Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
88% occupied
Based on a February 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 115
Capacity: 130
Deficiencies: 0
Date: Feb 26, 2026
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 2025-05-08 regarding staff conduct and care at the facility.
Complaint Details
The complaint included allegations that staff did not assist residents in a timely manner, physically force-fed medication, hit and mishandled residents, and did not provide sufficient activities. After investigation, all allegations were determined to be unsubstantiated due to insufficient evidence.
Findings
The investigation included interviews, record reviews, and observations related to allegations of delayed assistance, force-feeding medication, physical mistreatment, and insufficient activities. All allegations were found to be unsubstantiated based on the evidence gathered.
Report Facts
Capacity: 130
Census: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Met with during investigation and referenced in findings |
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 130
Deficiencies: 0
Date: Feb 20, 2026
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that staff did not properly address a resident's change in condition and did not provide required care and supervision to assist a resident with activities of daily living (ADLs).
Complaint Details
The complaint alleged that staff did not properly address a resident's change in condition and failed to provide required care and supervision for ADLs. After investigation including interviews and record review, the allegations were deemed unsubstantiated.
Findings
The investigation found no substantiation for the allegations. Interviews with the Administrator, staff, residents, and review of records indicated that the resident was monitored and assisted appropriately, and staff provided required care and supervision.
Report Facts
Capacity: 130
Census: 115
Number of residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Administrator | Facility Administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 130
Deficiencies: 0
Date: Feb 14, 2026
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations of staff neglect resulting in multiple falls and injuries to a resident, and failure to conduct a reassessment of the resident's needs.
Complaint Details
The complaint alleged staff neglect leading to multiple falls and injuries of Resident #1, and failure to conduct a reassessment of the resident's needs. After multiple visits, interviews with staff and residents, and review of medical and facility records, the allegations were found unsubstantiated.
Findings
The investigation found insufficient evidence to substantiate the allegations of staff neglect causing multiple falls and injuries, and failure to reassess the resident's needs. The resident's falls were associated with documented medical conditions and refusal to use assistive devices despite staff encouragement. The allegations were determined to be unsubstantiated.
Report Facts
Number of staff interviewed: 6
Facility capacity: 130
Facility census: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Facility administrator notified of the visit |
| Tuesday Cabiness | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Raymond Cromer | Licensing Program Analyst | Conducted initial complaint visit to gather evidence |
| Marina Adan | Med-tech | Met with Licensing Program Analyst during the visit |
| Nichelle Gillyard | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 130
Deficiencies: 0
Date: Jan 27, 2026
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate an allegation that staff hit a resident at the facility.
Complaint Details
The allegation was that staff member S1 slapped Resident #1. Interviews with staff and residents, as well as record reviews, found no supporting evidence. The allegation was unsubstantiated.
Findings
The investigation included interviews with staff, residents, and review of records. No evidence was found to support the allegation, and the complaint was determined to be unsubstantiated.
Report Facts
Residents interviewed: 10
Staff interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Administrator | Facility administrator interviewed during investigation |
| Nichelle Gillyard | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 130
Deficiencies: 0
Date: Jan 9, 2026
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff were not providing laundry services to a resident.
Complaint Details
The complaint alleged that staff were not providing laundry services to a resident. After investigation, the complaint was found to be without reasonable basis and was dismissed as unfounded.
Findings
The investigation found that staff do provide laundry services daily according to schedule, including additional laundry for incontinent residents. Interviews with residents and staff confirmed laundry services were being provided, and the allegation was deemed unfounded.
Report Facts
Capacity: 130
Census: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Conducted the complaint investigation |
| Adam Syncheff | Administrator | Met with investigators during the visit |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 130
Deficiencies: 0
Date: Dec 20, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that a resident was raped at the facility by an unknown perpetrator.
Complaint Details
The complaint alleged that resident #1 was raped at the facility by an unknown perpetrator. The investigation included interviews with the resident, staff, and administrator, as well as a review of facility records. The resident denied the allegation and stated they were treated well. The complaint was found to be unsubstantiated.
Findings
Based on inspection, interviews, and record review, there was insufficient information to verify the allegation. The resident denied being sexually assaulted or abused, and no health and safety hazards were noted. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 130
Census: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Adam Syncheff | Administrator | Facility administrator who was contacted during the investigation |
| Olivia Spindola | Senior Investigator | Conducted the investigation branch interview with the resident |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 130
Deficiencies: 1
Date: Dec 11, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-02-15 regarding multiple allegations including bed bug infestations, lack of transportation, housekeeping services, dietary needs, laundry services, and safeguarding of residents' personal belongings.
