Most inspections found no deficiencies, with several complaint investigations determined to be unsubstantiated. However, some reports cited deficiencies related primarily to medication assistance, resident care, and staff training. The most serious issues included a substantiated neglect case in May 2025 where a resident sustained a severe burn, and multiple missed medication doses documented in October 2025. The most recent report from October 7, 2025, had one deficiency for missed medication doses but no severe enforcement actions or fines were listed in the available reports. The facility’s record shows some improvement in areas like record keeping and supervision, though medication management and resident care remain areas needing attention.
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not providing proper medication assistance, shower assistance, and food service to a resident in care.
Findings
The investigation substantiated the allegation that staff failed to provide proper medication assistance to a resident, with multiple missed doses documented over a three-month period. Allegations regarding shower assistance and food service were unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for medication assistance failure but unsubstantiated for shower assistance and food service allegations. The preponderance of evidence standard was met for the medication allegation.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Failure to assist residents with self-administered medications as needed, resulting in missed doses for a resident over multiple days.
Type B
Report Facts
Medications missed: 9Capacity: 97Census: 69Plan of Correction Due Date: Oct 21, 2025
Employees Mentioned
Name
Title
Context
Ruth Martinez
Licensing Program Analyst
Conducted the complaint investigation visit.
Armando J Lucero
Licensing Program Manager
Oversaw the complaint investigation report.
Janette Hill
Executive Director
Facility representative interviewed during the investigation.
The visit was an unannounced case management visit to deliver amended complaint findings for Complaint Control # 22-AS-20250121161311.
Findings
The Licensing Program Analyst delivered an amended report to the Culinary Services Director and discussed the amended findings. An exit interview was conducted and a copy of the report and amended findings were provided to the facility.
Complaint Details
The visit was related to amended complaint findings for Complaint Control # 22-AS-20250121161311.
Employees Mentioned
Name
Title
Context
Kasan Soewono
Culinary Services Director
Met with during the visit and recipient of the amended complaint findings report.
Andrea Mendivil
Licensing Program Analyst
Conducted the unannounced visit and delivered the amended complaint findings.
Janette Hill
Administrator
Named as facility administrator.
Alisa Ortiz
Licensing Program Manager
Named as Licensing Program Manager overseeing the visit.
The inspection was an unannounced complaint investigation visit triggered by a complaint received on January 21, 2025, alleging that a resident sustained a severe burn as a result of neglect, and other allegations regarding medication administration and room cleanliness.
Findings
The investigation substantiated the allegation that Resident 1 sustained a severe burn due to neglect, confirmed by interviews, photographic evidence, and medical reports. The allegations that staff did not administer medications as prescribed and did not ensure the resident's room was cleaned were found to be unsubstantiated.
Complaint Details
The complaint investigation was substantiated for the allegation that Resident 1 sustained a severe burn as a result of neglect. The other allegations regarding medication administration and room cleanliness were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Basic services requirement was not met as licensee did not ensure Resident 1 was assisted properly with food services, resulting in the resident spilling coffee or hot liquids on themselves causing blisters.
Type A
Report Facts
Capacity: 97Census: 68Deficiencies cited: 1Plan of Correction Due Date: Jun 2, 2025
Employees Mentioned
Name
Title
Context
Janette Hill
Executive Director
Met with during inspection and named as facility administrator
Andrea Mendivil
Licensing Program Analyst
Conducted the complaint investigation and authored the report
An unannounced visit was conducted in conjunction with a complaint investigation for complaint control # 22-AS-20231117101241.
Findings
A deficiency was cited due to the facility's inability to locate Medication Administration Records from 2023, violating California Code of Regulations Title 22.
Complaint Details
Complaint investigation for complaint control # 22-AS-20231117101241. Deficiency cited based on missing Medication Administration Records from 2023.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidenced by facility did not obtain Medication Administration Records from 2023.
Type B
Report Facts
Capacity: 97Census: 59Plan of Correction Due Date: Due date for correction is 02/02/2025
Employees Mentioned
Name
Title
Context
Janette Hill
Executive Director
Met during inspection and discussed missing Medication Administration Records
An unannounced complaint investigation visit was conducted following a complaint received on 2023-11-17 regarding multiple allegations about medication distribution, medical care, dietary needs, record keeping, and assistance with showering at the facility.
