Inspection Reports for Elms Residential Home Care
67 E Barnett St, Ventura, CA 93001, CA, 93001
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related primarily to medication management, facility cleanliness, and safety issues such as malfunctioning fire sprinklers and emergency systems. Several complaint investigations were unsubstantiated, including allegations of staff abuse, drug use, and insufficient staffing. The facility received civil penalties totaling at least $350 for criminal record clearance violations and safety hazards. The most recent report from August 19, 2025, identified multiple deficiencies including non-functional fire sprinklers, an inoperable call button system, and incomplete records, with plans underway to address these issues amid a change of ownership. While some improvements were noted in earlier years, recent findings indicate ongoing concerns with safety and compliance.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
8.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
115% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
93% occupied
Based on a August 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 50
Capacity: 54
Deficiencies: 6
Date: Aug 19, 2025
Visit Reason
The inspection was an unannounced required annual visit to evaluate compliance with licensing regulations and ensure the facility meets health and safety standards.
Findings
The inspection identified several deficiencies including non-functional fire sprinklers, an outdated and inoperable call button system, incomplete personnel and resident records, lack of documented emergency drills, and missing annual staff training. The facility is undergoing a change of ownership and has plans to correct these deficiencies by specified due dates.
Deficiencies (6)
Sprinklers not in working condition posing immediate health and safety risk.
Outdated and inoperable signal system posing immediate health and safety risk.
Incomplete personnel files posing potential health and safety risk.
Staff not annually trained posing potential health and safety risk.
Missing and incomplete information in resident files posing potential health and safety risk.
Lack of documented emergency drills posing potential health and safety risk.
Report Facts
Civil penalty: 500
Number of resident files reviewed: 6
Number of staff files reviewed: 7
Days non-perishable food supply: 7
Days perishable food supply: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Spring | Director | Met during inspection and authorized Program Manager to sign report. |
| Juliana Anos | Administrator | Met during inspection and participated in facility tour. |
| Lesley Jamon | Program Manager | Met during inspection, authorized to sign report, agreed to plans of correction. |
| Valeria Conway | Licensing Program Analyst | Conducted inspection and signed report. |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on report. |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 54
Deficiencies: 0
Date: Apr 4, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 2024-08-09 regarding staff verbal abuse, inadequate food provision, drug activity on premises, resident utilization as staff, and financial abuse of residents.
Complaint Details
The complaint investigation was triggered by allegations of staff verbally abusing and threatening residents, inadequate food provision, failure to prevent drug activity, resident utilization as staff, and financial abuse of residents. All allegations were investigated and found unsubstantiated based on interviews and record reviews.
Findings
After interviews with staff and residents and review of records, all allegations were deemed unsubstantiated. Residents confirmed adequate food provision and no verbal abuse or threats by staff. Drug activity allegations were unsubstantiated despite some residents smoking marijuana and one issued an eviction notice. The resident incentive chore program was voluntary and paid. Financial abuse allegations were unsubstantiated with all P&I monies accounted for and no complaints of staff taking money.
Report Facts
Capacity: 54
Census: 50
Number of staff interviewed: 5
Number of residents interviewed: 5
P&I monies held: 5
Eviction notice duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation visit |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on report |
| Julie Anos | Acting administrator met during investigation | |
| Neil Cotton | Facility staff met during investigation | |
| Higgins, Fe Lilia | Administrator | Facility administrator named on report |
Inspection Report
Annual Inspection
Census: 42
Capacity: 54
Deficiencies: 0
Date: Aug 6, 2024
Visit Reason
The inspection was an unannounced required annual visit to the facility conducted by Licensing Program Analysts.
Findings
The Licensing Program Analyst conducted interviews, a health and safety tour, and met with staff and the administrator. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the annual inspection visit. |
| Fe Lilia Higgins | Licensee/Administrator | Facility licensee met during the inspection. |
| Irina Zendejas | Administrator met during the inspection. |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 54
Deficiencies: 0
Date: Jul 30, 2024
Visit Reason
The visit was conducted as a complaint investigation following an allegation that staff did not provide adequate care and supervision of the residents, including an incident where emergency personnel were summoned for a resident who was unresponsive.
Complaint Details
The complaint alleged that staff did not provide adequate care and supervision, citing an incident where emergency personnel were summoned for a resident who appeared unresponsive. The investigation included interviews with staff and residents, observation of staffing schedules, and review of the incident. The allegation was found unsubstantiated due to insufficient evidence.