Complaint Details
The complaint investigation was triggered by allegations that staff did not prevent bed bugs, failed to provide transportation, housekeeping, dietary services, and laundry services, and did not safeguard residents' personal belongings. The investigation included interviews with residents and staff, review of records and schedules, and multiple site visits. All allegations except the safeguarding of personal belongings were found unsubstantiated. The safeguarding allegation was substantiated.
Findings
All allegations except for the safeguarding of residents' personal belongings were found to be unsubstantiated after thorough investigation including interviews, record reviews, and observations. The allegation regarding missing personal belongings was substantiated due to missing or incomplete inventory logs and multiple resident reports of missing items.
Deficiencies (1)
Failure to safeguard residents' cash, personal property, and valuables as evidenced by missing personal items and incomplete inventory logs.
Report Facts
Capacity: 130
Census: 116
Deficiency count: 1
Plan of Correction Due Date: Nov 14, 2024
Staff interviewed: 5
Residents interviewed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation and met with the Administrator |
| Rena Hirsch | Administrator | Facility Administrator interviewed during the investigation |
| Nichelle Gillyard | Supervisor | Supervisor overseeing the licensing evaluation |
| Huma Rahimi | Licensing Program Analyst | Initiated the complaint investigation and conducted interviews |
| Eva Miller | Licensing Program Manager | Conducted additional visits for staff and resident interviews |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 130
Deficiencies: 0
Date: Nov 13, 2025
Visit Reason
The visit was conducted as an unannounced complaint investigation regarding allegations that the facility lacks an adequate amount of staff to meet residents' care needs in a timely manner.
Complaint Details
The complaint alleged that the facility is understaffed and that Resident #1 only receives minimal interaction limited to being brought to and from meals. The investigation included interviews, file reviews, and observations. The allegations were found to be unsubstantiated.
Findings
The investigation found no health or safety issues and determined that the facility maintains sufficient staff to provide adequate care and supervision. Interviews with staff and residents indicated no concerns about staffing levels. The allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Residents interviewed: 10
Total residents: 11
Staff response time: 2
Staff response time: 10
Resident room health checks frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Met with during investigation and exit interview |
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Naira Margaryan | Licensing Program Manager | Joined the investigation visit and conducted facility tour and interviews |
| Nichelle Gillyard | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Census: 109
Capacity: 130
Deficiencies: 0
Date: Sep 16, 2025
Visit Reason
An unannounced case management visit was conducted to review the facility's medical training documentation for medication technicians.
Findings
No health and safety issues were observed during the physical plant tour. The Licensing Program Analyst reviewed medical training documentation for ten medication technicians and requested verification of required training hours.
Report Facts
Number of medication technicians reviewed: 10
Required initial medication training hours: 24
Required in-service medication training hours: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Met with Licensing Program Analyst during inspection and agreed to provide requested documents |
| Raymond Comer | Licensing Program Analyst | Conducted the unannounced case management visit and medical training documentation review |
Inspection Report
Census: 109
Capacity: 130
Deficiencies: 0
Date: Sep 16, 2025
Visit Reason
An unannounced case management visit was conducted to review the facility's medical training documentation for medication technicians.
Findings
No health and safety issues were observed during the physical plant tour. The Licensing Program Analyst reviewed medical training records for ten medication technicians and requested documentation verifying completion of required initial and in-service medication training hours.
Report Facts
Medication training hours required: 24
Medication training hours required: 8
Medication tech staff reviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Facility Administrator met with Licensing Program Analyst and agreed to provide requested documents |
| Raymond Comer | Licensing Program Analyst | Conducted the unannounced case management visit and medical training review |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 130
Deficiencies: 0
Date: Sep 9, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that facility staff do not respond to call bells in a timely manner and are not adhering to resident care plans.
Complaint Details
The complaint investigation was unsubstantiated based on observations, interviews, and record reviews. Allegations included delayed call bell response and failure to adhere to a resident's care plan, both found unsubstantiated.
Findings
The investigation found insufficient evidence to substantiate the allegations. Observations and interviews indicated that call bell response times averaged four to five minutes, and the resident's care plan regarding food preparation was being followed. Therefore, both allegations were unsubstantiated.
Report Facts
Capacity: 130
Census: 107
Call bell response time: 4
Call bell response time: 5
Staff interviewed: 4
Residents interviewed: 10
Residents reporting timely response: 8
Residents reporting delayed response: 2
Wait time for two-person assist: 10
Wait time for two-person assist: 15
Call bell delay allegation: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Abbygail Macaso | Facility staff member met with during the investigation | |
| Adam Syncheff | Administrator | Facility administrator named in the report |
| Troy Agard | Supervisor | Supervisor named in the report |
Inspection Report
Annual Inspection
Census: 106
Capacity: 130
Deficiencies: 0
Date: Aug 15, 2025
Visit Reason
The inspection visit was conducted as a continuation of the required annual inspection initiated on 08/14/2025 to review multiple domains including medications, laundry, bedrooms, bathrooms, outdoor areas, staff records, and resident records.
