Inspection Report Summary
Most inspections found no deficiencies, with several annual visits confirming the facility was clean, safe, and compliant with infection control and safety standards. The most recent report from April 29, 2025, was generally positive, noting good repair and cleanliness, though the inspection was not fully completed and will continue later. In April 2022, the facility faced serious issues related to missing criminal background checks for several staff members and improper staff association, which posed immediate safety risks and resulted in civil penalties and a required correction plan. Since then, follow-up inspections have shown improvement, with no further deficiencies noted and complaint investigations, including one in December 2024 about falsified records, found unsubstantiated. Overall, the facility’s record shows resolution of past serious concerns and mostly clean inspections in recent years.
Deficiencies per Year
4
3
2
1
0
High
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 323
Capacity: 379
Deficiencies: 0
Apr 29, 2025
Visit Reason
The inspection was an unannounced annual facility inspection conducted to review compliance with licensing requirements, including emergency disaster plans, infection control, medication audits, fire safety, and facility conditions.
Findings
The inspection found the facility to be generally in good repair and clean, with passing fire safety inspections and adequate food supplies. The inspection was not fully completed and will continue at a later date.
Report Facts
Smoke detectors: 129
Carbon Monoxide Detectors: 9
Food supply days: 2
Food supply days: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marjan Albert | Administrator | Met with Licensing Program Analyst during inspection |
| Mark Jeffries | Licensing Program Analyst | Conducted the facility annual inspection |
Inspection Report
Complaint Investigation
Capacity: 379
Deficiencies: 0
Dec 4, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit triggered by allegations that staff falsified residents' medical documentation and billed residents for services not rendered.
Findings
The investigation found insufficient evidence to support the allegations of falsified medical documentation and billing for services not rendered. Records, therapy notes, billing invoices, and staff schedules were reviewed and found consistent. The allegations were deemed unsubstantiated.
Complaint Details
The complaint alleged staff falsified records for Physical and/or Occupational Therapy and billed residents for services not rendered. No specific residents or contact information were provided by the reporting parties. Interviews, document reviews, and resident statements were conducted. The complaint was unsubstantiated.
Report Facts
Facility capacity: 379
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melisa Rankin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Marjan Albert | Administrator | Met with Licensing Program Analyst during investigation |
| Irene Carrillo | Director of Rehabilitation | Interviewed regarding therapy services and billing |
Inspection Report
Annual Inspection
Census: 317
Capacity: 379
Deficiencies: 0
Apr 24, 2024
Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with regulatory standards.
Findings
The facility was found to be clean, safe, sanitary, and in good repair with functioning safety equipment and accessible outdoor areas. The medication record review was initiated but not completed due to time constraints, and the inspection will be continued at a later date.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Scott Bigler | Met with during the inspection and conducted the facility tour. | |
| Danielle Tervo-Shiffman | Administrator/Director | Named as facility administrator/director. |
| Kelly Burley | Licensing Program Manager | Conducted the inspection and named in the report. |
| Melisa Rankin | Licensing Program Analyst | Conducted the inspection and named in the report. |
Inspection Report
Annual Inspection
Census: 335
Capacity: 379
Deficiencies: 0
Feb 13, 2023
Visit Reason
An unannounced infection control annual inspection was conducted to evaluate compliance with infection control policies and procedures.
Findings
No deficiencies were observed during the visit; all infection control requirements were being followed, including screening, isolation, testing, PPE use, and staff background clearance.
Report Facts
Capacity: 379
Census: 335
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Small | Administrator | Facility Administrator mentioned in report |
| Linda Perez | Executive Director | Met during inspection and toured facility |
| Scott Bigler | Health Care Administrator | Met during inspection and toured facility |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager overseeing inspection |
| Jeannette Olson | Licensing Program Analyst | Conducted inspection and signed report |
Inspection Report
Annual Inspection
Census: 349
Capacity: 379
Deficiencies: 2
Apr 26, 2022
Visit Reason
An unannounced Annual Infection Control Inspection was conducted to evaluate compliance with criminal background fingerprint clearance requirements and other regulatory standards.
Findings
The inspection found that criminal background fingerprint clearances were not conducted for several staff members (S1, S2, S5), and that staff S3 and S4 were not properly associated with the facility, posing immediate health and safety risks. Civil penalties were issued and a plan of correction was required.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Criminal background fingerprint clearance was not conducted for Staff 1 (S1), Staff 2 (S2), and Staff 5 (S5), posing an immediate health and safety risk to persons in care. | Type A |
| Licensee did not ensure that Staff 3 (S3) and Staff 4 (S4) were associated with the facility, posing an immediate safety risk to persons in care. | Type A |
Report Facts
Capacity: 379
Census: 349
Deficiencies cited: 2
Plan of Correction Due Date: Apr 27, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Harris | Director of Human Resources | Confirmed staff without criminal background fingerprint clearance and association status |
| Jennifer Leggett | Associate Executive Director | Met during inspection and received report and civil penalty notification |
| Kristin Kontilis | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 349
Capacity: 379
Deficiencies: 0
Apr 26, 2022
Visit Reason
An unannounced continuance of an Annual Inspection and Infection Control Inspection visit was conducted to complete the annual visit due from the inspection conducted on 4/25/2022.
Findings
The facility was inspected for compliance with licensing requirements including infection control. A health and safety tour of the campus was conducted. Deficiencies noted were addressed in a Case Management report on 4/26/2022.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Leggett | Associate Executive Director | Met with during the inspection and explained the purpose of the visit. |
| Karen Harris | Human Resources Director | Met with upon arrival and explained the purpose of the visit. |
| Kristin Kontilis | Licensing Program Analyst | Conducted the unannounced continuance of the Annual Inspection and Infection Control Inspection visit. |
Inspection Report
Annual Inspection
Census: 348
Capacity: 379
Deficiencies: 0
Apr 25, 2022
Visit Reason
An unannounced one-year infection control inspection visit was conducted as a required annual inspection of the facility.
Findings
No deficiencies were cited at the time of the visit. Additional follow-up is needed due to time restraints, and the Licensing Program Analyst will return at a later date to continue the investigation.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Leggett | Associate Executive Director | Met with Licensing Program Analyst during inspection. |
| Karen Harris | Human Resources Director | Met with Licensing Program Analyst during inspection. |
| Michael Easbey | Administrator | Unavailable at the time of the visit. |
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