Most inspections, including the most recent on August 25, 2025, found no deficiencies and several complaint investigations were unsubstantiated. The complaints involved concerns about resident dignity, staff scope of work, staffing levels, hygiene, and pest control, but none were supported by evidence from interviews or observations. The facility demonstrated adequate staffing, proper hygiene practices, and clean living environments throughout these investigations. The pre-licensing inspection on March 5, 2025, also found the facility ready for operation with no issues. This record shows consistent compliance with regulations and no enforcement actions or fines listed in the available reports.
The visit was conducted as an unannounced complaint investigation following a complaint received on 2025-06-17 alleging that a resident was not accorded dignity by staff during an incident.
Findings
The investigation found the allegations to be unfounded based on interviews with staff and the resident, as well as record reviews. No deficiencies were cited.
Complaint Details
The complaint alleged that a resident (R1) was having a smoke break outside, tried to roll themselves in the street, and that facility staff did not assist and laughed at the resident. Interviews with staff and the resident contradicted this allegation, and the resident stated no issues occurred and that staff protect residents' rights.
Report Facts
Complaint Control Number: 26Capacity: 303Census: 27
Employees Mentioned
Name
Title
Context
Simranjit Rai
Licensing Program Analyst
Conducted the complaint investigation and interviews
Slyvia Chu
Executive Director
Met with Licensing Program Analyst during investigation and exit interview
Joyce Aquino
Administrator
Facility administrator named in report header
Romeo Manzano
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
The inspection was conducted as an unannounced complaint investigation following allegations received on 2025-05-28 regarding staff performing tasks outside their scope and lack of administrator response concerning staffing and resident assignments.
Findings
The investigation found the allegations to be unfounded based on staff interviews and record reviews. Staffing ratios were adequate, extra staff were available to cover breaks, and no safety concerns or delays in care were identified. Residents refused to answer questions about the allegations.
Complaint Details
The complaint alleged staff were performing tasks outside their defined scope without designated relievers, resulting in residents not receiving proper care and supervision, and that the administrator failed to respond to staffing and resident assignment concerns, putting residents at risk. The investigation concluded these allegations were unfounded.
Report Facts
Capacity: 303Census: 27
Employees Mentioned
Name
Title
Context
Simranjit Rai
Licensing Program Analyst
Conducted the complaint investigation
Romeo Manzano
Licensing Program Manager
Oversaw the complaint investigation
Slyvia Chu
Executive Director
Met with Licensing Program Analyst during inspection
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-05-22 regarding multiple allegations including pest infestation, staff hygiene, hand hygiene, staffing ratios, soiled undergarments, and unkempt resident bedrooms.
Findings
The investigation found no evidence to support the allegations. Facility staff were observed to maintain proper hygiene, adequate staffing ratios, and clean resident rooms. Pest control measures were in place and no pests were observed. Resident care plans and records showed appropriate care was provided. The allegations were determined to be unfounded.
Complaint Details
The complaint included allegations of pest infestation, poor staff hygiene during food preparation, failure to perform hand hygiene before and after resident care, unbalanced staff-to-resident ratios in the memory care unit, soiled resident undergarments, and unkempt resident bedrooms. After multiple inspections and staff interviews, all allegations were found to be unfounded.
Report Facts
Facility capacity: 303Census: 27Complaint received date: May 22, 2025Staff to resident ratio: 1
Employees Mentioned
Name
Title
Context
Simranjit Rai
Licensing Program Analyst
Conducted the complaint investigation and inspections
Romeo Manzano
Licensing Program Manager
Oversaw the complaint investigation report
Slyvia Chu
Executive Director
Facility representative met during inspection and exit interview
Inspection Report Original LicensingCapacity: 303Deficiencies: 0Mar 5, 2025
Visit Reason
The visit was a pre-licensing inspection conducted to evaluate the facility's readiness for licensing and to ensure compliance with applicable regulations prior to granting a license.
Findings
No issues were noted during the pre-licensing inspection. The facility was found to be ready for licensing with proper safety measures, equipment, and compliance with regulations, though final approval is subject to review by the Central Application Bureau.
Report Facts
Floors: 20Approved fire clearance capacity: 303Inspection start time: 900Inspection end time: 1535Refrigerator temperature: 35Freezer temperature: 0Hot water temperature range: 105.8-119.7Fire extinguisher inspection date: Jul 29, 2024
Employees Mentioned
Name
Title
Context
Joyce Aquino
Administrator
Facility Administrator named in the report and present during inspection.
Terry Ervin
Applicant
Applicant present during the pre-licensing inspection.
Simranjit Rai
Licensing Program Analyst
Conducted the pre-licensing inspection.
Romeo Manzano
Licensing Program Manager
Named as Licensing Program Manager on the report.
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