Most inspections found no deficiencies, with the facility generally meeting health and safety standards and maintaining clean, well-kept environments. The most recent report from January 23, 2025, was perfect with no deficiencies noted. Earlier reports included two minor issues in February 2024 involving water temperature in some bathrooms and a missed emergency drill, but these were isolated and not repeated. Several complaint investigations between 2022 and 2024 were unsubstantiated, including allegations about medication administration, reporting failures, and financial abuse linked to a private caregiver rather than facility staff. Overall, the facility’s compliance appears stable with improvement shown since the last cited deficiencies.
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 facility was found to be in compliance with all applicable regulations, with no citations issued. Resident rooms, common areas, kitchen, emergency equipment, and records were all in order and well maintained.
The visit was conducted as a complaint investigation following an allegation that facility staff were not ensuring that an appropriately skilled professional was assisting the resident with injections.
Findings
The investigation found insufficient evidence to support the allegation that caregivers or private caregivers were providing injections to residents. Interviews and medication records confirmed that residents self-administer medications and that injections are only provided by skilled nursing staff. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that a caregiver was providing medication injections to a resident. The investigation included interviews with residents, staff, and review of medication records. The allegation was found unsubstantiated due to lack of evidence.
Report Facts
Complaint Control Number: 29Number of residents interviewed: 10Number of staff interviewed: 3
Employees Mentioned
Name
Title
Context
Adam Pena
Administrator
Met with during investigation and denied allegation
Zabel Chochian
Licensing Program Analyst
Conducted complaint investigation
Desaree Perera
Licensing Program Manager
Oversaw complaint investigation
Clarissa Townes
Director of Health Services
Met with during investigation
Maria Rona Perez
Director of Health Care Services
Provided statements confirming facility policy on injections
The inspection was conducted as an unannounced complaint investigation following a complaint received on 07/19/2024 alleging that facility staff did not comply with reporting requirements.
Findings
The investigation found that the facility staff followed their reporting protocol and notified responsible parties as required. The allegation that staff failed to notify residents' responsible parties when sent to the hospital was unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged failure to notify residents' responsible parties when residents were sent to the hospital/ER. The investigation determined the allegation to be unsubstantiated.
Report Facts
Complaint Control Number: 29-AS-20240719154743Capacity: 216Census: 106
Employees Mentioned
Name
Title
Context
Adam Pena
Executive Director
Met with Licensing Program Analyst during investigation
The inspection was a required unannounced annual visit to ensure the facility's compliance with Title 22 Regulations and health and safety standards.
Findings
The facility was generally found to be in compliance with health and safety regulations, including proper maintenance of physical plant areas, infection control measures, and record keeping. However, deficiencies were cited related to water temperature exceeding 120 degrees Fahrenheit in four resident bathrooms and failure to conduct quarterly emergency disaster drills as required.
Severity Breakdown
Type A: 1Type B: 1
Deficiencies (2)
Description
Severity
Water temperature in four out of nine bathrooms exceeded 120 degrees Fahrenheit, posing an immediate health and safety risk.
Type A
Failure to conduct an emergency disaster drill since April 2023, which poses a potential health, safety, or personal rights risk.
Type B
Report Facts
Resident rooms inspected: 9Resident records reviewed: 6Personnel records reviewed: 6Residents receiving medication assistance: 9Staff interviewed: 6Residents interviewed: 6Plan of Correction Due Date: Feb 9, 2024Plan of Correction Due Date: Feb 29, 2024
Employees Mentioned
Name
Title
Context
Adam Pena
Administrator / Executive Director
Met with LPAs during inspection and agreed to plans of correction
The inspection was a required unannounced annual visit to evaluate compliance with Title 22 Regulations and ensure health and safety standards at the facility.
Findings
The facility was found to be in compliance with health and safety regulations, with no observed hazards or obstructions. Resident rooms and common areas were properly furnished and clean, infection control measures were adequate, and records including resident and personnel files were in order.
Report Facts
Residents receiving medication assistance: 9Resident records reviewed: 7Personnel records reviewed: 6Staff interviewed: 7Residents interviewed: 10
Employees Mentioned
Name
Title
Context
Kathleen K Glass
Executive Director
Met with Licensing Program Analysts during the inspection
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and infection control policies.
Findings
The facility was found to be in good condition with adequate emergency supplies, proper infection control measures including masking and screening, clean and accessible resident rooms, and a passed fire safety inspection. Resident rooms were cleaned weekly or as needed, and staff were trained on infection control practices.
Report Facts
Water temperature: 113.3Facility capacity: 216Resident census: 102
Employees Mentioned
Name
Title
Context
Adam Pena
Administrator
Met with Licensing Program Analyst during inspection and provided information
The inspection was an unannounced complaint investigation visit triggered by an allegation of financial abuse of a resident while in care.
Findings
The investigation found that the resident was financially abused; however, the staff member involved was a private caregiver hired independently and not a facility staff. Therefore, the allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged financial abuse of a resident in care. The allegation was investigated through interviews and documentation review. It was determined that the abuse was by a private caregiver, not facility staff, and the allegation was unsubstantiated.
Report Facts
Facility capacity: 216Census: 102
Employees Mentioned
Name
Title
Context
Patrick Shanahan
Licensing Program Analyst
Conducted the complaint investigation
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