Most inspections found no deficiencies, including the most recent report on September 11, 2025, which noted the facility was clean, organized, and had proper food and medication storage. However, the July 21, 2025 annual inspection cited a serious deficiency for hot water temperatures exceeding safe limits, posing an immediate safety risk that was addressed during the visit. Earlier, the July 26, 2024 inspection found multiple significant issues such as exceeding the fire clearance for non-ambulatory residents, staff working without background clearance, and unpaid licensing fees, resulting in immediate civil penalties. Several complaint investigations, including one in September 2024 regarding resident restraint, were unsubstantiated or resolved without deficiencies. The facility appears to have improved since mid-2024, with fewer and less severe issues noted in the most recent inspections.
This unannounced Case Management – Health Checks inspection was conducted for the purpose of a health and safety check.
Findings
The inspection found no health and safety issues; the facility was clean and organized, with proper food supplies and medication storage. Further investigation was advised.
Employees Mentioned
Name
Title
Context
Jesus Soto
Administrator
Met with Licensing Program Analyst during inspection and discussed inspection purpose.
This unannounced inspection was conducted by Licensing Program Analyst Sean Haddad for the purpose of a Required – 1 Year Inspection to evaluate compliance with licensing requirements.
Findings
The inspection included a tour of the facility, review of infection control, resident and staff files, interviews, and medication inspection. A deficiency was cited for hot water temperatures exceeding safe limits, posing an immediate safety risk, with a plan of correction initiated during the inspection.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Hot water tested at 138 degrees F in Room D5 and 135 degrees in the common bathroom in the C Wing, posing an immediate safety risk to persons in care.
Type A
Report Facts
Water temperature: 138Water temperature: 135Deficiencies cited: 1Census: 34Total capacity: 72
Employees Mentioned
Name
Title
Context
Sean Haddad
Licensing Program Analyst
Conducted the inspection and cited deficiencies
Jesus Soto
Administrator
Met with Licensing Program Analyst during inspection
The visit was an unannounced Case Management follow-up on an Incident Report received by Community Care Licensing regarding a resident found restrained with wrists tied together.
Findings
The facility was observed to be clean, safe, and sanitary with no health and safety concerns noted. Resident 1 appeared well kempt with no apparent signs of distress or injuries. No deficiencies were cited during the visit.
Complaint Details
The incident involved Resident 1 being found with wrists tied together by staff to prevent the resident from eating feces. Staff 2 confessed to restraining the resident and was suspended pending investigation. The incident was self-reported and investigated in-house.
This unannounced inspection was conducted as a Required – 1 Year Inspection to evaluate compliance with licensing regulations.
Findings
The inspection identified multiple deficiencies including the facility having 35 non-ambulatory residents but only a fire clearance for 25, a staff member working without background clearance, an administrator not properly designated, lack of an evacuation chair in the administrative building, and unpaid licensing fees. Immediate civil penalties were assessed.
Severity Breakdown
Type A: 2Type B: 3
Deficiencies (5)
Description
Severity
Facility has 35 residents all with dementia and non-ambulatory but only has a non-ambulatory fire clearance for 25, posing immediate safety risk.
Type A
Facility staff Jesenia D Vargas-Sandoval is not background cleared and has been working since May 28, 2024, posing immediate safety risk.
Type A
Current administrator started in 2023 but has not been properly designated, posing potential safety risk.
Type B
Administrative building lacks an evacuation chair on the second floor, posing potential safety risk.
Type B
Licensee has not paid licensing fees which are now past due, posing potential personal rights risk.
Type B
Report Facts
Residents present: 35Total licensed capacity: 72Non-ambulatory fire clearance: 25Plan of Correction Due Dates: Jul 27, 2024Plan of Correction Due Dates: Aug 23, 2024
Employees Mentioned
Name
Title
Context
Jesenia D Vargas-Sandoval
Facility Staff
Not background cleared and working at the facility since May 28, 2024
Jesus Soto
Administrator
Administrator present during inspection, started in 2023 but not properly designated
Jackie Escamilla
Facility Staff
Met with Licensing Program Analyst during inspection
Sean Haddad
Licensing Program Analyst
Conducted the inspection
Armando J Lucero
Licensing Program Manager
Supervisor overseeing the inspection
Inspection Report Original LicensingCensus: 26Capacity: 72Deficiencies: 0Mar 1, 2023
Visit Reason
Licensing Program Analyst Ruth Martinez conducted an announced visit to the facility for the purpose of a pre-licensing evaluation to assess readiness for licensure as an Adult Residential Facility for the Elderly.
Findings
The facility was found to have adequate accommodations, safety features, and supplies including bedrooms, bathrooms, emergency plans, food service, smoke detectors, and medication storage. The facility appears ready for licensure and the file will be submitted for approval.
Report Facts
Capacity: 72Census: 26Resident bedroom count: 30Bathroom count: 10Fire clearance date: Aug 4, 2021Water temperature range: 109.5-120.0
Employees Mentioned
Name
Title
Context
Ruth Martinez
Licensing Program Analyst
Conducted the pre-licensing evaluation visit
Armando J Lucero
Licensing Program Manager
Named as Licensing Program Manager on report
Patty Rager
Executive Director
Facility representative met during the visit
Sheryl Yvette McCaskill
Administrator
Facility Administrator named in report
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