Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance with regulations. The most recent report from October 16, 2024, was clean, showing the facility was well-maintained and infection control protocols were followed. Past issues included a substantiated complaint in January 2022 involving inadequate care and staffing that led to a resident’s fall and injuries, and a November 2023 finding of excessively high hot water temperatures posing a safety risk. Other deficiencies involved delays in providing resident records and staffing shortages, but these were isolated and less frequent. Overall, the facility’s record shows improvement over time, with the latest annual inspection free of deficiencies.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 34
Capacity: 72
Deficiencies: 0
Oct 16, 2024
Visit Reason
One (1) Year Required visit for this facility as part of the annual licensing inspection.
Findings
The facility was found to be clean, well-maintained, and compliant with infection control protocols. The kitchen, bedrooms, bathrooms, common areas, and medication storage were all observed to be in good condition with no hazards noted. Fire safety equipment was up to date and functional. Resident and staff records were complete and updated.
Report Facts
Fire inspection date: Mar 27, 2024
Sprinkler system test date: Mar 27, 2024
Fire extinguisher service date: Jun 3, 2024
Fire drill date: Sep 28, 2024
Residents reviewed: 4
Staff reviewed: 5
Facility temperature: 74
Hot water temperature range: 109.5
Hot water temperature range: 119.7
Non-ambulatory resident capacity: 72
Bedridden resident capacity: 40
Hospice waiver capacity: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gary Tan | Licensing Program Analyst | Conducted the inspection and authored the report |
| Magdalena Cabrera | Interim Administrator | Met with Licensing Program Analyst during inspection |
| David Monroy | Vice President of Operations | Met with Licensing Program Analyst during inspection |
| Troy Agard | Licensing Program Manager | Oversaw the licensing program and signed the report |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 72
Deficiencies: 0
May 6, 2024
Visit Reason
The visit was conducted to investigate a complaint received on 2022-07-21 regarding allegations of neglect, failure to follow care plan, lack of hot water, failure to consult with responsible party timely, and resident bathroom access issues at Foothill Retirement Care Home.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Interviews, document reviews, and physical plant inspections were conducted, but all allegations were determined to be unsubstantiated at this time.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included neglect resulting in infections, failure to follow care plan, no hot water, failure to consult with responsible party timely, and resident not having access to bathroom. Each allegation was investigated through interviews, document review, and physical inspection, but no evidence was found to support the claims.
Report Facts
Capacity: 72
Census: 32
Hot water temperature range: 105
Hot water temperature range: 111
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tuesday Cabiness | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Celia Garcia | Facility representative met during the investigation | |
| Jina Maleksarkissians | Administrator | Facility administrator named in the report |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 33
Capacity: 72
Deficiencies: 1
Nov 18, 2023
Visit Reason
The inspection was a required one-year unannounced visit to evaluate the facility's compliance with licensing regulations.
Findings
The facility was generally found to be clean, well-maintained, and compliant with infection control protocols, with adequate supplies and safety measures in place. However, a deficiency was cited for hot water temperatures in resident and common shower rooms exceeding the allowed range, posing a health and safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Hot water temperature controls were not maintained within the required range of 105°F to 120°F; temperatures measured between 122.4°F to 142.3°F in random bedrooms and common shower rooms, posing an immediate health and safety risk. | Type A |
Report Facts
Deficiency due date: Nov 20, 2023
Residents reviewed: 4
Staff reviewed: 5
Fire inspection last done: Aug 18, 2023
Fire inspection valid until: Jul 31, 2025
Sprinkler system last tested: Aug 18, 2023
Sprinkler system valid until: Jul 31, 2025
Fire extinguishers last serviced: Mar 2, 2023
Fire drill last conducted: Sep 26, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the inspection and authored the report |
| Claudia Torres | Executive Director | Facility representative met during inspection |
| Jecery Ninonuevo | Administrator | Facility administrator who agreed to plan of correction |
| Troy Agard | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 72
Deficiencies: 0
Apr 14, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations including staff yelling at a resident, illegal eviction, failure to issue a refund, disrepair of facility TV, residents left unsupervised, and staff not responding to a resident's call for help.
Findings
The investigation found the allegations to be unfounded, meaning they were either false, could not have happened, or lacked a reasonable basis. No staff or owner connections mentioned in the complaint were verified at the facility.