Findings
The investigation found insufficient evidence to support the allegation of inadequate care and supervision. Staff were present during the incident, and the resident was found sleeping deeply but easily woken. The allegation was deemed unsubstantiated.
Report Facts
Capacity: 54
Census: 42
Staffing: 2
Staffing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the complaint investigation and subsequent visit |
| Irina Zendejas | Administrator Assistant | Met with Licensing Program Analyst during investigation and manages residents' medication |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 54
Deficiencies: 3
Date: Jul 30, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-01-19 regarding failure to seek medical attention for a resident, failure to notify the resident's responsible person of injury, failure to safeguard confidential records, and failure to clean bedroom floors.
Complaint Details
The complaint investigation was substantiated. The resident had an unwitnessed fall resulting in multiple fractures that were not timely treated by staff. Staff also failed to notify the resident's responsible person of the injury. Confidential records were accessible to unauthorized persons, and resident bedrooms were found unclean. Multiple interviews and record reviews supported these findings.
Findings
The investigation substantiated all allegations: staff failed to seek timely medical attention for a resident with multiple fractures, did not notify the resident's responsible person of the injury, did not safeguard confidential resident records, and did not maintain cleanliness of resident bedrooms. Observations and interviews confirmed these violations.
Deficiencies (3)
Failure to ensure residents are regularly observed for changes in physical, mental, emotional and social functioning and to provide appropriate assistance when unmet needs are revealed.
Failure to maintain confidentiality of resident records, as staff had resident records accessible to others.
Failure to maintain facility common areas and resident rooms in a clean, sanitary, and odorless condition.
Report Facts
Capacity: 54
Census: 42
Deficiencies cited: 3
Plan of Correction Due Dates: Jul 31, 2024
Plan of Correction Due Dates: Aug 6, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Fe Lilia Higgins | Administrator | Facility administrator involved in investigation interviews |
| Irina Zendeja | Administrator Assistant | Met with Licensing Program Analyst during investigation and acknowledged deficiencies |
| Veronica Padilla | Investigator | Assigned investigator who conducted interviews and follow-up visits |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 54
Deficiencies: 2
Date: Jul 30, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including staff not keeping the facility free of bedbugs, failure to provide emergency personnel resident records, and failure to keep the facility clean and sanitary.
Complaint Details
The complaint investigation was substantiated for allegations related to bedbug infestation, unsanitary conditions, and failure to provide resident records to emergency personnel. The allegations of questionable death, failure to post the facility license prominently, and insufficient staffing were unsubstantiated.
Findings
The investigation substantiated that the facility had ongoing bedbug infestations and unsanitary conditions in resident rooms and common areas. Staff failed to provide resident records to emergency personnel during an incident. Other allegations such as questionable death, failure to post the facility license prominently, and insufficient staffing were found unsubstantiated.
Deficiencies (2)
Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by failure to keep the facility free of bed bugs and maintain cleanliness of facility common areas, resident rooms and bathrooms.
Resident Records: The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by staff not having access to Resident #1's records and therefore not providing them to emergency personnel.
Report Facts
Capacity: 54
Census: 42
Deficiencies cited: 2
Plan of Correction Due Date: Aug 6, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation |
| Irina Zendeja | Administrator Assistant | Met with the Licensing Program Analyst during the inspection and provided information regarding facility conditions and plans |
| Fe Lilia Higgins | Administrator | Facility administrator who acknowledged bedbug issues and staffing levels |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 54
Deficiencies: 0
Date: Jul 30, 2024
Visit Reason
The visit was conducted as a complaint investigation following an allegation received on 12/21/2023 regarding illegal drug use at the facility.
Complaint Details
The complaint alleged illegal drug use at the facility, specifically marijuana and other drugs. The allegation was investigated through interviews and record reviews but was found unsubstantiated due to lack of evidence.
Findings
The investigation found insufficient evidence to support the allegation of illegal drug use at the facility. Interviews with residents, staff, and the administrator denied knowledge of illegal drug use, and the allegation was deemed unsubstantiated.
Report Facts
Facility capacity: 54
Census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Fe Lilia Higgins | Administrator | Facility administrator interviewed during the investigation |
| Irina Zendeja | Administrator Assistant | Met with Licensing Program Analyst during the visit |
| Johnny Canto | Investigator | Conducted interviews as part of the complaint investigation |
| Marysol Magallanas | Staff | Interviewed during the initial complaint visit |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 54
Deficiencies: 0
Date: Jul 1, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-06-24 regarding lack of hot water, insufficient food, forced resident cleaning, and improper cleaning of residents' rooms.