Findings
The investigation included interviews with residents and staff and review of pertinent documents. All allegations were determined to be unsubstantiated based on interviews and document reviews indicating that medications were distributed and taken as prescribed, medical care was performed by skilled professionals, dietary needs were met, records were current, and residents received shower assistance as needed.
Complaint Details
The complaint included allegations that staff did not distribute residents' medications as prescribed, did not ensure residents took medications as prescribed, did not ensure skilled professionals performed medical care, did not meet residents' dietary needs, did not maintain current records, and did not assist residents with showering. The investigation found these allegations to be unsubstantiated.
Report Facts
Facility capacity: 97Census: 59
Employees Mentioned
Name
Title
Context
Andrea Mendivil
Licensing Program Analyst
Conducted the complaint investigation and interviews
Kimberly Lyman
Licensing Program Analyst
Assisted in the complaint investigation visit
Janette Hill
Executive Director
Met with investigators during the visit
Kameshi Taylor
Administrator
Facility administrator named in the report
Alisa Ortiz
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
Unannounced complaint investigation visit conducted due to allegations including staff authorizing medical decisions without proper consent, resident injury from a fall, failure to seek timely medical attention, and inadequate supervision.
Findings
The investigation found no corroborating evidence to support the allegations. Facility documentation and interviews indicated the resident was independent in many activities, no history or documentation of falls or hospitalizations was found, and staffing levels were adequate. The allegations were deemed unsubstantiated due to lack of preponderance of evidence.
Complaint Details
Allegations included staff authorizing medical decisions without proper consent, resident sustained injury from a fall, staff did not seek timely medical attention, and inadequate supervision. The complaint was unsubstantiated based on interviews and record review.
Licensing Program Analyst Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation of the facility.
Findings
The facility was found to be in compliance with Title 22 Division 6 of the California Code of Regulations with no deficiencies cited. Observations included inspection of physical plant, fire safety equipment, medication storage, staff training, and resident care activities.
Report Facts
Fire extinguisher service date: Aug 7, 2024Smoke detector test date: Apr 5, 2023Fire drill date: Nov 13, 2024Administrator certificate expiration: Jul 13, 2026Resident records reviewed: 6Staff training records reviewed: 5Hot water temperature range: Hot water temperatures measured between 109.4 and 116.7 degrees Fahrenheit.
Employees Mentioned
Name
Title
Context
Janette Hill
Executive Director
Met with Licensing Program Analyst during inspection and participated in exit interview.
RoseMarie Ruppert
Licensing Program Analyst
Conducted the unannounced annual inspection visit.
This unannounced Case Management – Other inspection was conducted to perform additional interviews related to Complaint Control No. 22-AS-20201103132810.
Findings
No deficiencies were observed during the inspection. Based on observations, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
Complaint Details
Inspection was conducted as a follow-up to a complaint (Complaint Control No. 22-AS-20201103132810).
Employees Mentioned
Name
Title
Context
Janette Hill
Administrator
Met with Licensing Program Analyst during inspection.
This unannounced Case Management – Deficiencies inspection was conducted to issue citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20201103132810.
Findings
The inspection found that the facility permanently closed a window in Resident #1's room, interfering with the resident's comfort and enjoyment, which violated the requirement for safe, healthful, and comfortable accommodations. The facility's emergency disaster exit plan did not rely on windows for evacuation, and the deficiency posed a personal rights risk.
Complaint Details
The visit was complaint-related, investigating allegations that a window in Resident #1's room was permanently screwed shut, affecting temperature regulation and comfort. The complaint was substantiated by observations and interviews.
Deficiencies (1)
Description
Failure to ensure Resident #1 had safe, healthful, and comfortable accommodations by permanently closing their window.
Report Facts
Capacity: 97Census: 68Plan of Correction Due Date: Jul 29, 2024
Employees Mentioned
Name
Title
Context
Sean Haddad
Licensing Program Analyst
Conducted the inspection and issued citations
Janette Hill
Administrator
Met with Licensing Program Analyst during inspection
Armando J Lucero
Licensing Program Manager
Supervisor and Licensing Program Manager overseeing the inspection
This unannounced complaint investigation was conducted to investigate allegations including failure to provide treatment for a resident with stage 3 pressure and ankle injury, failure to report the injury to the resident's responsible party, denial of visitation from the responsible party, and missed medication dosages by facility staff.