Complaint Details
The complaint investigation was initiated based on allegations received on 04/13/2023. The allegations were determined to be unfounded after the investigation.
Report Facts
Facility capacity: 72
Census: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jecery Ninonuevo | Administrator | Met with Licensing Program Analyst during the investigation and provided information about the allegations |
| Jose Gary Tan | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 72
Deficiencies: 1
Apr 13, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation that facility staff failed to provide a resident's records to an authorized representative.
Findings
The investigation found that the facility had not yet sent the requested resident records to the authorized representative, substantiating the allegation. A citation was issued and appeal rights were discussed.
Complaint Details
The complaint was substantiated. The allegation involved failure to provide resident records to an authorized representative. The formal request was made on 03/23/2023 and sent via FedEx on 03/24/2023, but the facility had not sent the records as of the investigation date.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee failed to provide Resident #1's records to the authorized representative, posing a potential personal rights risk to residents in care. | Type B |
Report Facts
Capacity: 72
Census: 41
Deficiencies cited: 1
Plan of Correction Due Date: Apr 21, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation |
| Mariana Agban | Licensing Program Analyst | Conducted the complaint investigation |
| Jecery Ninonuevo | Administrator | Interviewed during investigation and involved in findings |
Inspection Report
Annual Inspection
Census: 42
Capacity: 72
Deficiencies: 0
Nov 30, 2022
Visit Reason
The visit was a required one-year unannounced infection control inspection to evaluate compliance with health and safety standards at the facility.
Findings
The facility was found to be in compliance with infection control and safety standards, including adequate PPE supplies, proper food storage, locked medications and sharps, clean and well-maintained environment, and operational fire safety equipment. No health and safety hazards were noted during the visit.
Report Facts
Hot water temperature: 118.4
Fire extinguisher last inspection date: Feb 28, 2022
Licensed capacity: 72
Current census: 42
Non-ambulatory capacity: 72
Bedridden capacity: 40
Hospice waiver capacity: 10
Perishable food stock: 2
Non-perishable food stock: 7
Facility temperature: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the inspection and met with facility administrator |
| Tannya Quezada | Administrator | Facility administrator met during inspection |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 72
Deficiencies: 2
Jan 14, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that the facility failed to provide adequate care and supervision, resulting in client injury.
Findings
The investigation substantiated that the facility failed to provide adequate care and supervision, leading to a resident's fall and injuries including a fractured wrist and rib. Inadequate staffing and lack of updated care plans contributed to the incident.
Complaint Details
The complaint was substantiated based on interviews and record reviews. The resident fell on 08/01/2021 sustaining a fractured wrist and rib. The facility failed to conduct a new written appraisal after a previous fall and had inadequate staffing on the night of the fall, contributing to the incident.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. | Type A |
| Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, including activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications. | Type A |
Report Facts
Immediate Civil Penalty: 500
Capacity: 72
Census: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexander Pitz | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 72
Deficiencies: 1
Nov 4, 2021
Visit Reason
The visit was conducted as a Case Management report to address a deficiency that arose during the investigation of complaint #31-AS-20200922155620.
Findings
The facility did not agree to release pertinent facility records requested by the licensing agency, which poses a potential risk to the residents in care.
Complaint Details
The visit was triggered by complaint #31-AS-20200922155620. The deficiency was substantiated as the facility refused to release requested financial documents during the investigation.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. The facility did not agree to release pertinent facility records. | Type B |
Report Facts
Deficiency count: 1
Plan of Correction Due Date: Nov 30, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexander Pitz | Licensing Program Analyst | Generated the Case Management report and conducted the investigation. |
| Eva Miller | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the evaluation. |
| Jina Maleksarkissians | Administrator | Facility administrator who informed the analyst that the facility's headquarters did not believe they needed to release documentation. |
| Roy Manasan | Met with during the visit. |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 72
Deficiencies: 1
Nov 4, 2021
Visit Reason
The inspection visit was conducted in response to a complaint alleging that the facility was having financial issues.
Findings
The allegation that the facility was having financial issues was substantiated. The facility lacked sufficient financial resources to maintain adequate staffing, posing an immediate risk to residents. The facility was referred to an audit due to failure to provide requested financial documentation.
