishandling of medication, and mishandling of a resident's confidential information at Country Club Manor.
Findings
The investigation found no substantiation for the allegations after interviews, record reviews, and observations. Medication handling was appropriate, resident records were secure, and staff denied the alleged violations. The complaint was determined to be unsubstantiated or unfounded with no deficiencies cited.
Complaint Details
The complaint was unsubstantiated and unfounded. Allegations included inadequate care and supervision, medication mishandling, and mishandling of confidential information. Interviews with residents and staff, medication log review, and record security checks found no evidence to support the allegations.
Report Facts
Capacity: 112
Census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw the complaint investigation |
| Eliza Stonsby | Administrator | Facility administrator mentioned in report header |
Inspection Report
Census: 57
Capacity: 112
Deficiencies: 0
Aug 8, 2023
Visit Reason
An unannounced case management inspection was conducted to address areas of facility improvement.
Findings
The inspection found one bathroom in room 107 without required grab bars, with a work order scheduled to correct this. Residents expressed disappointment with food service, and advisory notes were provided to discuss menu and food preferences at the next resident council. No deficiencies were cited under California Code Regulation, TITLE 22.
Report Facts
Capacity: 112
Census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and noted findings |
| Romerico Foz | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 112
Deficiencies: 1
Jul 12, 2023
Visit Reason
Unannounced visit to investigate a complaint received on 2023-04-13 regarding allegations that the facility did not assist a resident with prescribed medication and other related concerns.
Findings
The investigation substantiated a prior finding of staff mismanaging resident medication on 2023-04-06 but did not cite any new deficiencies. Other allegations including failure to communicate with conservator, denial of resident pharmacy choice, failure to assist with medical care, failure to provide resident records, and failure to notify responsible party of condition changes were found unsubstantiated.
Complaint Details
Complaint investigation was substantiated for staff mismanaging resident medication on 4/6/2023. Other allegations were unsubstantiated due to lack of preponderance of evidence.
Deficiencies (1)
| Description |
|---|
| Staff mismanaging resident medication on 4/6/2023 |
Report Facts
Facility capacity: 112
Resident census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Wallace | Licensing Program Analyst | Conducted the complaint investigation and unannounced facility visit |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Mary Lindgren | Business Office Manager | Met with Licensing Program Analyst during the investigation and exit interview |
| Maricar Venegas | Administrator | Facility Administrator involved in discussion of complaint findings |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 112
Deficiencies: 0
Jul 12, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-05-03 regarding allegations including facility disrepair, unsafe environment, unauthorized individuals without fingerprint clearance, and staff stealing money.
Findings
The investigation found no evidence that the facility was in disrepair or that staff were stealing money. The allegation that the facility does not provide a safe environment for residents was unsubstantiated based on observations, interviews, and record reviews. No deficiencies were observed during the visit.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included facility disrepair, unsafe environment, unauthorized individuals without fingerprint clearance, and staff stealing money. No preponderance of evidence was found to prove the alleged violations occurred.
Report Facts
Capacity: 112
Census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Wallace | Licensing Program Analyst | Conducted the complaint investigation and facility visit |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on report |
| Maricar Venegas | Administrator | Facility administrator named in report |
| Mary Lindgren | Business Office Manager | Met with Licensing Program Analyst during visit and discussed findings |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 112
Deficiencies: 1
Jul 5, 2023
Visit Reason
The visit was an unannounced case management follow-up on an incident report submitted by the facility regarding a resident who ran into the kitchen and threw knives at staff.
Findings
The facility was found to have deficiencies for not ensuring knives were kept locked and inaccessible to residents, posing an immediate health and safety risk.
Complaint Details
The visit was triggered by an incident report submitted on 6/21/23 concerning a resident who grabbed knives and threw them at kitchen staff on 6/20/23. The complaint was substantiated by observations and interviews.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Knives were not stored inaccessible to residents with dementia, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 112
Census: 57
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Cimino | Licensee | Met during the visit and related to the deficiency findings |
| Tung Truong | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Czarrina A Camilon-Lee | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 57
Capacity: 112
Deficiencies: 0
Jun 30, 2023
Visit Reason
An unannounced 1 Year Annual Inspection visit was conducted to evaluate compliance with health and safety regulations at the facility.
