Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance with regulations. The most recent report from September 3, 2025, was a meeting to discuss resident care and did not identify any deficiencies. Earlier reports showed isolated issues such as a medication error in January 2025 and missing documentation related to staff clearances and emergency drills in November 2023, but no fines or enforcement actions were listed. The facility addressed these concerns with staff training and administrative follow-up. Overall, the record shows improvement over time with the latest inspections free of deficiencies.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Capacity: 49
Deficiencies: 0
Sep 3, 2025
Visit Reason
The purpose of this meeting was to discuss potential care options for the future of a specific resident and how to ensure the resident's health and safety going forward.
Findings
An office meeting was held via Microsoft Teams with various stakeholders to discuss the resident's care. The meeting was adjourned and rescheduled to include additional relevant parties.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Crocker | Licensing Program Manager | Attended the office meeting regarding resident care options. |
| Kayla Adkison | Licensing Program Analyst | Attended the office meeting regarding resident care options. |
| Melissa Morales | Administrator | Attended the office meeting regarding resident care options. |
| Michelle Cartier | Assistant Administrator | Attended the office meeting regarding resident care options. |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 49
Deficiencies: 1
Jan 27, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of questionable death and staff mismanagement of residents' medication.
Findings
The allegation of questionable death was found to be unsubstantiated due to insufficient evidence. The allegation of staff mismanaging residents' medication was substantiated based on an incident report showing a medication error where an employee exceeded the as-needed medication dosage. The facility conducted in-service training regarding medication management.
Complaint Details
The complaint investigation included two allegations: questionable death and staff mismanagement of residents' medication. The questionable death allegation was unsubstantiated. The medication mismanagement allegation was substantiated with evidence from an incident report dated August 9, 2024.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87465(c)(2) Incidental Medical and Dental Care: Facility staff did not administer the correct dosage of medication as outlined in the Physician Orders, presenting a potential health, safety, and personal rights risk to residents. | Type B |
Report Facts
Capacity: 49
Census: 41
Deficiency Type B count: 1
Plan of Correction Due Date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Lauren Crocker | Licensing Program Manager | Oversaw the complaint investigation |
| Michelle Sans-Cartier | Assistant Administrator | Facility representative who met with LPAs during the investigation |
| Melissa Morales | Administrator | Signed medication error documentation |
Inspection Report
Annual Inspection
Census: 41
Capacity: 49
Deficiencies: 0
Jan 14, 2025
Visit Reason
The inspection was an unannounced Required 1 year inspection conducted to evaluate the facility's compliance with regulations.
Findings
The facility was found to be clean, well-maintained, and compliant with safety and health standards. No deficiencies were cited during the inspection, although some technical violations related to staff training and resident file documentation were noted and addressed with the administrator.
Report Facts
Staff members lacking annual training: 1
Residents without updated LIC 602: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Aceves | Administrator | Met with Licensing Program Analysts during inspection and was educated on training and documentation requirements |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection and identified technical violations |
| Lauren Crocker | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 49
Deficiencies: 0
Sep 30, 2024
Visit Reason
The inspection was conducted as a subsequent complaint investigation following a complaint alleging that staff were not following protocols to prevent the spread of illness.
Findings
The investigation found inconsistent statements from staff interviews, but the facility was following Local Public Health guidelines related to staff who test positive for COVID-19. The complaint allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
Complaint alleged that staff were not following protocols to prevent the spread of illness. The allegation was unsubstantiated after investigation.
Report Facts
Capacity: 49
Census: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Aceves | Administrator | Met with Licensing Program Analyst during inspection and named in findings |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation |
| Lauren Crocker | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 49
Deficiencies: 0
Mar 14, 2024
Visit Reason
The visit was conducted in response to a complaint alleging that the administrator was under the influence and actively drinking while disbursing medications at the facility.
Findings
The investigation found no evidence to support the complaint. Video footage reviewed showed no indication that the administrator consumed alcohol while working or disbursing medications. The administrator denied the allegations and reported challenges with an employee who may have made the report.
Complaint Details
Complaint was not substantiated as no evidence was found to support the allegation that the administrator was under the influence or drinking while disbursing medications.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Morales | Administrator | Named in complaint allegation and investigation regarding alleged alcohol use while disbursing medications. |
| Lauren Crocker | Licensing Program Manager | Named as Licensing Program Manager involved in the report. |
| Jaynae Boyles | Licensing Program Analyst | Named as Licensing Program Analyst involved in the report. |
Inspection Report
Annual Inspection
Census: 40
Capacity: 49
Deficiencies: 3
Nov 28, 2023
Visit Reason
The visit was an unannounced 1-Year Required Annual Inspection conducted to ensure the health and safety of residents in care.
Findings
The facility was observed to be clean, in good repair, and odor-free with appropriate safety features. However, deficiencies were found including one staff file missing a criminal record clearance, lack of documentation for quarterly emergency disaster drills, and one resident with dementia missing an updated medical assessment within the last 12 months.
