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 (last 4 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a April 2025 inspection.
Census over time
Inspection Report
Annual Inspection| 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| 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| 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| 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| 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| 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| 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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