Findings
The inspection found no deficiencies. The physical plant, medication storage, food supplies, safety equipment, and emergency systems were all in good condition and compliant with regulations.
Report Facts
Resident files reviewed: 8
Staff files reviewed: 8
Document submission timeframe: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Cimino | Licensee | Met with Licensing Program Analyst during inspection |
| Romerico Foz | New Facility Administrator | Designated as new administrator with certificate #6013248740 expiring 6/25/2024 |
| Tung Truong | Licensing Program Analyst | Conducted the inspection |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report header |
Inspection Report
Follow-Up
Census: 103
Capacity: 112
Deficiencies: 1
May 2, 2023
Visit Reason
The visit was conducted to follow up on previously given citations and to amend a deficiency from a Type "A" to a Type "B" to reflect a non-immediate safety risk related to medication administration for resident R1.
Findings
During the visit, it was confirmed that medication orders for resident R1 were being followed and medications were present. However, a housekeeping cart was found unlocked and unattended in the main hallway with accessible toxins, posing an immediate health and safety risk. The cart was subsequently locked after staff intervention.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87309 Storage Space - Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by an unlocked housekeeping cart with accessible toxins. | Type A |
Report Facts
Deficiency due date: May 8, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the visit and assisted with the inspection |
| Stephenie Doub | Licensing Program Manager | Supervisor overseeing the inspection |
| Maricar Venegas | Administrator | Facility administrator named in the report |
Inspection Report
Census: 58
Capacity: 112
Deficiencies: 0
Apr 14, 2023
Visit Reason
The visit occurred to deliver an Order of Exclusion for a staff member and to inform the facility of the immediate exclusion.
Findings
The Licensing Program Analysts delivered an Order of Exclusion for a staff member named Maricar Venegas, who is no longer employed at the facility. The facility was informed that Maricar Venegas is not allowed in the facility effective immediately.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maricar Venegas | Administrator | Named in the Order of Exclusion and noted as no longer employed at the facility. |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 112
Deficiencies: 1
Apr 6, 2023
Visit Reason
Unannounced investigation of a complaint received on 2023-02-24 regarding staff mismanagement of resident medication at Country Club Manor.
Findings
The facility failed to follow the doctor's order for resident R1's medication, resulting in the resident being without prescribed medication from July 1, 2020 until February 22, 2023. The medication was discontinued without physician confirmation due to insurance coverage issues, and the replacement medication was delayed. The allegation was substantiated.
Complaint Details
The complaint alleging staff mismanaged resident medication was substantiated based on preponderance of evidence standards. The Licensee and Resident Care Coordinator responsible at the time are no longer employed.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Incidental Medical and Dental Care: The licensee did not assist residents with self-administered medications as needed, failing to ensure a proper medication order was followed for R1, posing an immediate health and safety risk. | Type B |
Report Facts
Capacity: 112
Census: 58
Estimated Days of Completion: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Stephenie Doub | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 58
Capacity: 112
Deficiencies: 0
Apr 6, 2023
Visit Reason
An unannounced case management inspection was conducted to discuss and obtain additional information regarding a reported incident involving alleged falsification of employee time sheets by the former administrator.
Findings
The inspection found evidence that the former administrator falsified employee time sheets and failed to meet staffing requirements. No deficiencies were issued during the inspection.
Report Facts
Staff files requested: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon Panariello | Licensing Program Analyst | Conducted the inspection and provided LIC 855 Declaration forms. |
| Kevin Gould | Licensing Program Analyst | Conducted the inspection. |
| Robert Godfrey | Regional Director of Operations | Met with LPAs to discuss the reported incident. |
| Maricar Venegas | Administrator | Former administrator suspected of falsifying employee time sheets. |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 112
Deficiencies: 0
Nov 10, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff allowed a resident to walk outside without shoes.
Findings
The investigation found that the resident did have slippers on while outside, which may not have been proper footwear but did constitute footwear. The complaint was determined to be unfounded.
