Inspection Report Summary
Most inspections found no deficiencies, with several complaint investigations unsubstantiated, reflecting generally good compliance. The most recent report from August 19, 2025, had no deficiencies cited, though it noted further investigation was needed after a death report. Earlier reports identified some isolated issues, including a serious deficiency in July 2025 when a resident left the facility unnoticed for several hours, posing an immediate health and safety risk, and deficiencies related to staff training on incontinence care and documentation of dentures in 2023 and 2022. Medication management was also cited once in 2021 for an inaccurate medication log, but no fines or enforcement actions were listed in the available reports. The facility appears to have improved recently, with no deficiencies in the latest inspections following earlier isolated concerns.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Census: 60
Capacity: 116
Deficiencies: 0
Aug 19, 2025
Visit Reason
This unannounced case management visit was conducted in response to a death report submitted by the facility.
Findings
The Licensing Program Analyst obtained some documentation from the facility. No deficiencies were cited, but the matter requires further investigation.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the unannounced case management visit in response to a death report. |
Inspection Report
Follow-Up
Census: 62
Capacity: 116
Deficiencies: 0
Jul 22, 2025
Visit Reason
This visit was conducted as a follow-up for complaint #59-AS-20250428114131 to interview staff regarding a resident.
Findings
No deficiencies were cited during this follow-up visit.
Complaint Details
Follow-up visit related to complaint #59-AS-20250428114131; no deficiencies cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the follow-up visit and interviewed staff regarding a resident. |
| Ivy Garner | Assistant Administrator | Met with during the inspection visit. |
| Gurprit Bains | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Census: 62
Capacity: 116
Deficiencies: 1
Jul 22, 2025
Visit Reason
This unannounced case management visit was conducted in response to a resident who left the facility without being noticed on July 19, 2025, and was not noticed gone until the early morning of July 20, 2025.
Findings
The facility failed to monitor residents properly, resulting in a resident leaving the facility unnoticed for multiple hours, which posed an immediate health and safety risk. Elopement drills and monitoring procedures are being implemented to address this issue.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee failed to monitor residents adequately, allowing a resident to leave the facility through the front door and remain missing for multiple hours, posing an immediate health and safety risk. | Type A |
Report Facts
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the unannounced case management visit |
| Troy Ordonez | Licensing Program Manager | Named in report as Licensing Program Manager |
| Ivy Garner | Assistant Administrator | Met with during inspection and provided information about the incident |
Inspection Report
Census: 60
Capacity: 116
Deficiencies: 0
Jul 2, 2025
Visit Reason
Licensing Program Analysts conducted a visit to deliver two amended complaint reports that were initially delivered on 05/01/2025 and 06/19/2025.
Findings
No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gurprit Bains | Administrator/Director | Named as facility administrator/director. |
| Gurpreet Kaur | Met with during the inspection. | |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the visit and signed the report. |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 116
Deficiencies: 0
Jun 19, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-04-28 regarding oral hygiene care, safeguarding personal belongings, and ensuring clean clothing for a resident.
Findings
The investigation found that the resident has dementia and it was difficult to determine the resident's ability to manage dentures and oral hygiene. Staff reported assisting with denture cleaning and observed clean clothes in the resident's room. The resident has the right to wear what they want, and staff need to work with the resident to ensure clean clothing. The allegations were found to be unsubstantiated with no deficiencies cited.
Complaint Details
The complaint involved allegations that facility staff did not provide oral hygiene care, did not safeguard the resident's personal belongings, and did not ensure the resident had clean clothing. The investigation concluded the allegations were unsubstantiated due to insufficient evidence to prove violations.
Report Facts
Complaint Control Number: 59
Capacity: 116
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the complaint investigation visit |
| Ivy Garner | Assistant Administrator | Met with Licensing Program Analyst during investigation |
| Gurprit Bains | Administrator | Named as facility administrator |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 116
Deficiencies: 0
May 1, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2025-02-24 regarding staff response to resident alerts, adequacy of care and supervision, and staff training on transfers and lifts.
Findings
The investigation found the allegations unsubstantiated or unfounded. There was insufficient evidence to prove staff failed to respond timely to resident alerts or provide adequate care. Staff training on transfers and lifts met Title 22 requirements. No deficiencies were cited.
Complaint Details
The complaint involved multiple allegations: staff did not timely respond to resident alerts, did not provide adequate care and supervision, and were not properly trained on transfers and lifts. The investigation concluded the first two allegations were unsubstantiated due to lack of evidence, and the third was unfounded as staff had required training.