Severity Breakdown
Type A: 1
Type B: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| One out of five staff files did not have a Criminal Records Clearance. | Type A |
| No documentation of quarterly emergency disaster drills was provided. | Type B |
| One resident with dementia did not have an updated annual medical assessment. | Type B |
Report Facts
Civil penalty amount: 500
Number of resident files reviewed: 5
Number of staff files reviewed: 5
Plan of Correction Due Date: Nov 29, 2023
Plan of Correction Due Date: Dec 5, 2023
Plan of Correction Due Date: Dec 1, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Morales | Administrator | Met with Licensing Program Analyst during inspection and involved in plan of correction discussions. |
| Jaynae Boyles | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Lauren Crocker | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Annual Inspection
Census: 39
Capacity: 49
Deficiencies: 0
Feb 7, 2023
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on infection control to ensure the health and safety of residents.
Findings
No immediate health, safety, or personal rights violations were observed. The facility was found to be in substantial compliance with infection control requirements and no deficiencies were cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Knight | Licensing Program Analyst | Conducted the inspection and was involved in infection control domain evaluation. |
| Melissa Morales | Administrator / Executive Director | Facility administrator and recipient of the inspection report. |
| Michelle Sans-Cartier | Resident Care Coordinator | Met with the Licensing Program Analyst during the inspection and toured the facility. |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 49
Deficiencies: 1
Dec 19, 2022
Visit Reason
The visit was an unannounced complaint investigation to deliver findings related to allegations received on 10/20/2022 concerning incident reporting and resident care.
Findings
One allegation was substantiated regarding failure to report incidents to the licensing agency when residents did not go to the hospital. Three other allegations related to resident falls, timely assistance, and soiled diaper care were unsubstantiated based on interviews and document reviews.
Complaint Details
The complaint investigation was substantiated for staff not safeguarding resident’s incident reports by failing to report incidents to the licensing agency if the resident did not go to the hospital. Other allegations about resident falls, timely assistance, and soiled diaper care were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report incidents to the licensing agency when residents did not go to the hospital, posing a potential health and safety risk. | Type B |
Report Facts
Incident reports reviewed: 3
Residents interviewed: 9
Staff interviewed: 6
Plan of Correction due date: Jan 3, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Morales | Administrator | Met with during investigation and named in findings |
| Rebecca Knight | Licensing Program Analyst | Conducted the complaint investigation |
| Troy Ordonez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 35
Capacity: 49
Deficiencies: 0
Jan 4, 2022
Visit Reason
The visit was a case management visit conducted to deliver an Order to Individual of Immediate Exclusion from all facilities and the Order to Licensee/Facility of Immediate Exclusion from Facility.
Findings
The Licensing Program Analyst served an immediate exclusion order to staff person Jacqueline Mejia, prohibiting her from working, being present, or having contact with clients in any licensed facility due to actions related to this facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaclyn Avila | Licensing Program Analyst | Conducted the case management visit and served the Order to Individual of Immediate Exclusion. |
| Melissa Morales | Administrator | Met with Licensing Program Analyst during the visit. |
| Jacqueline Mejia | Staff Person | Subject of the Immediate Exclusion Order due to actions related to the facility. |
Inspection Report
Annual Inspection
Census: 35
Capacity: 49
Deficiencies: 0
Jan 4, 2022
Visit Reason
The inspection was an unannounced annual/random visit conducted to perform a Required 1-Year Inspection focusing on the infection control domain.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Morales | Administrator | Met with Licensing Program Analyst during inspection and named in report. |
| Jaclyn Avila | Licensing Program Analyst | Conducted the inspection and named in report. |
| Rayna L Bryson | Licensing Program Manager | Named in report as Licensing Program Manager. |
Inspection Report
Annual Inspection
Census: 37
Capacity: 49
Deficiencies: 0
Dec 14, 2021
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure health and safety of residents in care.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed, and no deficiencies were cited as a result of the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Morales | Executive Director | Met with Licensing Program Analyst during inspection and named in report narrative. |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 49
Deficiencies: 0
Mar 12, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 09/21/2020 regarding the facility conditions and care.
Findings
The investigation found insufficient information to substantiate the allegations that the resident's room was cold due to a lock box on the thermostat, that residents' belongings were missing, and that the facility food had too much sodium and was unhealthy. No deficiencies were cited.
Complaint Details
The complaint was unsubstantiated. Allegations included a cold resident room with a lock box on the thermostat, missing resident belongings, and unhealthy food with too much sodium. The investigation included telephone interviews and review of statements and documents, concluding insufficient evidence to prove violations.
Report Facts
Facility capacity: 49
Census: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Morales | Administrator | Met with during complaint investigation and involved in findings |
| Pheej Cheng | Licensing Program Analyst | Conducted the complaint investigation |
| Rayna L Bryson | Licensing Program Manager | Oversaw the complaint investigation |
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