Complaint Details
The complaint alleged that staff allowed a resident to walk outside without shoes. The complaint was found to be unfounded, meaning the allegation was false, could not have happened, and/or was without reasonable basis.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation. |
| Maricar Venegas | Administrator | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Census: 58
Capacity: 112
Deficiencies: 1
Jun 21, 2022
Visit Reason
The visit was an unannounced case management follow-up to address a 3-day eviction notice given to a resident without prior written approval from Community Care Licensing.
Findings
The licensee was found deficient for issuing a 3-day eviction notice to a resident without obtaining the required prior written approval from the licensing agency, posing a potential health and safety risk to residents in care.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to obtain prior written approval from the licensing agency before issuing a 3-day eviction notice to a resident. | Type B |
Report Facts
Capacity: 112
Census: 58
Plan of Correction Due Date: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maricar Venegas | Administrator | Met with Licensing Program Analyst during the visit and involved in the eviction notice finding |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager overseeing the visit |
Inspection Report
Annual Inspection
Census: 58
Capacity: 112
Deficiencies: 0
Jun 21, 2022
Visit Reason
The inspection was an unannounced required 1 year annual inspection conducted to ensure compliance with health and safety regulations.
Findings
The facility was found to be clean, odor-free, and in good repair with all safety measures in place including proper water temperature, fire safety equipment, and secure storage of medications and toxins. No deficiencies were cited during the inspection.
Report Facts
Water temperature: 115
Capacity: 112
Census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maricar Venegas | Administrator | Met with Licensing Program Analyst and conducted facility tour |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 112
Deficiencies: 0
Mar 7, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that residents were not being provided activities and that food services were inadequate.
Findings
The investigation found that due to COVID-19, normal activities were paused but residents were provided with in-room activities such as word puzzles, word searches, reading, and bingo. Regarding food services, the facility provided alternative menu options for residents who did not want to eat the prepared meals. The complaint findings were deemed unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Although the allegations may have happened or be valid, there was not enough evidence to prove the alleged violations did or did not occur.
Report Facts
Capacity: 112
Census: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation |
| Maricar Venegas | Administrator met with during the investigation | |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Capacity: 6
Deficiencies: 0
Feb 17, 2022
Visit Reason
An unannounced Required 1-Year Visit was conducted to evaluate the facility's compliance and infection control measures.
Findings
The facility was observed to have no residents in care and was undergoing remodeling. No deficiencies were cited during the visit, and technical assistance was provided regarding infection control and COVID-19 mitigation.
Report Facts
Capacity: 6
Census: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mirjana Bujosevic | Administrator | Met with Licensing Program Analyst during inspection and discussed infection control |
| Sabel Martinez | Licensing Program Analyst | Conducted the inspection visit |
| Denise Powell | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 112
Deficiencies: 0
Dec 17, 2021
Visit Reason
The visit was an unannounced case management inspection regarding an incident involving Resident 1 and Staff 1, where Resident 1 claimed inappropriate touching by Staff 1 on 12/7/21 and 12/9/21.
Findings
The investigation found no direct witnesses to the incident. Staff 1 was placed on temporary leave pending investigation, and a mandatory staff training meeting was scheduled. No deficiencies were cited as a result of the visit.
Complaint Details
The complaint involved allegations by Resident 1 of inappropriate touching by Staff 1. The Residential Care Coordinator conducted interviews but found no direct witnesses. Staff 1 was placed on temporary leave and reassigned pending further action.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maricar Venegas | Administrator | Met with Licensing Program Analyst during the visit and involved in the investigation and corrective actions. |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the case management visit and investigation. |
Inspection Report
Census: 51
Capacity: 112
Deficiencies: 0
Dec 15, 2021
Visit Reason
The visit was an unannounced case management visit to follow up on a delinquent notice regarding an outstanding payment issue charged to Solar Senior Living 2 LLC.
Findings
No deficiencies were cited during the visit. The facility provided lien release documents clearing the outstanding payment, and requested documents were noted.