Complaint Details
The complaint alleging financial issues was substantiated based on interviews and observations. The facility lacked staffing due to financial hardship and refused to release financial documents for audit.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee did not have a financial plan sufficient to maintain adequate staffing, posing an immediate risk to residents. | Type A |
Report Facts
Capacity: 72
Census: 40
Deficiencies cited: 1
Plan of Correction Due Date: Nov 5, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexander Pitz | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation |
| Jina Maleksarkissians | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Routine
Census: 40
Capacity: 72
Deficiencies: 0
Nov 1, 2021
Visit Reason
An unannounced infection control inspection was conducted as a required one-year routine visit to assess compliance with COVID-19 protocols and overall infection control practices.
Findings
The facility demonstrated strong infection control measures including high resident and staff vaccination rates, proper use of PPE, clean common areas, and effective screening and testing protocols. No active or past COVID-19 cases were reported since January 2021, and the facility maintains adequate supplies and training.
Report Facts
Residents vaccinated: 99
Residents in living quarters: 24
Residents in living quarters: 12
Residents in living quarters: 4
Unvaccinated residents under surveillance testing: 1
Inspection Report
Complaint Investigation
Census: 42
Capacity: 72
Deficiencies: 0
Sep 30, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that a resident had multiple pressure wounds.
Findings
The allegation that the resident had multiple pressure wounds was unsubstantiated based on records reviewed and interviews conducted. The resident was admitted to the hospital with pressure injuries and was receiving home health services for wound care, which is an allowable health condition under Title 22.
Complaint Details
The complaint investigation was unsubstantiated. The resident was admitted to the hospital on 3/10/20 with multiple stage 1 and stage 2 pressure injuries, and was receiving home health services for wound care. No deficiencies were cited.
Report Facts
Capacity: 72
Census: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexander Pitz | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 72
Deficiencies: 1
Sep 30, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 09/22/2020 regarding staffing shortages, inadequate food service, and insufficient supplies at the facility.
Findings
The investigation substantiated the allegation that the facility is lacking staff, specifically in the memory care unit where only one dedicated caregiver is assigned with backup from a med tech. Allegations regarding inadequate food service and insufficient supplies were unsubstantiated based on interviews and observations. A deficiency was cited for insufficient staffing posing potential risk to residents.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility is lacking staff. The allegations that the facility was not providing adequate food service and did not have adequate supplies were unsubstantiated.
Deficiencies (1)
| Description |
|---|
| 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The facility does not ensure that the memory care unit is sufficiently staffed, posing a potential risk to the health, safety or personal rights of residents. |
Report Facts
Residents in memory care unit: 13
Residents with dementia diagnosis: 12
Residents requiring assistance with dressing and bathing: 12
Residents requiring assistance with toileting: 11
Non-ambulatory residents: 10
Incontinent residents: 7
Residents experiencing sundowning: 5
Residents exhibiting wandering/inappropriate/confused behavior: 4
Aggressive residents: 3
Residents requiring continuous bed care: 2
Residents with history of skin breakdown: 2
Residents requiring assistance with eating: 2
Staff interviewed indicating additional staff necessary: 6
Residents interviewed indicating additional staff necessary: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexander Pitz | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation |
| Jina Maleksarkissians | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 72
Deficiencies: 0
Nov 20, 2020
Visit Reason
The visit was conducted due to an incident report received on 11/19/2020 regarding alleged abuse of a resident by a staff member on 11/17/2020. The purpose was to investigate the incident and gather information.
Findings
The Licensing Program Analyst conducted a virtual case management incident visit, interviewed the administrator, staff, and residents, and reviewed documentation. The staff member involved was no longer providing direct services to the resident pending investigation. The incident was cross-reported to local authorities and the Long-Term Care Ombudsman. Additional information was requested.
Complaint Details
The complaint involved alleged abuse of a resident (R1) by a staff member (S1). The incident was reported on 11/19/2020 for an event occurring on 11/17/2020. The staff member was removed from direct care pending investigation. The incident was cross-reported to the police and Long-Term Care Ombudsman.
Report Facts
Capacity: 72
Census: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jina Maleksarkissians | Administrator | Met during the visit and involved in the incident investigation |
| Martina Berry | Licensing Program Analyst | Conducted the case management incident visit |
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