Report Facts
Facility capacity: 116
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the complaint investigation |
| Ivy Garner | Assistant Administrator | Met with Licensing Program Analyst during investigation |
| Gurprit Bains | Administrator | Named as facility administrator |
| Troy Ordonez | Licensing Program Manager | Named as licensing program manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 60
Capacity: 116
Deficiencies: 0
Oct 16, 2024
Visit Reason
This was an unannounced annual inspection visit conducted as a required one-year inspection to evaluate the facility's compliance with licensing regulations.
Findings
The licensing program analyst toured the facility and reviewed resident and staff records. No issues of concern or deficiencies were observed during the inspection.
Report Facts
Resident rooms: 59
Private bathrooms (full): 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gurpreet Kaur | Resident Care Coordinator | Toured the facility with the licensing program analyst |
| Gurprit Bains | Administrator/Director | Named as facility administrator/director |
| Troy Ordonez | Licensing Program Manager | Named as licensing program manager |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 116
Deficiencies: 0
Apr 24, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-01-24 regarding staff mistreating residents and residents not being allowed to use the phone.
Findings
The investigation found the allegation of staff mistreating residents to be unsubstantiated due to conflicting witness accounts and lack of proof. The allegation that residents were not allowed to use the phone was found to be unfounded, as residents had access to telephones and no one was told they could not use them.
Complaint Details
The complaint involved allegations of staff mistreating residents and residents not being allowed to use the phone. The mistreatment allegation was unsubstantiated, meaning there was not a preponderance of evidence to prove the violation occurred. The phone use allegation was unfounded, meaning it was false or without reasonable basis.
Report Facts
Capacity: 116
Census: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ivy Garner | Assistant Administrator | Met with during the investigation and interviewed regarding allegations |
| Todd Tryon | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 72
Capacity: 116
Deficiencies: 0
Oct 19, 2023
Visit Reason
This was an unannounced annual inspection visit conducted as a required one-year evaluation of the facility.
Findings
The inspection included review of resident records and staff files, observation of facility layout and infection control practices, and discussion of multiple topics. No deficiencies were cited, but updates to certain documents must be submitted within 30 days.
Report Facts
Resident rooms: 59
Private bathrooms with full bath: 3
Inspection Report
Complaint Investigation
Capacity: 116
Deficiencies: 1
Apr 24, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-01-03 regarding the facility not communicating with the responsible party and other allegations related to resident care and property.
Findings
The investigation substantiated that the facility failed to notify the responsible party about a missing item, although the facility had contacted the doctor to adjust the resident's dietary needs. Another allegation regarding safeguarding resident's personal property and following the care plan was found unsubstantiated due to insufficient evidence.
Complaint Details
The complaint was substantiated regarding failure to communicate with the responsible party about a missing item. Another complaint about safeguarding resident's personal property and adherence to the care plan was unsubstantiated due to lack of evidence.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify responsible parties regarding resident personal belongings going missing, violating personal rights of residents. | Type B |
Report Facts
Capacity: 116
Deficiency Plan of Correction Due Date: May 24, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the complaint investigation |
| Lauren Crocker | Licensing Program Manager | Oversaw the complaint investigation and signed the report |
| Gurprit Bains | Administrator | Facility administrator named in the report |
| Ivy Garner | Administrator Assistant | Interviewed during the investigation regarding communication with responsible party |
Inspection Report
Complaint Investigation
Capacity: 116
Deficiencies: 1
Apr 24, 2023
Visit Reason
The visit was conducted as a case management in response to a complaint investigation regarding a resident who wore dentures that were not documented in the resident's plan of care or annual assessments.
Findings
The investigation found that the resident's written plan of care and annual assessments did not mention the use of dentures, nor did they address the resident's physical and mental capabilities related to wearing dentures despite the resident having dementia. This was a deficiency cited under Title 22 Regulations and the California Health and Safety Code.
Complaint Details
The visit was triggered by complaint control number 25-AS-20230103141558. The complaint was substantiated as the resident wore dentures that were not documented in care plans or assessments.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to include dentures in the resident's annual medical assessment and plan of care, including reassessment of dementia care needs. | Type B |
Report Facts
Facility capacity: 116
Plan of Correction due date: May 24, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the case management and complaint investigation |
| Lauren Crocker | Licensing Program Manager | Supervisor and named in the report |
Inspection Report
Annual Inspection
Census: 65
Capacity: 116
Deficiencies: 0
Dec 1, 2022
Visit Reason
This was an unannounced annual inspection visit required by the licensing authority to evaluate facility compliance.
Findings
The inspection found no deficiencies. Several resident and staff files were reviewed, and multiple topics were discussed. Some documents were required to be updated and submitted within 30 days.