Report Facts
Outstanding payment amount: 21948.24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maricar Venegas | Administrator | Met with Licensing Program Analyst during the case management visit |
| Johnathan Harris | Management member | Solar Senior Living 2 LLC Management member spoken to regarding payment issues |
| Bryan Hart | Controller | Controller handling finances for Cimino Care, discussed resolution of payment issues |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the case management visit |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 112
Deficiencies: 1
Nov 10, 2021
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2021-11-05 regarding issues such as a resident having no call button and staff not maintaining a comfortable temperature in the facility.
Findings
The investigation substantiated that Resident 1's call button was not working, posing a potential threat to resident safety, but found the complaint about facility temperature to be unsubstantiated as temperatures were adequate.
Complaint Details
The complaint investigation was substantiated for the allegation that Resident 1 had no working call button. The allegation that staff did not maintain a comfortable temperature was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Call button in Resident 1's room was not in proper functioning order. | Type B |
Report Facts
Capacity: 112
Census: 53
Temperature range: 73
Temperature range: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Ciscoe | Administrator | Met with Licensing Program Analyst during complaint investigation and involved in addressing call button deficiency |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 112
Deficiencies: 0
Oct 22, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 10/07/2021 regarding uncomfortable facility temperature and medication mismanagement.
Findings
Based on interviews with residents and staff, and review of pertinent documents, there was no substantial evidence to support or disprove the alleged violations. The complaint findings were deemed unsubstantiated due to lack of physical evidence and witness statements.
Complaint Details
The complaint investigation was unsubstantiated as there was no preponderance of evidence to prove the alleged violations occurred. Allegations included staff not maintaining comfortable temperature and mismanaging residents' medication.
Report Facts
Resident interviews conducted: 8
Staff interviews conducted: 3
Facility capacity: 112
Facility census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Tuck | Licensing Program Analyst | Conducted the complaint investigation |
| Maria Ciscoe | Administrator | Facility administrator met during the investigation and exit interview |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Follow-Up
Census: 48
Capacity: 112
Deficiencies: 1
Sep 9, 2021
Visit Reason
The visit was an unannounced follow-up to clear the Plan of Correction (POC) items from a previous visit dated 06/25/2021.
Findings
The deficiencies cited during the 06/25/2021 visit, specifically related to water temperature regulation, have been cleared as of this visit on 09/09/2021.
Deficiencies (1)
| Description |
|---|
| Water temperature was initially too high at 130 degrees; facility administrator lowered it to below 120 degrees and will conduct water temperature logs for two weeks to ensure compliance. |
Report Facts
Capacity: 112
Census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Ciscoe | Administrator | Facility administrator who turned down the water temperature |
| Albert Johnson | Licensing Program Analyst | Named in report as licensing program analyst |
| Stephenie Doub | Licensing Program Manager | Named in report as licensing program manager |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 112
Deficiencies: 1
Aug 23, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation of insufficient staff resulting in a resident wandering out of the facility and sustaining an injury.
Findings
The investigation substantiated that a 101-year-old resident fell outside in the gated back parking lot without staff supervision, posing an immediate health and safety risk. Another complaint regarding staff restricting residents from sugar food/drink items was found to be unfounded.
Complaint Details
The complaint was substantiated regarding insufficient staff supervision leading to a resident fall. The allegation about restricting residents from sugar food/drink items was found to be unfounded.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure resident was properly supervised, resulting in a fall with no supervision around. | Type A |
Report Facts
Capacity: 112
Census: 53
Deficiencies cited: 1
Plan of Correction Due Date: Aug 26, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Ciscoe | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 112
Deficiencies: 0
Aug 12, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2021-04-26 regarding facility heater disrepair and food being served cold.
Findings
The investigation found the complaint about the facility heater being in disrepair to be unfounded, as the heater was observed to be in working order and the facility temperature was adequate. The complaint about food being served cold was unsubstantiated due to insufficient evidence, with residents reporting food was mostly warm.
Complaint Details
The complaint investigation was conducted for two allegations: 1) Facility heater is in disrepair, which was found to be unfounded, and 2) Food is being served cold, which was found to be unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 112
Census: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Ciscoe | Administrator | Met with during investigation and exit interview |
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 112
Deficiencies: 1
Jul 30, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-01-19 alleging that the facility was not administering medications as prescribed, interfering with medical care, and not providing regular showers to a resident.