Complaint Details
The complaint included allegations that the facility did not have hot water, staff did not ensure enough food for residents, staff made residents clean the facility, and staff were not properly cleaning residents' rooms. All allegations were deemed unsubstantiated based on interviews, observations, and documentation.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. The water heater was broken but promptly replaced restoring hot water within 24 hours. Food quantity was sufficient with three meals and two snacks daily. Residents were not forced to clean; one resident voluntarily collected recycling. Staff were assigned to cleaning duties and rooms were cleaned unless residents refused.
Report Facts
Capacity: 54
Census: 42
Meals and snacks served daily: 5
Complaint receipt date: Jun 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation visit |
| Fe Lilia Higgins | Administrator | Facility administrator interviewed during investigation |
| Irina Zendejas | Facility Staff | Facility staff interviewed during investigation |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 43
Capacity: 54
Deficiencies: 0
Date: Jun 12, 2024
Visit Reason
The visit was a Case Management visit to discuss the future plans for the facility due to the pending sale of the property.
Findings
During the visit, Licensing Program Analysts and Managers interviewed the administrator, reviewed resident files, and participated in a telephone call with other relevant parties. An entrance and exit interview were conducted, and a copy of the report was provided.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fe Higgins | Administrator/Licensee | Met with Licensing Program Analysts and Managers during the visit. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 54
Deficiencies: 1
Date: Mar 20, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility electrical panel was malfunctioning.
Complaint Details
The complaint was substantiated. The allegation was that the facility electrical panel was malfunctioning. The investigation confirmed the issue and corrective actions were taken.
Findings
The investigation confirmed that the facility electrical panel was malfunctioning due to a broken valve and a low battery, which posed a potential health and safety risk. Maintenance staff replaced the broken valve and installed a new battery, and the panel is now operating properly. The allegation was substantiated.
Deficiencies (1)
Maintenance and Operation: The facility fire panel was malfunctioning due to a broken valve and low battery, posing a potential health and safety risk to clients in care.
Report Facts
Capacity: 54
Census: 43
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the complaint investigation visit |
| Fe Lilia Higgins | Administrator | Facility administrator unavailable during the visit |
| Irina Zendejas | Staff member met with during the investigation | |
| Ariel Vargs | Maintenance staff | Confirmed and repaired the electrical panel malfunction |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 44
Capacity: 54
Deficiencies: 0
Date: Oct 27, 2023
Visit Reason
The visit was conducted to meet with the Licensee/Administrator to discuss the potential future closure of the facility and proper closure procedures.
Findings
The Licensee was informed about the Health and Safety Code 1569.682 requirements for closure, including the need to submit a closure plan and provide a 60-day notification to residents. The Licensee acknowledged understanding of these requirements and has assistance from a consultant and Ventura County Behavior Health for the closure process.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fe Lilia Higgins | Licensee/Administrator | Met with during the visit and discussed closure procedures. |
| Esther Cortez | Licensing Program Analyst | Conducted the visit. |
| Kasandra Lopez | Licensing Program Manager | Conducted the visit and discussed closure requirements with Licensee. |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 54
Deficiencies: 0
Date: Oct 2, 2023
Visit Reason
The inspection visit was conducted to investigate a complaint alleging that the facility had a bedbug infestation.
Complaint Details
The complaint alleged a bedbug infestation at the facility. The allegation was investigated through room inspections, resident interviews, and discussions with the pest control company and administrator. The complaint was found to be unsubstantiated as no current infestation was observed.
Findings
The investigation found that although there was a bedbug infestation reported in early September 2023, the facility took timely corrective actions including replacing mattresses and pillows, washing bedding, and conducting monthly pest control. At the time of the inspection, no bedbugs or signs of infestation were observed, and the allegation was deemed unsubstantiated.
Report Facts
Number of rooms inspected: 10
Residents interviewed: 20
Residents reporting bedbugs in early September: 8
Residents reporting no bedbug problems: 11
Residents reporting past bedbug issues last year: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Urena | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Fe Lilia Higgins | Administrator | Facility administrator interviewed during the investigation |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 54
Deficiencies: 1
Date: Sep 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff mismanaged residents' medications.
Complaint Details
The complaint was substantiated based on evidence that residents missed medications due to the facility's inability to pick up medications from the pharmacy. Two residents reported missed medications on one occasion. The allegation regarding facility disrepair was unsubstantiated after resident interviews and confirmation of extermination service for bed bugs.