Findings
The facility was found to be in compliance with licensing requirements with no immediate health and safety hazards observed. Medications were properly stored and labeled, laundry and bedrooms were secure and clean, bathrooms were sanitary with required safety fixtures, and staff and resident records were complete and current.
Report Facts
Staff files reviewed: 6
Resident files reviewed: 7
Hot water temperature: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Met with Licensing Program Analyst during inspection |
| Raymond Comer | Licensing Program Analyst | Conducted the inspection and signed the report |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 106
Capacity: 130
Deficiencies: 0
Date: Aug 15, 2025
Visit Reason
The inspection visit was conducted to continue the required annual inspection initiated on 08/14/2025, as part of the Case Management - Annual Continuation.
Findings
The inspection found that medication storage and documentation were properly maintained, laundry and bedrooms were secure and clean, bathrooms were sanitary with required safety fixtures, and outdoor areas were well maintained. Staff and resident records were reviewed and found to be complete and current. No immediate health and safety hazards were observed.
Report Facts
Staff files reviewed: 6
Resident files reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Met with Licensing Program Analyst during inspection |
| Raymond Comer | Licensing Program Analyst | Conducted the inspection visit |
| Nichelle Gillyard | Licensing Program Manager | Named in report header and narrative |
Inspection Report
Annual Inspection
Census: 106
Capacity: 130
Deficiencies: 0
Date: Aug 14, 2025
Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with licensing requirements and assess the physical plant, safety systems, and infection control measures.
Findings
The facility was found to be generally clean and well-maintained with functioning fire detection and suppression systems, proper kitchen sanitation, and adequate infection control measures. Due to time constraints, the inspection was not fully completed and will be finished at a later date.
Report Facts
Fire Extinguisher service date: Mar 5, 2025
Fire suppression system inspection date: Apr 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Facility Administrator | Met with Licensing Program Analyst during inspection |
| Raymond Comer | Licensing Program Analyst | Conducted the inspection |
| Nichelle Gillyard | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 106
Capacity: 130
Deficiencies: 0
Date: Aug 14, 2025
Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with licensing requirements and assess the physical plant, safety systems, and infection control measures.
Findings
The facility was found to be generally compliant with licensing requirements, including fire safety systems, kitchen cleanliness, and infection control plans. No deficiencies were explicitly stated in the report, and the facility maintains proper safety and health protocols. The inspection was not fully completed due to time constraints and will be finished at a later date.
Report Facts
Fire Extinguisher service date: Mar 5, 2025
Fire suppression system inspection date: Apr 1, 2025
Fire drill last conducted: 202507
Disaster drills last conducted: 202507
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Facility Administrator | Met with Licensing Program Analyst during inspection |
| Raymond Comer | Licensing Program Analyst | Conducted the inspection |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 130
Deficiencies: 0
Date: Jul 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate an allegation of lack of supervision resulting in a resident being assaulted by another resident.
Complaint Details
The complaint alleged lack of supervision resulting in Resident 1 being assaulted by Resident 2, their roommate. Interviews with the reporting party, administrator, staff, and residents revealed no supervision issues and no injuries sustained. The licensee submitted an Incident Report regarding the incident. The allegation was deemed unsubstantiated.
Findings
The investigation found that although an altercation occurred between two residents, there was no corroborating evidence that lack of supervision contributed to the incident. Staff were present and intervened promptly, and the allegation was deemed unsubstantiated.
Report Facts
Capacity: 130
Census: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Administrator | Facility administrator interviewed during investigation |
| Eva Miller | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 130
Deficiencies: 0
Date: Jul 8, 2025
Visit Reason
This was an unannounced complaint investigation visit conducted to investigate allegations that facility staff were not properly supervising residents who are a fall risk and did not seek timely medical attention for a resident.
Complaint Details
The complaint alleged that facility staff failed to properly supervise a fall-risk resident and did not seek timely medical attention after a fall incident in December 2024. The investigation found that staff followed the resident's care plan, provided mobility assistance, responded appropriately to the fall, and notified the family. The allegations were unsubstantiated.
Findings
Based on records review, interviews with staff and the responsible family member, the allegations were deemed unsubstantiated at this time. The facility followed proper procedures regarding resident care and medical attention after the fall incident.
Report Facts
Capacity: 130
Census: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Met with Licensing Program Analyst during investigation |
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 130
Deficiencies: 0
Date: Jun 17, 2025
Visit Reason
An unannounced complaint investigation was conducted to investigate the allegation that facility staff were not properly transferring a resident to their wheelchair, resulting in injury.