Findings
The investigation substantiated the allegation that the facility failed to administer medications as prescribed, evidenced by over 25 unsigned medication administration records between December 2020 and January 2021. Other allegations regarding interference with medical care and lack of regular showers were found to be unfounded.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility was not administering medications as prescribed. The other allegations of interfering with medical care and residents not receiving showers regularly were found to be unfounded.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Unsigned medication administration dates for prescribed routine medications in December 2020 and January 2021 for resident R1, posing an immediate threat to resident health and safety. | Type A |
Report Facts
Unsigned medications: 25
Deficiency Type: 1
Capacity: 112
Census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Lusby | Licensing Program Analyst | Investigator who conducted the complaint investigation |
| Maria Ciscoe | Administrator | Facility administrator named in the report and during exit interview |
| Anthony Perez | Licensing Program Manager | Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 112
Deficiencies: 0
Jul 30, 2021
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that facility staff yell at residents.
Findings
The investigation found that the allegation was unfounded as the preponderance of evidence standards was not met. Interviews with staff and residents did not support the complaint.
Complaint Details
The complaint alleged that facility staff yell at residents. The allegation was found to be unfounded.
Report Facts
Capacity: 112
Census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Lusby | Evaluator | Conducted the complaint investigation |
| Maria Ciscoe | Administrator | Facility administrator met during the investigation |
Inspection Report
Annual Inspection
Census: 48
Capacity: 112
Deficiencies: 1
Jun 25, 2021
Visit Reason
The inspection was conducted as a required 1 year annual inspection to evaluate the facility's compliance with health and safety regulations.
Findings
The facility was generally clean, odor-free, and in good repair with required furniture and safety equipment. However, water temperatures in two rooms did not meet regulatory standards, posing a health and safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Water temperatures in rooms 6 and 152 were recorded at 93.5 and 130 degrees Fahrenheit respectively, which does not meet the required 105-120 degree Fahrenheit regulation. | Type A |
Report Facts
Water temperature: 93.5
Water temperature: 130
Plan of Correction Due Date: Jun 28, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Ciscoe | Administrator | Met with Licensing Program Analyst during inspection and observed adjusting water temperature |
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and documented findings |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 112
Deficiencies: 0
May 10, 2021
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2020-12-29 regarding staff communication of COVID-19 guidelines and misinformation about a resident's dementia status.
Findings
The investigation found that staff did communicate COVID-19 outbreak and quarantine guidelines to residents and their responsible parties, and the resident in question was not diagnosed with dementia. Therefore, the allegations were determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff did not communicate facility COVID-19 guidelines to a resident and her authorized representative, and that staff were misguided to believe the resident had dementia. The complaint was determined to be unsubstantiated.
Report Facts
Complaint Control Number: 27
Capacity: 112
Census: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danyle Wolter | Licensing Program Analyst | Conducted the complaint investigation and communicated findings |
| Maria Ciscoe | Administrator | Facility administrator met during investigation |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 112
Deficiencies: 0
Apr 19, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including the facility not providing a refund for overpaid rent and being unable to locate a resident's property.
Findings
The allegation regarding the refund of overpaid rent was found to be unfounded as the facility waived the 30-day notice fee and issued the refund after about seven months. The allegation about the missing resident's property was unsubstantiated because the facility could not prove or disprove when the item went missing.
Complaint Details
The complaint investigation was based on allegations that the facility did not provide a refund for overpaid rent and was unable to locate a resident's property. The refund allegation was unfounded, and the property allegation was unsubstantiated.
Report Facts
Facility capacity: 112
Census: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Ciscoe | Administrator | Named in relation to complaint findings and exit interviews |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Troy Ordonez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 112
Deficiencies: 1
Apr 19, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-12-24 alleging the facility was denying residents access to phones, interfering with medical care, and restricting resident movements.
Findings
The allegation that the facility denied residents access to phones was substantiated due to lack of a phone in a common area and restricted phone use. Allegations regarding interfering with medical care and restricting resident movements were unsubstantiated due to conflicting information and insufficient evidence.
