Inspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on September 11, 2025, which was clean with no deficiencies cited. Earlier reports showed a few isolated issues, such as a medication error in June 2023 that posed an immediate health risk and a failure to observe a resident’s change in condition in April 2025. Several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. Minor deficiencies related to food safety, like uncovered food in the refrigerator, appeared in 2023 but were not repeated later. The facility’s record shows improvement over time, with recent inspections consistently meeting licensing requirements and no enforcement actions or fines listed in the available reports.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
1.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
87% occupied
Based on a September 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 118
Capacity: 135
Deficiencies: 0
Sep 11, 2025
Visit Reason
The visit was an unannounced required comprehensive annual inspection conducted by Licensing Program Analyst Mary Rico to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be operating within its licensed capacity and in good repair with no obstructions or safety hazards. Resident bedrooms and common areas were properly equipped and maintained. Food supply and care staffing were sufficient. Record reviews showed compliance with admission agreements, physician reports, medication, hospice, and staff certifications. No deficiencies were cited during this inspection.
Report Facts
Resident files reviewed: 10
Resident medications reviewed: 10
Hospice files reviewed: 5
Staff files reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Hunt | Administrator | Met with Licensing Program Analyst during inspection and discussed report |
| Mary Rico | Licensing Program Analyst | Conducted the unannounced annual inspection |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 135
Deficiencies: 0
May 19, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-03-04 regarding improper cleaning and sanitizing of dishes and utensils, failure to follow hand hygiene procedures, and failure to treat residents with dignity and respect.
Findings
The investigation included resident and staff interviews, facility tour, and document review. All three allegations were found to be unsubstantiated based on evidence, with no deficiencies cited during the visit.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included improper cleaning and sanitizing of dishes and utensils, failure to follow hand hygiene procedures, and failure to treat residents with dignity and respect. Evidence did not support these allegations.
Report Facts
Staff interviewed: 6
Residents interviewed: 8
Allegations investigated: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Hunt | Administrator | Met during investigation and named in report |
| Mary Rico | Licensing Program Analyst | Conducted the complaint investigation |
| Antionette Davis | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 124
Capacity: 135
Deficiencies: 1
Apr 23, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff did not dispense medication as prescribed resulting in hospitalization, and that staff did not address a change in a resident's condition.
Findings
The investigation substantiated that facility staff failed to observe a resident's change in condition, resulting in a deficiency citation. However, the allegation that medication was incorrectly dispensed causing a stroke was unsubstantiated due to lack of evidence. One deficiency was cited related to failure to observe resident condition changes.
Complaint Details
The complaint investigation was triggered by allegations that facility staff did not dispense medication as prescribed resulting in hospitalization and failed to address a resident's change in condition. The medication error allegation was unsubstantiated, but the failure to observe change in condition was substantiated with one deficiency cited.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to observe a change in condition for Resident #1, posing an immediate health, safety, or personal rights risk. | Type A |
Report Facts
Facility capacity: 135
Census: 124
Deficiencies cited: 1
Medication dosage error multiplier: 3
Time to stroke after medication error: 36
Plan of Correction due date: Apr 24, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Rico | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lisa Hunt | Administrator | Facility administrator met during investigation and exit interview |
| Efren Malagon | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 124
Capacity: 135
Deficiencies: 1
Apr 23, 2025
Visit Reason
An unannounced case management visit was conducted to deliver findings related to a complaint control 56-AS-20231107145012 concerning a medication error.
Findings
The investigation found that on 2023-06-28, staff member S2 administered resident R1's medication incorrectly by increasing the dosage to three times the prescribed amount instead of lowering it to half. One Type A deficiency was cited due to this medication error posing an immediate risk to health and safety.
Complaint Details
The visit was complaint-related, investigating a medication error where staff administered incorrect medication dosage to resident R1. The deficiency was substantiated and cited as Type A.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| S2 provided R1 the wrong medication dosage, increasing it to three times the prescribed amount instead of lowering it to half, posing an immediate health, safety, or personal rights risk. | Type A |
Report Facts
Deficiencies cited: 1
Medication dosage error multiplier: 3
Plan of Correction due date: Apr 23, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Hunt | Administrator | Met with Licensing Program Analyst during inspection and named in report |
| Mary Rico | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
Inspection Report
Annual Inspection
Census: 119
Capacity: 135
Deficiencies: 0
Nov 8, 2024
Visit Reason
The visit was an unannounced required comprehensive annual inspection conducted by the Licensing Program Analyst Mary Rico to evaluate the facility's compliance with regulations.
Findings
The facility was found to be operating within approved capacity and in good repair with no obstructions or safety hazards. Resident rooms and common areas were adequately furnished and maintained. Food service and care staffing were sufficient. No deficiencies were cited during the inspection.
Report Facts
Resident files reviewed: 6
Resident medications reviewed: 6
Hospice files reviewed: 6
Staff files reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Hunt | Administrator | Met with Licensing Program Analyst during inspection and named in report |
| Mary Rico | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Efren Malagon | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 125
Capacity: 135
Deficiencies: 1
Nov 13, 2023
Visit Reason
The visit was an unannounced Health and Safety check conducted simultaneously with the annual inspection to observe the facility's conditions including food supply, medications, physical plant, and residents in care.