Complaint Details
The complaint alleged improper transfer of a resident to their wheelchair resulting in injury. The allegation was unsubstantiated after investigation including staff interviews, record review, and physical observation.
Findings
The investigation included interviews with staff and review of records related to the alleged incident. The resident was reported to have slid down from their chair but was assisted to the floor in a controlled manner, with no signs of injury observed. The allegation was found to be unsubstantiated based on interviews, observations, and record reviews.
Report Facts
Capacity: 130
Census: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Segovia | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Executive Director | Met with Licensing Program Analyst during investigation |
| Troy Agard | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 130
Deficiencies: 0
Date: Jun 17, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that facility staff were not properly transferring a resident to their wheelchair, resulting in injury.
Complaint Details
The complaint alleged that facility staff were not properly transferring a resident to their wheelchair, resulting in injury. The resident was reported to have slid down from their chair in the shower area but was assisted to the floor in a controlled manner. The resident showed no signs of injury or pain, and the incident was properly reported by the facility. The allegation was unsubstantiated based on interviews, record review, and observations.
Findings
The investigation included interviews with staff and review of records related to the alleged incident. The allegation was found to be unsubstantiated as there was insufficient evidence to verify improper transfer or injury. No immediate health or safety issues were observed during the visit.
Report Facts
Capacity: 130
Census: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Segovia | Licensing Program Analyst | Conducted the complaint investigation visit |
| Adam Syncheff | Executive Director | Met with Licensing Program Analyst during the investigation |
| Troy Agard | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 130
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff did not administer a resident's medications as prescribed.
Complaint Details
The complaint alleged that staff did not administer Resident 1's medications as prescribed. The allegation was investigated through interviews with medical technician staff, residents, and review of Resident 1's medication administration record. The allegation was found unsubstantiated.
Findings
The investigation found insufficient evidence to corroborate the allegation. Interviews with staff and residents, as well as a review of medication administration records, confirmed that medications were administered as prescribed. The allegation was deemed unsubstantiated.
Report Facts
Facility capacity: 130
Census: 104
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Facility Administrator met during the investigation and involved in interviews |
| Raymond Comer | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Eva Miller | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 130
Deficiencies: 0
Date: Apr 28, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2025-03-18 alleging multiple issues including failure to follow doctor's dietary recommendations, unmet bathing needs, call button disrepair, lack of dignity and respect by staff, and failure to comply with reporting requirements.
Complaint Details
The complaint involved nine allegations regarding dietary needs, bathing assistance, call button functionality, staff respectfulness, and reporting compliance. All allegations were investigated and deemed unsubstantiated based on interviews, observations, and documentation.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Observations, interviews with staff, residents, and family members confirmed that dietary needs were met, bathing assistance was provided despite resident refusal, call buttons were functional, staff treated residents with dignity and respect, and reporting requirements were followed.
Report Facts
Facility capacity: 130
Census: 104
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Facility Administrator interviewed during the investigation |
| Raymond Comer | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Eva Miller | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 130
Deficiencies: 0
Date: Apr 28, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-03-18 regarding staff not following resident's doctor recommended dietary needs, not meeting bathing needs, call button disrepair, lack of dignity and respect, and failure to comply with reporting requirements.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to follow dietary recommendations, bathing neglect, call button disrepair, disrespectful staff behavior, and failure to comply with reporting requirements. Each allegation was investigated through interviews, observations, and document review, resulting in no substantiation.
Findings
The investigation found insufficient evidence to corroborate any of the allegations. Observations, interviews with staff, residents, and family members confirmed that dietary needs, bathing assistance, call button functionality, respectful treatment, and reporting requirements were adequately met. Therefore, all allegations were deemed unsubstantiated.
Report Facts
Facility capacity: 130
Resident census: 104
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Met with Licensing Program Analyst during investigation and provided information regarding allegations |
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 130
Deficiencies: 0
Date: Apr 23, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that facility staff did not ensure a resident had an adequate amount of food and access to a phone.
Complaint Details
The complaint investigation was unsubstantiated based on interviews and record reviews indicating that the issues were related to family decisions and medical advice rather than facility neglect.
Findings
The investigation found that the resident was on hospice care with a liquid diet per doctor's orders and that the family member, not the facility, was withholding food. Regarding phone access, the resident's phone was removed by family on doctor's advice due to anxiety, but the facility provides cordless phones accessible to all residents. The allegations were deemed unsubstantiated.
Report Facts
Capacity: 130
Census: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Haigaz Kazazian | Business Office Manager | Met with the evaluator during the investigation |
| Adam Syncheff | Administrator | Facility administrator named in the report |
| Troy Agard | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 130
Deficiencies: 0
Date: Apr 23, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that facility staff did not ensure that a resident had an adequate amount of food and access to a phone.
