Most inspections found no deficiencies, with the facility generally meeting regulatory standards and maintaining a clean, safe environment. Several complaint investigations were unsubstantiated, including recent ones in June 2025 and December 2022, indicating that many concerns raised were not supported by evidence. However, the facility had isolated deficiencies related to resident supervision in the most recent report dated July 10, 2025, when a resident left the premises unsupervised due to issues with monitoring devices. Earlier deficiencies included inadequate heating during a 2021 power outage and food service problems in 2020, but these were isolated and not repeated in recent years. The overall trend shows improvement with the latest annual inspection in April 2025 reporting no deficiencies.
The visit was a case management follow-up on an Unusual Incident/Injury Report received on July 7, 2025, regarding a resident who was unable to be located on the premises on July 5, 2025.
Findings
The facility failed to ensure proper supervision of resident R1, resulting in the resident leaving the premises unsupervised (AWOL). The facility identified issues with the wanderguard device and camera coverage, and corrective actions including updating the care plan and increasing supervision were planned. A deficiency was cited related to care and supervision.
Deficiencies (1)
Description
Facility did not ensure that resident R1 was properly supervised, resulting in AWOL, posing a potential health, safety, and personal rights risk to residents in care.
Report Facts
Deficiency Type: 1Plan of Correction Due Date: Jul 16, 2025Distance: 5
Employees Mentioned
Name
Title
Context
Michael Hood
Licensing Program Analyst
Conducted the case management visit and authored the report.
Alicia Rist
Executive Director
Met with Licensing Program Analyst during the visit and participated in exit interview.
Anthony Perez
Licensing Program Manager
Named as Licensing Program Manager overseeing the inspection.
An unannounced complaint investigation was conducted in response to an allegation that staff did not follow the resident's hospice care plan.
Findings
The investigation included interviews with hospice representatives and facility staff, and a review of relevant documentation. The allegation was found to be unfounded as the care plan was met by the facility and no neglect was identified.
Complaint Details
The complaint alleged that staff did not follow the resident's hospice care plan. The investigation found no evidence to support this allegation, deeming it unfounded.
Report Facts
Capacity: 160Census: 126
Employees Mentioned
Name
Title
Context
Michael Hood
Licensing Program Analyst
Conducted the complaint investigation
Anthony Perez
Licensing Program Manager
Oversaw the complaint investigation
Becca Deges
Resident Care Director
Interviewed during investigation regarding resident care
Alicia Rist
Executive Director
Interviewed during investigation regarding resident care
Sydney Lawson
Business Services Manager
Met with Licensing Program Analyst at start of investigation
The inspection was a Required-1 Year unannounced visit conducted to ensure compliance with Title 22 regulations for the care home.
Findings
The inspection found the facility to be in compliance with all applicable regulations, with no deficiencies cited. Observations included proper furnishing and maintenance of apartments and bathrooms, adequate food supply, operational safety equipment, and secure medication storage.
The inspection was an unannounced Required-1 Year Inspection conducted to ensure compliance with Title 22 regulations for the care home facility.
Findings
The inspection found the facility to be in compliance with regulations, with properly furnished apartments, sanitary bathrooms, adequate food supply, operational safety equipment, and secure medication storage. No deficiencies were cited during this visit.
The visit was a case management incident review conducted by the Licensing Program Analyst regarding multiple incident reports received by the Department.
Findings
The facility reported incidents including a lost wallet, falls, and a resident-on-resident altercation. No deficiencies were cited as a result of this visit.
Report Facts
Incident dates: Falls incidents dated 11/10/2023, 12/28/2023, and 1/3/2024; resident altercation dated 2/17/2024; lost wallet incident dated 3/1/2024
Employees Mentioned
Name
Title
Context
Alicia Rist
Executive Director
Met with Licensing Program Analyst during case management visit
This was an unannounced case management follow-up visit related to an incident report submitted by the facility on 10/17/2023 regarding a resident fall that resulted in hospitalization.
Findings
No issues or deficiencies were found during the visit. A few other topics were discussed but no deficiencies were cited.
The visit was conducted to conclude the annual inspection of the facility as part of the case management annual continuation.
Findings
No deficiencies were cited during the inspection. The Licensing Program Analyst completed the Compliance and Regulatory Enforcement Tool and CARE Tool for the annual inspection and obtained a copy of the staff evacuation chair training.
Report Facts
Capacity: 160Census: 130
Employees Mentioned
Name
Title
Context
Melissa Parks
Licensing Program Analyst
Conducted the annual inspection and completed regulatory tools
The inspection was conducted as the required annual unannounced inspection to evaluate compliance with regulatory standards.
Findings
The facility was found to be clean, well organized, and current on fire drills. All resident and staff files reviewed contained the required paperwork and training. No deficiencies were cited during this inspection.
The visit was an unannounced case management visit to confirm orders for immediate exclusion of an individual from all facilities.
Findings
The facility was informed of an immediate exclusion order effective 01/24/2023, requiring removal of employee S1 from any contact with clients and prohibiting physical presence in the facility.