Findings
The allegation that staff mismanaged residents' medications was substantiated due to missed medications and failure to provide medication pickup services, with two out of five residents confirming missed doses. A separate allegation regarding facility disrepair, including bed bugs and toilet issues, was investigated and found unsubstantiated.
Deficiencies (1)
Staff mismanaged residents' medications, resulting in missed medications and failure to provide medication pickup services.
Report Facts
Capacity: 54
Census: 43
Residents interviewed: 5
Date of bed bug extermination service: Sep 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Fe Higgins | Administrator | Facility administrator interviewed regarding medication management and facility conditions |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 54
Deficiencies: 1
Date: Sep 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that residents were not receiving their medications and that there was insufficient staffing to meet residents' care needs.
Complaint Details
The complaint investigation was substantiated regarding medication administration failures, specifically that one resident did not receive their PRN medication on 9/12/23 due to the facility's delay in ordering. The staffing allegation was unsubstantiated based on interviews and observations.
Findings
The allegation that residents were not receiving their medications was substantiated due to a failure to timely order medication for one resident, posing an immediate health risk. The allegation of insufficient staffing was unsubstantiated as observations and resident interviews confirmed adequate staffing to meet needs.
Deficiencies (1)
Failure to assist residents with self-administered medications as needed, evidenced by one resident not receiving their medication on 9/12/23 due to untimely ordering.
Report Facts
Capacity: 54
Census: 43
Deficiencies cited: 1
Plan of Correction Due Date: Sep 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fe Lilia Higgins | Administrator | Named in relation to medication administration and staffing findings |
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation |
| Kasandra Lopez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 43
Capacity: 54
Deficiencies: 11
Date: Aug 29, 2023
Visit Reason
The inspection was an unannounced required annual visit to evaluate compliance with Title 22 Regulations and ensure health and safety standards at the facility.
Findings
The inspection identified multiple deficiencies including expired and improperly labeled food items, unsanitary conditions in resident bedrooms and bathrooms, improper storage of cleaning supplies, expired staff CPR/first aid certifications, missing resident pre-appraisals and admission agreements, lack of quarterly emergency drills, and incomplete medication records.
Deficiencies (11)
Detergent was present in a resident's bedroom, posing an immediate health and safety risk.
Cleaning supplies stored inside the kitchen next to food preparation area, posing an immediate health and safety risk.
Resident's bathroom wall and toilet were stained and dirty, posing a potential health and safety risk.
Resident's bedroom observed with dirt and liquid on the floor, posing a potential health and safety risk.
All staff's first aid/CPR certification expired in May 2023, posing a potential health and safety risk.
Five out of five resident files missing pre-appraisal, posing a potential health and safety risk.
Three out of five resident files missing or incomplete admission agreements, posing a potential health and safety risk.
Expired food items found in pantry, posing a potential health and safety risk.
Facility staff writing information on medication bottle caps with marker, violating labeling regulations.
Facility has not conducted emergency drills quarterly as required, posing a potential health and safety risk.
Facility not maintaining centrally stored medication and destruction record for all residents, posing a potential health and safety risk.
Report Facts
Census: 43
Total Capacity: 54
Expired food items: 31
Resident files reviewed: 5
Staff files presented: 2
Resident interviews conducted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fe Lilia Higgins | Licensee/Administrator | Named in relation to inspection and findings |
| Esther Cortez | Licensing Program Analyst | Conducted inspection and authored report |
| Martha Arroyo | Licensing Program Analyst | Conducted inspection |
| Desaree Perera | Licensing Program Manager | Supervisor of licensing evaluation |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 54
Deficiencies: 0
Date: Jul 20, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to allegations including insufficient staffing to meet residents' care needs, residents being used as substitutes for required staff, and staff intimidation and retaliation against residents.
Complaint Details
The complaint investigation was triggered by allegations of insufficient staffing, residents substituting for staff, and staff intimidation and retaliation. After interviews and investigation, all allegations were found unsubstantiated.
Findings
All allegations were deemed unsubstantiated based on interviews with residents, staff, and the administrator. Residents reported sufficient staffing and no intimidation or retaliation by staff. Residents volunteer for some household duties but not as substitutes for staff. No deficiencies were observed.
Report Facts
Capacity: 54
Census: 43
Staff present: 4
Residents interviewed: 5
Staff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Fe Higgins | Administrator | Facility administrator interviewed during investigation |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 54
Deficiencies: 0
Date: Jun 23, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility had an infestation of bed bugs.