Complaint Details
The complaint investigation was substantiated for the allegation of denying access to phones. The allegations of interfering with medical care and restricting resident movements were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility does not have a phone in a common area for residents to make or receive confidential calls, violating residents' personal rights. | Type B |
Report Facts
Capacity: 112
Census: 47
Deficiency POC Due Date: May 3, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Ciscoe | Administrator | Met with during investigation and named in findings |
| Danyle Wolter | Licensing Program Analyst | Conducted the complaint investigation |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 112
Deficiencies: 0
Mar 25, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was withholding Personal Protective Equipment (PPE) from staff and requiring COVID-19 symptomatic staff to return to work.
Findings
The investigation found that the facility ordered and obtained PPE supplies, including surgical masks, but not N95 masks. Staff interviews revealed conflicting information about whether symptomatic staff were required to return to work. The allegations were determined to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 112
Census: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Ciscoe | Administrator | Met with during the investigation and named in the report |
| Danyle Wolter | Licensing Program Analyst | Conducted the complaint investigation |
| Laura Munoz | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 112
Deficiencies: 7
Feb 23, 2021
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations including staff not properly trained, failure to safeguard residents' belongings, violation of residents' personal rights, administrator qualifications, cleaning supplies not locked up, and failure to communicate residents' change in condition.
Findings
The investigation substantiated multiple allegations including improper medication administration and documentation, incomplete resident personal property records, failure to screen visitors during the pandemic, unlocked cleaning supplies accessible to residents, failure to communicate changes in resident condition, and inadequate administrator qualifications. One allegation regarding insufficient staffing was unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations including staff not properly trained, failure to safeguard residents' belongings, violation of residents' personal rights, cleaning supplies not locked up, failure to communicate residents' change in condition, and administrator qualifications. The allegation of insufficient staffing was unsubstantiated.
Severity Breakdown
Type A: 2
Type B: 5
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to assist residents with self-administered medications as needed, including missed medication due to lack of timely refills and improper documentation. | Type B |
| Incomplete and unsigned Client/Resident Personal Property and Valuable records. | Type B |
| Failure to maintain adequate safeguards and accurate records of residents' cash resources and valuables. | Type B |
| Failure to screen visitors prior to visits during the COVID-19 pandemic, allowing unscreened visitors to enter resident rooms. | Type B |
| Cleaning supplies were found unlocked and accessible to residents on cleaning carts at various times. | Type A |
| Failure to communicate residents' change in condition to responsible parties or physicians, including unreported incidents and increased dementia behaviors. | Type A |
| Administrator failed to recruit, employ, and train qualified staff and ensure staff performed satisfactorily. | Type B |
Report Facts
Capacity: 112
Census: 48
Deficiency counts: 7
Plan of Correction Due Date: Mar 9, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Ciscoe | Administrator | Named in findings related to administrator qualifications and facility operations |
| Danyle Wolter | Licensing Program Analyst | Conducted the complaint investigation |
| Laura Munoz | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 112
Deficiencies: 1
Feb 12, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was incorrectly billing the responsible party for rent invoices already paid.
Findings
The investigation found the complaint to be substantiated, confirming that the responsible party was incorrectly billed for rent invoices already paid, which is inconsistent with the facility's admission agreement and poses a potential health and safety risk to residents.
Complaint Details
The complaint was substantiated based on a preponderance of the evidence standard. The allegation was that the facility incorrectly billed the responsible party for rent invoices already paid.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The responsible party was incorrectly billed for invoices already paid, which is not consistent with the facility's admission agreement. | Type B |
Report Facts
Deficiencies cited: 1
Plan of Correction due date: Feb 26, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danyle Wolter | Licensing Program Analyst | Conducted the complaint investigation and contacted the administrator |
| Maria Ciscoe | Administrator | Facility administrator involved in the investigation |
| Laura Munoz | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 112
Deficiencies: 1
Jan 14, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 04/24/2020 regarding staff mishandling a resident's medication, failure to refill medication in a timely manner, and failure to arrange transportation for a resident following a doctor's visit.