Employees Mentioned
Name
Title
Context
Sydney Lawson
Assistant to the Executive Director
Met with Licensing Program Analyst during the visit and acknowledged the purpose of the immediate exclusion order.
The inspection was an unannounced complaint investigation conducted in response to allegations received on 2022-12-05 regarding non-adherence to COVID-19 protocols and inadequate staffing to meet residents' needs.
Findings
The investigation found that proper COVID-19 precautions were followed during a recent event and that staffing levels were adequate with use of staffing agencies when needed. No evidence supported the allegations, and the complaint was found to be unfounded.
Complaint Details
The complaint included allegations that facility staff did not adhere to COVID-19 protocol and that the facility did not have adequate staff to meet residents' needs. The investigation concluded these allegations were unfounded based on interviews, staffing schedules, and evidence reviewed.
Report Facts
Capacity: 160Census: 118Estimated Days of Completion: 0Number of staffing agencies: 4
Employees Mentioned
Name
Title
Context
Melissa Parks
Licensing Program Analyst
Conducted the complaint investigation
Maribeth Senty
Licensing Program Manager
Oversaw the complaint investigation
Tighe Hammam
Administrator
Facility administrator interviewed during investigation
The inspection was an unannounced complaint investigation conducted in response to allegations received on 2021-12-29 regarding the facility's failure to supply heat and light to residents' bedrooms and lack of staff to serve meals.
Findings
The investigation substantiated that the facility did not maintain resident bedrooms at a comfortable temperature of at least 68 degrees F during a power outage caused by a snowstorm, posing a potential health and safety risk. However, the allegation that the facility did not supply light to residents' bedrooms was unsubstantiated as battery-operated lanterns were provided. The facility was short staffed but still managed to provide meals to residents.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility did not supply heat to residents' bedrooms during a power outage caused by a snowstorm between 12/27/2021 and 12/29/2021. The allegation that the facility did not supply light to residents' bedrooms was unsubstantiated. The allegation that the facility did not have staff to serve meals was found to be substantiated but the facility managed to provide meals despite being short staffed.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Facility did not ensure that resident bedrooms were heated to a minimum of 68-degrees F during a power outage, posing a potential health, safety, and personal rights risk to residents.
Type B
Report Facts
Capacity: 160Census: 120Deficiency due date: Jul 8, 2022
Employees Mentioned
Name
Title
Context
Michael Hood
Licensing Program Analyst
Conducted the complaint investigation
Anthony Perez
Licensing Program Manager
Oversaw the complaint investigation
Cameron Uhlir
Executive Director
Facility representative met during investigation and exit interview
Adam Hill
Administrator
Facility administrator interviewed during investigation
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2021-12-28 regarding the sufficiency of the facility's Emergency Disaster Plan.
Findings
The investigation reviewed the facility's Emergency Disaster Plan and determined it to be sufficient in relation to Title 22 regulations. The allegation was found to be unfounded.
Complaint Details
The complaint alleged that the facility's Emergency Disaster Plan was not sufficient. The allegation was found to be unfounded, meaning it was false, could not have happened, or was without reasonable basis.
Report Facts
Capacity: 160Census: 120
Employees Mentioned
Name
Title
Context
Michael Hood
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Cameron Uhlir
Executive Director
Met with the Licensing Program Analyst during the investigation and acknowledged receipt of the report
The inspection was an unannounced Required-1 Year Inspection focusing on infection control conducted by the Licensing Program Analyst to ensure compliance with health and safety regulations.
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
Cameron Uhlir
Executive Director
Met with Licensing Program Analyst during inspection
Sydney Lawson
Assistant Executive Director
Met with Licensing Program Analyst during inspection
An unannounced complaint investigation visit was conducted regarding allegations that staff were not providing meals to residents in a timely manner and not providing adequate food service.
Findings
The investigation substantiated that residents received meals late or not at all during October 2020, and that residents were served burnt toast and frozen or undercooked vegetables, posing potential health and safety risks.
Complaint Details
The complaint was substantiated based on interviews with 10 staff and 12 residents, confirming incidents of late or missed meals and inadequate food quality including burnt toast and undercooked vegetables.
Severity Breakdown
Type B: 2
Deficiencies (2)
Description
Severity
Licensee did not provide meal services on time which poses a potential health and safety risk to residents in care.
Type B
Licensee did not ensure that frozen and/or undercooked food were not served to residents which poses a potential health and safety risk to residents in care.
Type B
Report Facts
Capacity: 160Census: 125Staff interviews: 10Resident interviews: 12Plan of Correction Due Date: Aug 2, 2021
Employees Mentioned
Name
Title
Context
Pheej Cheng
Licensing Program Analyst
Conducted the complaint investigation
Maribeth Senty
Licensing Program Manager
Named in report as Licensing Program Manager
Monica Avalos
Resident Care Coordinator II
Met with during investigation and mentioned in findings
The inspection was a required unannounced 1-year annual inspection focusing on the infection control domain.
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
Sean Beloud
Administrator
Met with Licensing Program Analysts during the inspection and involved in infection control domain completion.
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