Complaint Details
The complaint alleged a bed bug infestation. After interviews with residents and staff, and review of pest control records, the allegation was found unsubstantiated due to lack of current evidence of infestation.
Findings
The investigation found that while the facility had a past issue with bed bugs, current evidence showed no active infestation. The facility had taken appropriate pest control measures, and the allegation was deemed unsubstantiated.
Report Facts
Residents interviewed: 10
Staff interviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Fe Higgins | Administrator | Facility administrator informed of the visit and named in the report |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 54
Deficiencies: 0
Date: Jun 1, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-05-23 regarding staffing sufficiency, medication administration, and assistance with showers at the facility.
Complaint Details
The complaint investigation addressed three allegations: insufficient staffing to meet resident needs, failure to ensure residents take medications, and lack of assistance with showers. All allegations were deemed unsubstantiated based on interviews and observations.
Findings
The investigation found all allegations to be unsubstantiated. Residents and staff confirmed that staffing was sufficient to meet resident needs, medications were administered properly, and residents did not require assistance with showers. No deficiencies were observed during the visit.
Report Facts
Capacity: 54
Census: 42
Number of residents interviewed: 10
Number of staff interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Fe Lilia Higgins | Administrator | Facility administrator interviewed during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 54
Deficiencies: 2
Date: Apr 21, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-04-05 regarding the facility's meal nutrition, laundry services, and dietary needs of residents.
Complaint Details
The complaint investigation was substantiated for allegations that facility staff do not serve nutritious meals and do not provide basic laundry service. The allegation that staff do not meet residents' dietary needs was unsubstantiated.
Findings
The investigation substantiated that the facility failed to provide adequate fresh fruits and vegetables during meals and did not provide timely basic laundry services due to staffing issues. However, the allegation that staff do not meet residents' dietary needs was unsubstantiated.
Deficiencies (2)
Facility failed to provide adequate amounts of fresh fruits and vegetables, posing a potential health risk to residents.
Facility failed to provide basic laundry service in a timely manner due to staff retention and scheduling issues, posing a potential health risk to residents.
Report Facts
Capacity: 54
Census: 41
Deficiencies cited: 2
Plan of Correction Due Date: Apr 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Angie Perez | Assistant Manager | Met with during the inspection and exit interview |
| Fe Lilia Higgins | Administrator | Facility administrator contacted but not present during visit |
| Reynaldo Tabing | Night Supervisor | Greeted Licensing Program Analyst during visit |
| Karena Higgins | Interim Administrative Assistant | Met with during the inspection |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 54
Deficiencies: 1
Date: Apr 21, 2023
Visit Reason
The visit was an unannounced Case Management - Deficiencies inspection conducted in conjunction with a subsequent complaint visit to issue citations for deficiencies observed during the complaint investigation that were not related to the complaint.
Complaint Details
The visit was conducted in conjunction with a complaint investigation (Complaint Control #29-AS-20230405151719). The deficiencies cited were not related to the complaint but were observed during the complaint investigation.
Findings
The licensee failed to comply with the criminal record clearance requirement by not associating staff member S1 to the facility, posing an immediate health, safety, and personal rights risk to persons in care. Civil penalties of $100 were assessed.
Deficiencies (1)
Failure to associate staff member S1 to the facility as required by criminal record clearance regulations.
Report Facts
Civil Penalty Amount: 100
Deficiency Count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fe Lilia Higgins | Administrator | Administrator contacted by phone and authorized Angie Perez to sign and receive the report. |
| Angie Perez | Assistant Manager | Met with Licensing Program Analyst during the visit and authorized to sign and receive the report. |
| Esther Cortez | Licensing Program Analyst | Conducted the unannounced Case Management - Deficiencies visit. |
| Desaree Perera | Licensing Program Manager | Supervisor of the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 54
Deficiencies: 1
Date: Apr 12, 2023
Visit Reason
The visit was an unannounced Case Management - Deficiencies inspection conducted in conjunction with a complaint investigation to issue citations for deficiencies observed that were not related to the complaint.
Complaint Details
The visit was conducted in conjunction with a complaint visit (Complaint Control #29-AS-20230405151719). The deficiencies cited were not related to the complaint.
Findings
The facility was cited for failure to have an administrator or designee present during the visit to assist the Licensing Program Analyst, and staff was unable to provide necessary documentation for the investigation.