Findings
One deficiency was cited during the annual inspection for not covering a tray of Jello in the refrigerator, resulting in a type B deficiency.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Tray of Jello uncovered in the refrigerator | Type B |
Report Facts
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Gardner | Licensing Program Analyst | Conducted the Health and Safety check and annual inspection |
| Lisa Hunt | Administrator | Facility administrator met during the inspection |
| Efren Malagon | Licensing Program Manager | Named in the report header |
Inspection Report
Annual Inspection
Census: 125
Capacity: 135
Deficiencies: 1
Nov 13, 2023
Visit Reason
The visit was an unannounced required comprehensive annual inspection conducted by the Licensing Program Analyst Ryan Gardner to evaluate compliance with regulations at the Residential Care Facility for the Elderly.
Findings
The facility was found to be operating safely and in good repair with sufficient staffing and proper record keeping. One deficiency was cited for a food service violation where uncovered Jello was found in the refrigerator, posing a potential health risk.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Uncovered Jello containers in the refrigerator, violating food service requirements for storing perishable foods in covered containers. | Type B |
Report Facts
Residents files reviewed: 8
Staff files reviewed: 8
Deficiencies cited: 1
Water temperature: 114.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Hunt | Administrator | Met with Licensing Program Analyst during inspection and received report |
| Ryan Gardner | Licensing Program Analyst | Conducted the inspection and authored the report |
| Efren Malagon | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 135
Deficiencies: 0
Jun 20, 2023
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that staff did not properly assess residents' needs.
Findings
The investigation found the allegation unsubstantiated based on observations and interviews. The report details an incident involving a deceased resident and staff response, concluding there was insufficient evidence to prove the alleged violation.
Complaint Details
The complaint alleged that staff did not properly assess residents' needs. The allegation was found unsubstantiated after investigation, meaning there was not a preponderance of evidence to prove the violation occurred.
Report Facts
Facility capacity: 135
Census: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Hunt | Executive Director | Met with Licensing Program Analyst during investigation and named in report findings |
| Javina George | Licensing Program Analyst | Conducted the complaint investigation visit |
| Joel Esquivel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 135
Deficiencies: 2
Jun 20, 2023
Visit Reason
An unannounced case management deficiencies visit was conducted in correlation to complaint control number 18-AS-20200513115313 to investigate reported deficiencies.
Findings
The facility failed to meet resident needs due to staff connecting a resident to the wrong respiratory machine, and failed to report the incident as required. Staff received counseling and the facility provided training on the difference between oxygen and nebulizer treatments.
Complaint Details
Visit was triggered by complaint control number 18-AS-20200513115313. The complaint was substantiated as deficiencies were cited related to neglect and failure to report.
Deficiencies (2)
| Description |
|---|
| Neglect/lack of care and supervision - staff failed to meet resident's needs by connecting Resident #1 to the wrong respiratory machine. |
| Failure to follow reporting requirements - the facility did not report the incident of Resident #1 not being hooked up to their oxygen machine as required. |
Report Facts
Capacity: 135
Census: 125
Plan of Correction Due Date: Jul 4, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Hunt | Executive Director | Facility administrator present during the inspection and named in the exit interview. |
| Javina George | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Joel Esquivel | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Annual Inspection
Census: 126
Capacity: 135
Deficiencies: 0
Sep 23, 2022
Visit Reason
The visit was an unannounced required annual inspection with an emphasis on infection control due to the COVID-19 pandemic.
Findings
The facility was found to be in compliance with no deficiencies cited. The facility has a comprehensive COVID-19 infection control plan, adequate PPE supplies, and follows Community Care Licensing Division guidelines.
Report Facts
Staff present: 22
PPE supply duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Gardner | Licensing Program Analyst | Conducted the inspection and authored the report |
| Morgan Cadmus | Regional Director of Operations | Facility representative met during inspection and exit interview |
| Karen Clemons | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 135
Deficiencies: 0
Mar 8, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2022-03-02 regarding staff behavior towards residents, including rough handling, yelling, and pushing.
Findings
The investigation included interviews with staff and residents. No evidence was found to substantiate the allegations; staff and residents denied or were unable to corroborate the claims. The allegations were determined to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated as there was no preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 135
Census: 107
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Semin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lisa Hunt | Administrator | Facility administrator met during the investigation |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 103
Capacity: 135
Deficiencies: 0
Sep 9, 2021
Visit Reason
The visit was an unannounced annual inspection limited to infection control, including a COVID-19 Risk Assessment Screening.
Findings
The facility was found to be successfully incorporating its COVID-19 Mitigation Plan with adequate hand sanitizer availability, stocked bathrooms, multiple infection control postings, and properly stored PPE supplies. Staff fit testing for N95 masks was ongoing with many already completed.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Hunt | Administrator | Met with Licensing Program Analyst during inspection and discussed infection control practices. |
| Jennifer Semin | Licensing Program Analyst | Conducted the inspection and COVID-19 Risk Assessment Screening. |
| Karen Clemons | Licensing Program Manager | Named in report header. |
Report
June 20, 2023
File
report_11_331880546_inx10_2023-06-20.pdf
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