Findings
The investigation substantiated that the facility failed to provide proper treatment and timely reporting for a resident's stage 3 pressure injury, denied visitation during COVID-19 lockdown beyond guidelines, and missed multiple medication dosages leading to potential health risks. Other allegations such as failure to call 911, overmedication, falsified care plan documentation, and unlawful increase in care cost were unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations related to failure to provide treatment for a stage 3 pressure injury, failure to timely notify the resident's responsible party, denial of visitation during COVID-19 lockdown, and missed medication dosages. Other allegations including failure to call 911, overmedication, falsified care plan documentation, and unlawful increase in care cost were unsubstantiated.
Severity Breakdown
Type A: 3Type B: 1
Deficiencies (4)
Description
Severity
The licensee did not ensure R1, who had known skin issues, received proper assistance and medical care resulting in R1 developing an unstageable wound.
Type A
The licensee did not ensure R1’s worsening skin condition was noted and brought to the attention of their responsible party.
Type B
The licensee did not ensure that R1 was free to leave or depart from the facility without being forced to quarantine in their room upon return.
Type A
The licensee did not ensure R1 received multiple medications as prescribed.
Type A
Report Facts
Facility capacity: 97Census: 68Deficiency count: 4Plan of Correction due date: Jul 16, 2024Plan of Correction due date: Jul 29, 2024
Employees Mentioned
Name
Title
Context
Sean Haddad
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Armando J Lucero
Licensing Program Manager
Oversaw the complaint investigation
Janette Hill
Administrator
Facility administrator met with Licensing Program Analyst during inspection
An unannounced complaint investigation visit was conducted to investigate the allegation that the facility does not have adequate staffing to meet the resident's needs.
Findings
The investigation included interviews, facility tour observations, and documentation review. The allegation was found to be unsubstantiated due to insufficient evidence to prove or refute the claim. Staffing was reported as adequate at the time of the visit, though some interviewees noted staffing challenges during the COVID-19 pandemic.
Complaint Details
The complaint alleged inadequate staffing to meet resident needs. The investigation found no preponderance of evidence to substantiate the allegation, deeming it unsubstantiated.
Report Facts
Facility census at time of complaint: 65Current staffing levels: 3Current staffing levels: 2Current staffing levels: 1Total licensed capacity: 97Current census: 63
Employees Mentioned
Name
Title
Context
Rosie Quiroz
Licensing Program Analyst
Conducted the complaint investigation visit
Alisa Ortiz
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
Carrie Galloway
Executive Director
Met with during investigation and provided staffing information
An unannounced complaint investigation visit was conducted to investigate allegations that staff were not providing adequate care and supervision to residents.
Findings
The investigation included interviews with staff and residents, and review of documentation and staffing schedules. The allegation was deemed unsubstantiated due to insufficient evidence to prove or refute the claim, with most interviewees indicating adequate care and supervision was provided.
Complaint Details
The complaint alleged inadequate care and supervision by staff. The investigation found staffing challenges during the COVID-19 pandemic but current staffing levels were adequate. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 97Census: 63Complaint receipt date: Nov 9, 2021Staffing during complaint timeframe: 33Interviewees: 15Interviewees indicating adequate care: 14Interviewees with no knowledge of facility during complaint timeframe: 8Interviewees indicating staffing challenges during COVID-19: 7
Employees Mentioned
Name
Title
Context
Rosie Quiroz
Licensing Program Analyst
Conducted the complaint investigation visit
Alisa Ortiz
Licensing Program Manager
Oversaw the complaint investigation
Carrie Galloway
Executive Director
Facility representative met during investigation and exit interview
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff were not meeting residents' needs due to lack of staff.
Findings
The investigation included interviews, review of resident records, and scheduling records from February to June 2020. The Department was unable to ascertain if the allegations occurred as reported due to lack of preponderance of evidence, and therefore the allegations were deemed unsubstantiated.
Complaint Details
The complaint alleged that staff were not meeting residents' needs due to lack of staff. The complaint was found to be unsubstantiated due to insufficient evidence to prove or refute the allegation.