Deficiencies (1)
The administrator designated by the licensee was not present at the facility when temporarily absent, and no designee was available to assist the Licensing Program Analyst during the visit. Staff was unable to provide necessary documentation.
Report Facts
Capacity: 54
Census: 41
Deficiencies cited: 1
Plan of Correction Due Date: Due date for Plan of Correction is 04/19/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fe Lilia Higgins | Administrator | Named as the administrator who was not present during the visit |
| Karena Higgins | Interim Administrative Assistant | Staff present during the visit who was unable to assist with documentation |
| Esther Cortez | Licensing Program Analyst | Conducted the inspection visit |
| Desaree Perera | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 54
Deficiencies: 1
Date: Mar 16, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff do not provide adequate meal service to residents in care.
Complaint Details
The complaint was substantiated. The allegation was that staff do not provide adequate meal service, specifically that food was served cold and residents lacked variety in fruits, vegetables, and breakfast items. The investigation confirmed insufficient perishable fruit supply and occasional cold meals.
Findings
The investigation found that the facility did not have a sufficient supply of perishable fruit for the census of 42 residents, and residents confirmed they do not receive fresh fruit every day. Some residents also reported occasionally receiving cold meals. There was no evidence supporting insufficient vegetable supply or breakfast variety complaints.
Deficiencies (1)
Failure to maintain sufficient supplies of perishable fruit as required by CCR 87555(b)(26), posing a potential health risk to persons in care.
Report Facts
Census: 42
Total Capacity: 54
Number of residents interviewed: 7
Plan of Correction due date: Mar 23, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fe Higgins | Administrator | Met with during inspection and exit interview |
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation |
| Kasandra Lopez | Licensing Program Analyst | Assisted in conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 54
Deficiencies: 1
Date: Mar 16, 2023
Visit Reason
An unannounced Case Management - Deficiencies inspection was conducted due to a deficiency observed during a complaint investigation.
Complaint Details
Inspection was triggered by a deficiency observed during a complaint investigation.
Findings
The facility failed to provide or post a food menu as required by regulations, resulting in a cited deficiency related to general food service requirements.
Deficiencies (1)
Failure to have a written food menu posted and available, violating General Food Service Requirements for facilities with sixteen or more persons.
Report Facts
Deficiency count: 1
Plan of Correction Due Date: Mar 23, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fe Lilia Higgins | Administrator | Met with Licensing Program Analysts during inspection and was involved in the deficiency finding. |
| Kasandra Lopez | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Esther Cortez | Licensing Program Analyst | Conducted the inspection. |
| Desaree Perera | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 54
Deficiencies: 0
Date: Jan 6, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that neglect and lack of supervision resulted in a resident injuring another resident.
Complaint Details
The complaint alleged neglect and lack of supervision leading to a resident injury during an altercation. Interviews revealed no physical fight occurred, only a verbal argument involving a resident and a temporary staff member. The resident refused to disclose details. The allegation was unsubstantiated.
Findings
The investigation found conflicting information regarding the alleged altercation between residents. Staff and resident interviews indicated no physical altercation occurred, only a minor argument that was promptly defused. The allegation was deemed unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 54
Census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation |
| Fe Higgins | Administrator | Facility administrator met during the investigation |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 54
Deficiencies: 1
Date: Jan 6, 2023
Visit Reason
The visit was a Case Management - Deficiencies inspection conducted following a complaint alleging short staffing and unauthorized staff working at the facility.
Complaint Details
The complaint investigation revealed the facility was short staffed and an individual without fingerprint clearance was asked to work at the facility and help with laundry. The deficiency was substantiated by record review and interviews.
Findings
The inspection found that an individual (I1) worked at the facility without having the required criminal record clearance and fingerprinting, posing an immediate health, safety, and personal rights risk to persons in care. Civil penalties of $100 were assessed.
Deficiencies (1)
Failure to obtain a criminal record clearance for an individual working at the facility, violating Health and Safety Code Section 1569.17(b).
Report Facts
Civil Penalty Amount: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fe Lilia Higgins | Administrator | Named in relation to the finding of unauthorized staff working without fingerprint clearance. |
| Emily Peraldi | Licensing Program Analyst | Conducted the inspection and documented findings. |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 54
Deficiencies: 0
Date: Oct 11, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation of neglect and lack of supervision resulting in a client hitting another client.
Complaint Details
The complaint alleged neglect and lack of supervision led to Client #1 being hit by Client #2. After interviews with clients, staff, residents, and a case manager, the allegation was found unsubstantiated due to insufficient evidence.