Report Facts
Resident rooms: 59
Private bathrooms with full bath: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gurprit Bains | Administrator | Facility administrator named in the report |
| Ivy Garner | Assistant Administrator | Met with the licensing analyst during the inspection |
| Troy Ordonez | Licensing Program Manager | Named as licensing program manager |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the inspection and named as licensing program analyst |
Inspection Report
Census: 65
Capacity: 116
Deficiencies: 0
Jun 21, 2022
Visit Reason
The visit was a case management visit to advise the facility administrator about the proper use of a Hoyer Lift following a complaint visit on 04/12/22 regarding staff use of the lift to transport a resident from bed to bathroom.
Findings
The investigation determined that the Hoyer Lift should only be used to transfer a resident from bed to wheelchair or bedside commode, not for transfers from one room to another. The administrator acknowledged understanding the proper use. No deficiencies were cited.
Complaint Details
The visit was related to a complaint received about improper use of a Hoyer Lift during a resident transfer on 04/12/22. The complaint was investigated and found to be a misuse of the lift, but no deficiencies were cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ivy Garner | Assistant Administrator | Met during the visit and advised about proper Hoyer Lift use. |
| Donna Gurriere | Licensing Program Analyst | Conducted the visit and COVID-19 screening protocols. |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 116
Deficiencies: 0
May 18, 2022
Visit Reason
The visit was an unannounced case management investigation triggered by a reported incident involving Resident 1 who had an unwitnessed fall on 12/25/2022 resulting in a fracture and emergency room visit.
Findings
The investigation found that Resident 1 was under Hospice care with documented 2-hour precaution checks. Staff last checked on the resident shortly before the incident and responded immediately by assessing the resident and contacting 911. No citations were issued during this visit.
Complaint Details
The complaint involved an unwitnessed fall of Resident 1 on 12/25/2022 resulting in a fracture. The facility had precautions in place and documented checks. The complaint was investigated with no citations issued.
Report Facts
Capacity: 116
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Thomas | Residential Service Director | Met with Licensing Program Analysts during the visit and discussed the incident |
| Ivy Garner | ED in Training | Met with Licensing Program Analysts during the visit and discussed the incident |
| Mai Thao | Licensing Program Analyst | Conducted the case management visit |
| Melissa Bennett | IB Investigator | Conducted the case management visit |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 116
Deficiencies: 0
May 3, 2022
Visit Reason
An unannounced complaint investigation was conducted following allegations that a resident was left in a soiled diaper for 2.5 days and that staff were not giving a resident prescribed medication for a rash.
Findings
The investigation included interviews with staff and review of documentation. It was found that there was no preponderance of evidence to prove the allegations, and both claims were unsubstantiated.
Complaint Details
The complaint alleged that a resident was left in a soiled diaper for 2.5 days and that staff were not administering prescribed medication for a rash. After investigation, including interviews and document review, the allegations were found unsubstantiated due to lack of evidence.
Report Facts
Capacity: 116
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Perez | Licensing Program Manager | Named in report as Licensing Program Manager |
| Ivy Garner | Assistant Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 116
Deficiencies: 0
Apr 26, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 10/11/2021 regarding medication administration, resident care, food service, and resident property issues at Emerald Oaks facility.
Findings
The investigation found no preponderance of evidence to substantiate any of the allegations, including inaccurate medication dosage, unqualified staff administering medication, untimely diaper changes causing rash, delayed response to call buttons, stolen resident belongings, and inadequate food service. All findings were unsubstantiated and no deficiencies were cited in this report.
Complaint Details
The complaint investigation was unsubstantiated. Despite multiple allegations, including medication errors, staff qualifications, resident care, and food service issues, the evidence did not support the claims. The resident involved had moved and was not interviewed. Staff interviews and document reviews did not confirm violations.
Report Facts
Capacity: 116
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Ivy Garner | Assistant Administrator | Met with Licensing Program Analyst during investigation and interviewed regarding allegations |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 116
Deficiencies: 1
Apr 26, 2022
Visit Reason
The visit was conducted to investigate a complaint (#25-AS-20211011102847) regarding residents with incontinence and bladder issues.
Findings
The investigation found a substantiated deficiency related to the facility smelling of urine due to inadequate management of incontinent residents, posing a potential safety risk. The facility was in the process of changing the carpet in the affected resident's room.
Complaint Details
The deficiency was substantiated based on the preponderance of evidence standard. The citation is related to the complaint #25-AS-20211011102847. Appeal rights were provided and the exit interview was conducted.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Managed Incontinence - The licensee did not ensure that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. | Type B |
Report Facts
Capacity: 116
Census: 65
Plan of Correction Due Date: May 17, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the investigation and cited the deficiency |
| Ivy Garner | Assistant Administrator | Met with Licensing Program Analyst during the visit and provided information about the resident and facility conditions |
| Anthony Perez | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 116
Deficiencies: 0
Apr 12, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that residents do not receive food in a timely manner, staff serve residents cold food, staff do not follow protocol to prevent the spread of illness, and the facility has bed bugs.