Findings
The investigation substantiated the allegation that staff mishandled a resident's medication by administering the wrong dosage and medication not prescribed to the resident. The facility was found to have the medication but the staff member did not locate it properly. The allegations regarding failure to refill medication timely and failure to arrange transportation were found to be unsubstantiated.
Complaint Details
The complaint investigation was substantiated for staff mishandling resident medication, specifically administering a like-product medication with incorrect dosage not prescribed to the resident. The allegations that staff did not refill medication timely and did not arrange transportation for the resident were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that each employee assisting residents with self-administration of medications meets all training requirements, including 16 hours of hands-on shadowing training prior to assisting with medication administration. | Type B |
Report Facts
Facility capacity: 112
Deficiency type count: 1
Plan of Correction due date: Feb 1, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Ciscoe | Administrator | Named in medication mishandling finding and retraining process |
| Jasmine McCrory | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 112
Deficiencies: 1
Dec 30, 2020
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-05-18 regarding staff mishandling resident medications.
Findings
The allegation that staff mishandled resident medications was substantiated based on interviews, observations, and record review. However, allegations related to personal rights and insufficient staffing were found to be unsubstantiated.
Complaint Details
The complaint was substantiated regarding staff mishandling resident medications due to unqualified staff administering medications as a result of short staffing and lack of proper training. Allegations of personal rights violations and insufficient staffing were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that each employee assisting residents with self-administration of medications completed required training, including 16 hours of hands-on shadowing prior to assisting with medication administration. | Type B |
Report Facts
Capacity: 112
Census: 49
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Ciscoe | Administrator | Admitted loss of caregivers due to COVID-19 fears and efforts to ensure adequate staffing |
| Jasmine McCrory | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 112
Deficiencies: 1
Dec 30, 2020
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not qualified to distribute medication.
Findings
The investigation substantiated that staff administered medications without completing required training, partly due to short staffing caused by employee call-offs and suspensions. The facility did not ensure qualified assistance was given to residents regarding medication administration.
Complaint Details
The complaint alleged staff were not qualified to distribute medication. The allegation was substantiated based on interviews, observations, and record review.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure each employee assisting residents with self-administration of medications completed required training, including 24 hours of initial training and 16 hours of hands-on shadowing prior to assisting. | Type B |
Report Facts
Staff listed as Med Aides or Med Techs: 17
Staff with Medication Training verifications: 7
Medication mismanagement incidents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Ciscoe | Administrator | Admitted loss of caregivers due to COVID-19 fears and discussed staffing challenges related to medication administration |
| Jasmine McCrory | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 112
Deficiencies: 1
Dec 30, 2020
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation of staff mismanaging resident's medication received on 06/08/2020.
Findings
The investigation found the allegation of medication mismanagement substantiated based on interviews, observations, and record review. The facility had experienced staff shortages due to COVID-19 fears, leading to medication not being pre-poured or passed on some days. Deficiencies related to employee training on medication assistance were cited.
Complaint Details
The complaint alleging staff mismanaging resident's medication was substantiated. The investigation included interviews, documentation review, and observations. The facility admitted to medication mismanagement incidents on 05/22/2020 and 05/25/2020 due to employee call-offs and suspensions.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure employees assisting residents with self-administration of medication met training requirements as required by HSC 1569.69. | Type B |
Report Facts
Facility Capacity: 112
Census: 49
Medication mismanagement incidents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Ciscoe | Administrator | Admitted staff shortages and medication mismanagement issues during investigation |
| Jasmine McCrory | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Oversaw the complaint investigation process |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 112
Deficiencies: 0
Nov 5, 2020
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations that the facility was not allowing residents to access common rooms without just cause.
Findings
The investigation found that due to a current positive COVID-19 case at the facility, the administrator's actions to restrict access to common rooms were justified. Therefore, the allegation was determined to be unfounded.
Complaint Details
The complaint alleged that the facility was not allowing residents to access common rooms without just cause. The allegation was found to be unfounded due to justifiable COVID-19 precautions.
Report Facts
Facility capacity: 112
Census: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Ciscoe | Administrator | Facility Administrator involved in the complaint investigation |
| Jasmine McCrory | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report |
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