Findings
The investigation found conflicting accounts of the incident between the involved clients. Staff were not in the immediate area during the incident, and no evidence supported lack of supervision. Residents felt safe and staff reported appropriate intervention practices. The allegation was deemed unsubstantiated.
Report Facts
Facility capacity: 54
Census: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report signature and oversight |
| Fe Higgins | Facility staff member interviewed during investigation |
Inspection Report
Annual Inspection
Census: 42
Capacity: 54
Deficiencies: 3
Date: Aug 23, 2022
Visit Reason
Licensing Program Analyst JoAnn Rosales conducted a Required 1-Year unannounced visit to inspect infection control practices and overall facility compliance.
Findings
The inspection found deficiencies including hot water temperature exceeding regulatory limits, accessible disinfectants posing health risks, and inadequate supply of nonperishable fruit. Civil penalties of $250 were issued.
Deficiencies (3)
Hot water temperature in resident bathroom was 136 degrees F, exceeding the allowed maximum of 120 degrees F, posing an immediate health and safety risk.
Disinfectant and cleaning solutions were accessible to residents, posing an immediate health risk.
Facility did not maintain a one week supply of nonperishable fruit, posing a potential health and personal rights risk.
Report Facts
Civil penalty amount: 250
POC Due Date: Aug 24, 2022
POC Due Date: Aug 30, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joann Rosales | Licensing Program Analyst | Conducted the inspection and documented findings |
| Fe Lilia Higgins | Administrator | Facility administrator met with LPA during inspection and responsible for corrective actions |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 54
Deficiencies: 0
Date: Feb 22, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of lack of supervision resulting in a resident being assaulted by another resident.
Complaint Details
The complaint investigation was unsubstantiated according to the report delivered on 09/16/2021.
Findings
The Licensing Program Analyst conducted a physical plant inspection and staff interviews. The allegation was deemed unsubstantiated as of the report date.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Balisi | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Fe Lilia Higgins | Administrator | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 54
Deficiencies: 1
Date: Jan 6, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the Administrator increased rental rates without proper notice.
Complaint Details
The complaint was substantiated. The allegation was that the Administrator increased rental rates without proper notice. Interviews and document review confirmed that residents did not receive the required 60 days prior written notice.
Findings
The investigation found that the Administrator did not provide proper written notice of the rental rate increase to residents, which was a violation of regulation 87507(g)(4). The allegation was substantiated based on interviews and document review.
Deficiencies (1)
Failure to provide at least 60 days prior written notice to residents of any rate or rate structure change as required by CCR 87507(g)(4).
Report Facts
Capacity: 54
Census: 43
Deficiency count: 1
Plan of Correction Due Date: Jan 10, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joann Rosales | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Fe Lilia Higgins | Administrator | Named in the complaint and investigation findings regarding rental rate increase notice |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 43
Capacity: 54
Deficiencies: 4
Date: Jan 6, 2022
Visit Reason
The visit was a Case Management - Deficiencies inspection conducted to review compliance with regulations, including admission agreements and medication storage.
Findings
The inspection found that several resident admission agreements were incomplete or missing, and medications were not stored securely, posing health risks. Specifically, resident #1's medication was accessible to residents despite the resident being unable to self-administer or store medications.
Deficiencies (4)
Resident #8's medication was not kept in a safe locked place accessible only to responsible employees, posing an immediate health risk.
Admission agreements for 7 out of 11 residents were missing required information such as rate increases, refund conditions, preadmission fees, and involuntary transfer or eviction requirements.
Admission agreements were missing for residents #8, #9, #10, and #11.
Admission agreements did not comply with regulations in 4 out of 11 resident records, posing a potential personal rights risk.
Report Facts
Deficiencies cited: 4
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joann Rosales | Licensing Program Analyst | Conducted the Case Management - Deficiencies visit and authored the report |
| Fe Lilia Higgins | Administrator | Facility administrator met during the inspection |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 54
Deficiencies: 0
Date: Nov 5, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that facility staff did not provide a resident's medical information to the resident's health care provider.
Complaint Details
The complaint alleged that facility staff did not provide resident #1's medical information (COVID vaccination dates) to the resident's health care provider. The allegation was investigated and found to be unsubstantiated.
Findings
The investigation found that although the facility initially did not provide exact COVID vaccination dates for resident #1 to the health care provider, the information was later provided. Based on the investigation, the allegation was deemed unsubstantiated.