Complaint Details
The complaint was unsubstantiated based on interviews and record reviews. The resident's family member was withholding food, and the phone was removed on doctor's advice due to resident's anxiety and non-responsiveness.
Findings
The investigation found that the allegations were unsubstantiated. The resident was on hospice care with a liquid diet per doctor's orders, and the family member was withholding food, not the facility. Regarding phone access, the resident's phone was taken by family on doctor's advice due to anxiety, and the facility provides cordless phones accessible to all residents.
Report Facts
Facility capacity: 130
Resident census: 105
Complaint control number: 31-AS-20250416154440
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Haigaz Kazazian | Business Office Manager | Met with Licensing Program Analyst during investigation |
| Adam Syncheff | Administrator | Facility administrator named in report header |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager overseeing investigation |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 130
Deficiencies: 0
Date: Apr 7, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that staff do not ensure that a resident's bed is in good working order.
Complaint Details
The complaint alleged that resident #1's hospital electric bed rolled up on top of them like an accordion three times. The allegation was unsubstantiated after investigation.
Findings
The investigation found no sufficient evidence to prove the alleged violation occurred. Interviews with the resident, staff, and maintenance director, as well as physical inspection of the bed, indicated the bed was in good working order and no issues were reported. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 130
Census: 104
Number of residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Executive Director | Interviewed during the investigation |
| Emily Cordova | Concierge | Granted entrance to Licensing Program Analyst |
| Naira Margaryan | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 130
Deficiencies: 0
Date: Apr 7, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation that staff do not ensure that a resident's bed is in good working order.
Complaint Details
The complaint alleged that resident #1's hospital electric bed rolled up on top of them like an accordion three times. After inspection and interviews with the resident, Executive Director, Maintenance Director, and staff, no evidence supported the allegation. The bed was functioning properly and the resident had not reported any issues. The allegation was unsubstantiated.
Findings
The investigation found no sufficient evidence to prove the alleged violation occurred. Interviews with the resident, staff, and observations confirmed that the resident's hospital electric bed was in good working order and no health or safety hazards were noted. The allegation was determined to be unsubstantiated.
Report Facts
Residents interviewed: 10
Facility capacity: 130
Current census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Adam Syncheff | Executive Director | Interviewed during the investigation regarding the bed allegation. |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 130
Deficiencies: 0
Date: Apr 6, 2025
Visit Reason
An unannounced complaint investigation visit was conducted due to allegations that residents contracted a viral infection due to neglect and that a resident received hospice services without consent.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included neglect causing residents to contract a Rhino viral infection and a resident receiving hospice services without consent. Both allegations were found unsubstantiated based on interviews and records review.
Findings
The investigation found no evidence to substantiate the allegations. Interviews with staff, residents, and the administrator confirmed no known viral infections or outbreaks during the time in question, and hospice services were provided with resident consent. No health and safety hazards were noted at the time of the visit.
Report Facts
Capacity: 130
Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Ubaldo Guerrero | Met with the Licensing Program Analyst during the visit | |
| Rena Hirsch | Administrator | Facility administrator interviewed during the investigation |
| Tihesha Smith | Licensing Program Analyst | Conducted initial investigation activities on 06/28/2024 |
| Naira Margaryan | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 130
Deficiencies: 0
Date: Apr 6, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that residents contracted a viral infection due to neglect and that a resident received hospice services without consent.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included neglect causing residents to contract a viral infection and a resident receiving hospice services without consent. Both allegations were found unsubstantiated based on interviews and records review.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with staff, residents, and the facility administrator, as well as document reviews, indicated no known viral infections or outbreaks and confirmed resident consent for hospice services. No health and safety hazards were noted at the time of the visit.
Report Facts
Facility capacity: 130
Resident census: 107
Complaint control number: 31-AS-20240621110324
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Ubaldo Guerrero | Facility representative met during the visit | |
| Rena Hirsch | Administrator | Facility administrator interviewed during the investigation |
| Tihesha Smith | Licensing Program Analyst | Conducted preliminary investigation activities on 06/28/2024 |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 130
Deficiencies: 0
Date: Mar 28, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation that staff did not administer a resident's medications as prescribed.
Complaint Details
The complaint alleged that night staff did not distribute Resident #1's medications as prescribed. The allegation was investigated through interviews with staff, residents, and review of medication records. The complaint was determined to be unsubstantiated.
Findings
The investigation found that the facility assisted the resident with proper medication administration as prescribed. Staff and residents refuted the allegation, and medication administration records were consistent and in good order. The allegation was deemed unsubstantiated.
Report Facts
Capacity: 130
Census: 106
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Met with Licensing Program Analyst during complaint investigation and refuted the medication administration allegation |
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 130
Deficiencies: 0
Date: Jan 28, 2025
Visit Reason
An unannounced complaint investigation visit was conducted regarding allegations that facility staff failed to inform a resident's representatives of medical services provided and health status updates while in care.