Findings
The investigation included interviews with staff and residents, review of policies, menus, medical and pest control documentation. The findings concluded that there was insufficient evidence to substantiate the allegations, and all claims were determined to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included delayed food service, cold food, failure to follow illness prevention protocols, and presence of bed bugs. Evidence reviewed included interviews, facility policies, medical reports, and pest control invoices. No violations were proven.
Report Facts
Capacity: 116
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation |
| Ivy Garner | Assistant Administrator | Met with Licensing Program Analyst during investigation |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 116
Deficiencies: 1
Apr 12, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that a resident was being transferred from bed to toilet in an unsafe manner and that a resident was left in bed in her own urine.
Findings
The investigation included interviews with staff and the resident, review of documentation, and observation of equipment use. It was found that there was no preponderance of evidence to prove the allegations, and both were unsubstantiated. However, staff had not been trained by a skilled professional on the bowel and bladder program as required, leading to a separate citation.
Complaint Details
The complaint investigation was unsubstantiated for both allegations: unsafe transfer of a resident using a Hoyer Lift and a resident being left in bed in her own urine. The resident reported feeling safe during transfers, and staff followed an incontinence schedule. However, staff training on the bowel and bladder program was inadequate.
Deficiencies (1)
| Description |
|---|
| Staff have not been trained by a skilled professional on the bowel and bladder program as required. |
Report Facts
Capacity: 116
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation and met with facility staff |
| Ivy Garner | Assistant Administrator | Met with Licensing Program Analyst during investigation |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 116
Deficiencies: 1
Apr 12, 2022
Visit Reason
The visit was conducted as part of an investigation of Complaint #25-AS-20210722143123, alleging that a resident was left in bed in her own urine.
Findings
The investigation found that although it was not indicated that the resident was left in bed in her own urine, the staff failed to receive required training by a skilled professional on the bowel and bladder program, which was substantiated as a deficiency.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The allegation was that a resident was left in bed in her own urine, but the deficiency cited was related to lack of staff training on the bowel and bladder program.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that staff providing incontinence care were trained by a skilled professional as required, posing an immediate safety risk to residents. | Type A |
Report Facts
Facility Capacity: 116
Census: 65
Plan of Correction Due Date: Apr 13, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the investigation and authored the report |
| Ivy Garner | Assistant Administrator | Met with Licensing Program Analyst during the investigation |
| Anthony Perez | Licensing Program Manager / Supervisor | Supervisor of the licensing evaluation |
Inspection Report
Annual Inspection
Census: 62
Capacity: 116
Deficiencies: 0
Dec 8, 2021
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure health and safety compliance at the facility.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Keane | Licensing Program Analyst | Conducted the inspection and was involved in infection control domain evaluation. |
| Ivy Garner | Assistant Executive Director | Met with Licensing Program Analyst during the inspection and participated in the facility tour. |
Inspection Report
Census: 59
Capacity: 116
Deficiencies: 0
Aug 31, 2021
Visit Reason
The visit was an unannounced case management visit regarding an incident involving resident falls and injuries.
Findings
The Licensing Program Analyst conducted COVID-19 screening protocols and reviewed incidents of two unwitnessed resident falls resulting in injuries. No deficiencies were cited during the visit.
Report Facts
Resident falls reported: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the case management visit and COVID-19 screening. |
| Rayna L Bryson | Licensing Program Manager | Named in the report as Licensing Program Manager. |
| Gurprit Bains | Administrator | Facility administrator present during the visit. |
| Ivy Garner | Met with during the visit. |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 116
Deficiencies: 1
Apr 16, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to a complaint received on 2020-12-28 regarding staff mismanaging a resident's medication and other allegations.
Findings
The investigation substantiated the allegation that staff mismanaged a resident's medication, specifically that medication was not properly logged into the facility's Centrally Stored Medication Log. Other allegations regarding a resident wandering away and staff not meeting hygiene needs were found to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for medication mismanagement but unsubstantiated for allegations that a resident wandered away and staff not meeting hygiene needs.
Deficiencies (1)
| Description |
|---|
| Licensee did not maintain an accurate centrally stored medication log for 1 resident which poses a potential health and safety risk. |
Report Facts
Capacity: 116
Census: 54
Deficiency Type: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pheej Cheng | Licensing Program Analyst | Conducted the complaint investigation |
| Rayna L Bryson | Licensing Program Manager | Oversaw the complaint investigation |
| Ivy Garner | Executive Director in Training | Met with Licensing Program Analyst during investigation |
| Becky Baker | Administrator | Facility administrator named in the report |
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