Report Facts
Facility census at time of complaint: 69Scheduled nursing shifts: 3Nurses on morning shift: 2Nurses on afternoon shift: 2Nurses on night shift: 2Caregivers on morning shift: 4Caregivers on afternoon shift: 4Care staff on morning shift: 6Care staff on afternoon shift: 3Care staff on night shift: 4
Employees Mentioned
Name
Title
Context
Ruth Martinez
Licensing Program Analyst
Conducted the complaint investigation
Armando J Lucero
Licensing Program Manager
Named in report as Licensing Program Manager
Carrie Galloway
Executive Director
Met with Licensing Program Analyst during investigation
This unannounced Case Management – Incident inspection was conducted for a health and safety check and to follow up on a self-reported incident involving Resident #1 who left the facility unassisted on 10/20/2023.
Findings
The inspection found no immediate health and safety issues with the facility or Resident #1 during the visit. However, a deficiency was cited for inadequate supervision when Resident #1 left the facility unassisted, posing an immediate safety risk. The facility has since implemented motion alarms, updated resident supervision lists, and conducted staff training.
Complaint Details
The visit was complaint-related, triggered by a self-reported incident received on 10/25/2023 regarding Resident #1 leaving the facility unassisted on 10/20/2023. The complaint was investigated and substantiated by the cited deficiency.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Licensee did not provide adequate supervision to Resident #1 when they left the facility without assistance, posing an immediate safety risk to persons in care.
Type A
Report Facts
Deficiency count: 1Plan of Correction Due Date: Oct 31, 2023
Employees Mentioned
Name
Title
Context
Sean Haddad
Licensing Program Analyst
Conducted the inspection and authored the report
Armando J Lucero
Licensing Program Manager
Supervisor overseeing the inspection
Carrie Galloway
Administrator
Facility administrator interviewed during inspection
An unannounced complaint investigation was conducted based on allegations including lack of a facility emergency disaster plan, residents sustaining pressure injuries due to neglect, unmet dietary needs, staffing shortages, bruises on residents, and lack of required staff training.
Findings
The investigation found the allegation regarding the emergency disaster plan to be unfounded. Allegations related to pressure injuries, dietary needs, staffing shortages, and bruises were deemed unsubstantiated due to insufficient evidence. However, the allegation that facility staff lacked required training was substantiated, with seven out of seven staff lacking evidence of required annual training.
Complaint Details
The complaint investigation was initiated due to multiple allegations: lack of a facility emergency disaster plan, residents sustaining pressure injuries due to neglect, unmet dietary needs, staffing shortages, bruises on residents, and lack of required staff training. The emergency disaster plan allegation was unfounded. The allegations about pressure injuries, dietary needs, staffing, and bruises were unsubstantiated. The allegation regarding lack of staff training was substantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Licensees shall maintain in the personnel records verification of required staff training and orientation.
Type B
Report Facts
Capacity: 97Census: 63Staff training records reviewed: 7Fire drill training dates observed: 2Plan of Correction Due Date: Nov 1, 2023
Employees Mentioned
Name
Title
Context
Kimberly Lyman
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Alisa Ortiz
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
Kameshi Taylor
Administrator
Facility administrator named in the report
Carrie Galloway
Facility representative met during the investigation
An unannounced complaint investigation visit was conducted to investigate the allegation that the facility did not ensure that a resident received prescribed medication.
Findings
After review of medication administration records, staff interviews, and observations, the allegation was found to be unsubstantiated. All treatments appeared to have been administered and documented accurately, with no preponderance of evidence to prove or refute the alleged violation.
Complaint Details
The complaint alleged that the facility did not ensure that a resident received prescribed medication. The investigation included record reviews, staff interviews, and a tour of the memory care unit. The allegation was deemed unsubstantiated.
Report Facts
Capacity: 97Census: 49
Employees Mentioned
Name
Title
Context
Tyre Richards
Assisted Living Program Director
Met with during the investigation and involved in locating absent documentation
An unannounced complaint investigation visit was conducted in response to allegations including insufficient staffing to meet resident needs, staff not meeting residents' toileting needs, unsafe environment for residents, and residents not being served nutritious meals.
Findings
Based on interviews with residents and staff, review of documentation, and observations, the allegations were determined to be unfounded. Most residents and staff reported that resident needs were met, the environment was safe, and food quality was acceptable. The complaint was found to be without reasonable basis.
Complaint Details
The complaint investigation was unannounced and based on multiple allegations related to staffing, resident care, safety, and nutrition. The investigation included interviews with residents and staff, review of staff schedules, staffing agency invoices, and menus. The complaint was determined to be unfounded.