Complaint Details
The complaint alleged that staff failed to inform Resident #1's representative of wound care services and notification of transfer to hospital for health assessment. The allegation was deemed unsubstantiated based on document review and interviews with staff, the administrator, and family members.
Findings
The investigation found that the allegation was unsubstantiated. Documentation and interviews confirmed that wound care services were provided and that the resident's responsible family member was notified of wound care status and hospital transfer. Six responsible family members also confirmed consistent reporting by facility staff.
Report Facts
Capacity: 130
Census: 104
Number of responsible family members interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 130
Deficiencies: 0
Date: Jan 14, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-08-21 regarding staff communication abilities, room cleanliness, medical needs, service provision, and incontinence management for residents.
Complaint Details
The complaint involved multiple allegations including staff lacking ability to communicate with residents, unsanitary resident rooms, unmet medical needs, inconsistent service provision, and inadequate incontinence care. After investigation, all allegations were determined to be unsubstantiated.
Findings
The investigation included interviews with staff and residents, observations, and document reviews. All allegations were found to be unsubstantiated due to lack of preponderance of evidence, with staff and residents confirming satisfactory communication, clean and sanitary rooms, proper medical care, consistent service provision, and timely incontinence management.
Report Facts
Capacity: 130
Census: 107
Staff interviewed: 3
Residents interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Met with Licensing Program Analyst during investigation |
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 130
Deficiencies: 0
Date: Jan 14, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-08-21 regarding communication barriers, unsanitary resident rooms, unmet medical needs, inconsistent service provision, and incontinence management at the facility.
Complaint Details
The complaint investigation addressed multiple allegations including staff communication barriers with residents, unsanitary resident rooms, unmet medical needs such as hydration and diet, inconsistent provision of services, and inadequate management of incontinence. After thorough investigation including interviews with three staff and seven residents, review of resident files, and direct observations, all allegations were determined to be unsubstantiated.
Findings
The investigation included interviews with staff and residents, review of resident files, and physical observations. All allegations were found to be unsubstantiated due to lack of preponderance of evidence, with observations and interviews indicating satisfactory communication, clean and sanitary rooms, proper medical care, consistent service provision, and timely incontinence management.
Report Facts
Resident interviews: 7
Staff interviews: 3
Facility capacity: 130
Facility census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Met with Licensing Program Analyst during investigation |
| Raymond Comer | Licensing Program Analyst | Conducted complaint investigation |
| Eva Miller | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 130
Deficiencies: 0
Date: Jan 13, 2025
Visit Reason
The visit was conducted to investigate a complaint alleging that the facility failed to comply with Title 22 regulations regarding the admission of residents receiving hospice care services.
Complaint Details
The complaint alleged non-compliance with approved Hospice Waiver regulations. The allegation was unsubstantiated after review of resident records and interviews.
Findings
The investigation found that the facility had four residents receiving hospice care with appropriate approved hospice waivers, terminal diagnoses, and signed agreements. There were no health and safety issues observed, and the allegation was deemed unsubstantiated due to insufficient evidence.
Report Facts
Residents receiving hospice care: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Administrator met with during investigation | |
| Eva Miller | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 130
Deficiencies: 0
Date: Jan 13, 2025
Visit Reason
The visit was conducted to investigate a complaint alleging that the facility was not in compliance with the approved Hospice Waiver, specifically regarding the admission of residents receiving hospice care services.
Complaint Details
The complaint alleged non-compliance with Title 22 regulations regarding admission of residents receiving hospice care. The allegation was unsubstantiated due to insufficient evidence.
Findings
The investigation found that the facility had four residents receiving hospice care with appropriate documentation including approved hospice waivers, terminal diagnoses, and signed agreements for room sharing. Based on interviews and record reviews, there was insufficient evidence to substantiate the alleged violation, and the complaint was deemed unsubstantiated.
Report Facts
Residents receiving hospice care: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on report |
| Adam Syncheff | Facility Administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 130
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
An unannounced complaint investigation was conducted to investigate allegations that staff do not ensure residents' care plans are being followed, specifically regarding Resident #1's care.
Complaint Details
The complaint alleged that staff did not provide Resident #1 a juice beverage, did not elevate Resident #1's legs when sitting in a recliner, and did not charge Resident #1's smart watch. The complaint was deemed unsubstantiated based on observations, interviews, and document review.
Findings
The investigation found no substantiated issues; staff were observed providing care as per the care plan, including providing juice, elevating the resident's legs, and charging the resident's smart watch. Interviews with staff and residents and document reviews supported these findings.
Report Facts
Capacity: 130
Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Karla Garcia | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 130
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff do not ensure residents' care plans are being followed.