Report Facts
Facility capacity: 54
Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fe Higgins | Administrator | Met during the investigation and involved in providing information about the complaint |
| Joann Rosales | Licensing Program Analyst | Conducted the complaint investigation |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 54
Deficiencies: 0
Date: Nov 5, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that a resident was intimidating and verbally abusing other residents, and violating house rules by smoking in their room.
Complaint Details
The complaint involved allegations that resident #1 intimidated residents, verbally abused residents, and violated house rules by smoking in their room. The investigation concluded the allegations were unsubstantiated.
Findings
The investigation found that the resident did verbally intimidate and verbally abuse staff and residents during behavioral episodes and violated house rules by smoking in their room. However, the allegations were deemed unsubstantiated at this time. The administrator committed to ensuring resident health and safety and to providing staff training on handling behavioral episodes.
Report Facts
Capacity: 54
Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joann Rosales | Licensing Program Analyst | Conducted the complaint investigation |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
| Fe Higgins | Administrator | Facility Administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 54
Deficiencies: 1
Date: Oct 18, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff did not assist a resident with medications as prescribed.
Complaint Details
The complaint was substantiated. The allegation was that facility staff did not assist resident #1 with medications as prescribed, specifically PRN Ondansetron 4 mg. The investigation confirmed missed doses during the PM shift on 1 or 2 days the prior week.
Findings
The investigation substantiated the allegation that staff failed to assist resident #1 with PRN medications as prescribed, specifically Ondansetron 4 mg, which posed an immediate health risk. The facility was cited for not assisting residents with self-administered medications as required.
Deficiencies (1)
The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by failure to assist resident #1 with PRN medications.
Report Facts
Resident medications not assisted: 1
Census: 43
Total Capacity: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joann Rosales | Licensing Program Analyst | Conducted the complaint investigation visit |
| Fe Lilia Higgins | Administrator | Met with Licensing Program Analyst and provided information regarding medication assistance |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 43
Capacity: 54
Deficiencies: 1
Date: Oct 18, 2021
Visit Reason
The visit was a Case Management - Deficiencies unannounced inspection conducted to evaluate compliance and address deficiencies at the facility.
Findings
During the facility tour, the Licensing Program Analyst observed bleach and bed bug killer stored in an unlocked closet accessible to residents, which posed an immediate health risk. A deficiency was cited for failure to store disinfectants and poisons where inaccessible to clients.
Deficiencies (1)
Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients were not stored where inaccessible to clients, evidenced by bleach and bed bug killer found in an unlocked closet accessible to residents.
Report Facts
Capacity: 54
Census: 43
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fe Lilia Higgins | Administrator | Met with Licensing Program Analyst during inspection |
| JoAnn Rosales | Licensing Program Analyst | Conducted the Case Management - Deficiencies visit |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 41
Capacity: 54
Deficiencies: 0
Date: Jul 9, 2021
Visit Reason
The visit was an unannounced required annual inspection with a specific emphasis on infection control practices and procedures.
Findings
The facility was found to be in compliance with Title 22 regulations with no health or safety hazards observed. Infection control practices were adequate, with sufficient PPE supplies and cleaning protocols. No citations were issued during the visit.
Report Facts
Number of bedrooms: 20
Social distancing spacing: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fe Lilia Higgins | Administrator | Met with Licensing Program Analyst during inspection |
| Angel Ascencio | Licensing Program Analyst | Conducted the inspection |
| Kristin Heffernan | Licensing Program Manager | Named in report header |
| Amor Aquino | Staff member present during inspection |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 54
Deficiencies: 1
Date: Jul 9, 2021
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff failed to keep the facility clean.
Complaint Details
The complaint was substantiated. The allegation was that staff failed to keep the facility clean. Interviews with residents and staff confirmed that rooms and restrooms were not cleaned frequently, with some residents reporting their rooms had not been cleaned in 2-3 weeks. Staffing shortages were noted as a contributing factor.
Findings
The investigation found sufficient evidence to substantiate the allegation that staff failed to keep the facility clean, with multiple residents and staff reporting that rooms and restrooms were not cleaned regularly, posing potential health and safety risks.
Deficiencies (1)
87303 Maintenance and Operations (a): The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
Report Facts
Residents reporting unclean rooms/restrooms: 4
Staff reporting unclean rooms/restrooms: 4
Plan of Correction Due Date: Jul 23, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fe Lilia Higgins | Administrator | Met with Licensing Program Analyst during investigation |
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
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