Complaint Details
The complaint alleged that staff did not provide Resident #1 with a juice beverage, did not elevate the resident's legs when sitting in a recliner, and did not charge the resident's smart watch. The investigation found these allegations unsubstantiated based on interviews, observations, and care plan documentation.
Findings
The investigation found that the allegation was unsubstantiated. Observations, document reviews, and interviews with staff and residents confirmed that care plan services were being provided as required.
Report Facts
Capacity: 130
Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Named in report as Licensing Program Manager |
| Karla Garcia | Facility Administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 130
Deficiencies: 0
Date: Nov 19, 2024
Visit Reason
The visit was conducted to investigate a complaint alleging that staff were not assisting a resident in a timely manner, specifically that staff took an average of two hours to respond to Resident #1's call button activation.
Complaint Details
The complaint alleged that staff took an average of two hours to respond to Resident #1's call button. The investigation found no evidence to support this, with response times observed between 2 to 7 minutes and most residents reporting satisfactory response times. The complaint was deemed unsubstantiated.
Findings
The investigation included observations, interviews with staff, residents, and a family member, and inspection of resident rooms. Staff response times to call buttons were found to be between 2 to 7 minutes on average, with most residents reporting satisfactory response times. The allegation that staff failed to respond timely was unsubstantiated.
Report Facts
Census: 105
Total Capacity: 130
Response Time Range: 2
Response Time Range: 7
Resident Survey: 7
Resident Survey: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Facility Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 130
Deficiencies: 0
Date: Nov 19, 2024
Visit Reason
The visit was conducted to investigate a complaint alleging that staff were not assisting a resident in a timely manner, specifically that staff took an average of two hours to respond to Resident #1's call button activation.
Complaint Details
The complaint alleged that staff took an average of two hours to respond to Resident #1's call button. The investigation included observations and interviews, and the allegation was deemed unsubstantiated.
Findings
Observations, interviews with staff, residents, and a family member revealed that caregiver staff responded to call buttons within 2 to 7 minutes on average, with most residents reporting satisfactory response times. The allegation that staff failed to respond timely was unsubstantiated.
Report Facts
Capacity: 130
Census: 105
Response time range: 2
Response time range: 7
Resident interview count: 9
Residents satisfied: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Adam Syncheff | Facility Administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 130
Deficiencies: 0
Date: Nov 12, 2024
Visit Reason
The visit was conducted as a case management follow-up related to a complaint alleging that staff were not providing laundry services to residents. The complaint was initially received on 02/15/2024 and investigated through prior visits.
Complaint Details
The complaint alleging that staff were not providing laundry services to residents was substantiated initially but later found to be unfounded after further investigation and observations.
Findings
The investigation found that the allegation of not providing laundry services was unfounded. Interviews with the Executive Director and Housekeeper, review of the Admission Agreement, and observation of laundry operations confirmed that laundry services are provided weekly to all residents.
Report Facts
Complaint control number: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Executive Director | Met with Licensing Program Analysts during the inspection and provided information regarding laundry services |
| Huma Rahimi | Licensing Evaluator | Conducted the inspection and signed the report |
| Angela Panushkina | Licensing Program Analyst | Conducted the inspection visit |
| Nichelle Gillyard | Supervisor | Named as supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 130
Deficiencies: 1
Date: Nov 12, 2024
Visit Reason
The inspection was conducted as an unannounced visit in conjunction with a complaint received on 02/15/2024 regarding alleged abuse and failure to report by facility staff.
Complaint Details
Complaint control #31-AS-20240215114434 was received on 02/15/2024. The complaint was substantiated based on investigation findings that facility staff failed to report abuse.
Findings
The facility failed to report suspected abuse involving a resident (R2 withholding food from R1), which posed a potential risk to the resident's health and personal rights. An additional deficiency was issued based on interviews and record review.
Deficiencies (1)
Failure to report suspected abuse as required by CCR 87211(c), specifically the facility staff did not report R2 withholding food from R1.
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Jan 31, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Executive Director | Met with during inspection and explained reason for visit |
| Huma Rahimi | Licensing Program Analyst | Conducted inspection and authored report |
| Angela Panushkina | Licensing Program Analyst | Conducted inspection |
| Nichelle Gillyard | Supervisor | Supervisor overseeing inspection |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 130
Deficiencies: 1
Date: Nov 12, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation related to a complaint received on 02/15/2024 concerning potential abuse and failure to report by facility staff.
Complaint Details
The complaint was substantiated based on interviews and record review. The facility staff failed to report that R2 withheld food from R1, who was on a special diet, and R2 was not the Power of Attorney or conservator for R1.
Findings
The facility failed to report suspected abuse involving a resident's food being withheld by another individual who was not authorized to control the resident's food or decision making. This posed a potential risk to the resident's health and personal rights.
Deficiencies (1)
Failure to report suspected abuse involving withholding food from a resident to the appropriate authorities within 24 hours.
Report Facts
Census: 108
Total Capacity: 130
Plan of Correction Due Date: Jan 31, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Huma Rahimi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Executive Director | Met with Licensing Program Analysts during the inspection |
| Nichelle Gillyard | Licensing Program Manager | Oversaw the inspection process |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 130
Deficiencies: 0
Date: Nov 12, 2024
Visit Reason
The inspection was conducted as a case management visit in conjunction with a complaint alleging that staff were not providing laundry services to residents.
Complaint Details
The complaint was substantiated initially but later found to be unfounded and dismissed after further investigation and case management.
Findings
The complaint alleging that laundry services were not provided was found to be unfounded after interviews, record review, and observation of laundry operations. The facility provides weekly laundry services as part of basic services to all residents.
Report Facts
Complaint control number: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Executive Director | Met with during inspection and provided information regarding laundry services |
| Huma Rahimi | Licensing Program Analyst | Conducted the inspection and investigation |
| Angela Panushkina | Licensing Program Analyst | Conducted the inspection and investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 130
Deficiencies: 0
Date: Oct 31, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that staff left a resident soiled in urine resulting in a rash and that the call button was not accessible to the resident.
Complaint Details
The complaint investigation was triggered by allegations that staff left a resident soiled in urine causing a rash and that the call button was not accessible, causing delays in caregiver response. After investigation, both allegations were deemed unsubstantiated.
Findings
The investigation included interviews, observations, and record reviews. The allegations were found to be unsubstantiated as there was insufficient evidence to prove neglect regarding timely care or call button accessibility. The resident appeared well-groomed and clean, and staff responded promptly to call button activation.
Report Facts
Capacity: 130
Census: 107
Residents interviewed: 5
Call button response time: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Administrator | Met with Licensing Program Analyst and interviewed during investigation |
| Eva Miller | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 130
Deficiencies: 0
Date: Oct 31, 2024
Visit Reason
The visit was an unannounced complaint investigation initiated due to allegations that staff left a resident soiled in urine resulting in a rash and that the call button was not accessible to the resident.
Complaint Details
The complaint involved two allegations: 1) staff left a resident soiled in urine causing a rash, and 2) the call button was not accessible to the resident, causing long wait times. Both allegations were investigated through interviews, observations, and document reviews and were deemed unsubstantiated.
Findings
The investigation included interviews, observations, and records review. The allegations were found to be unsubstantiated as there was insufficient evidence that the resident was left soiled for an extended period and staff responded promptly to call button activation.
Report Facts
Capacity: 130
Census: 107
Response time: 3
Resident interviews: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Adam Syncheff | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 130
Deficiencies: 0
Date: Oct 4, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff do not safeguard residents' personal property and that the licensee retaliates against facility staff for reporting.
Complaint Details
The complaint investigation was unsubstantiated based on interviews with seven residents and four staff members, as well as records review and interviews with the administrator. No preponderance of evidence was found to prove the alleged violations occurred.
Findings
The investigation found no sufficient evidence to support the allegations. Interviews with residents and staff indicated that residents believe staff provide satisfactory service regarding safeguarding personal belongings, and no evidence of retaliation against staff was found. Both allegations were unsubstantiated.
Report Facts
Residents interviewed: 7
Staff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Administrator | Facility administrator interviewed during investigation |
| Eva Miller | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 130
Deficiencies: 0
Date: Oct 4, 2024
Visit Reason
The visit was conducted as an unannounced complaint investigation following allegations received on 07/23/2024 regarding staff not safeguarding residents' personal property and licensee retaliation against staff for reporting.
Complaint Details
The complaint involved allegations that staff do not safeguard residents' personal property and that the licensee retaliates against staff for reporting such incidents. Both allegations were found to be unsubstantiated based on interviews and records review.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews with residents and staff did not support claims of theft or retaliation, and no health and safety issues were observed during the facility tour.
Report Facts
Residents interviewed: 7
Staff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation and facility tour. |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Adam Syncheff | Administrator | Facility Administrator interviewed during the investigation. |
| Rena Hirsch | Administrator | Named as facility administrator in report header. |
Inspection Report
Complaint Investigation
Capacity: 130
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
The visit was conducted as a complaint investigation regarding an allegation that the facility's signal system was not consistently functional, specifically that Resident 1's service call system did not work consistently and staff response took a minimum of 25 minutes.
Complaint Details
The complaint alleged that the facility signal system was not consistently functional, with Resident 1's call system failing to confirm responses and staff taking at least 25 minutes to respond. The investigation found the system functional and the allegation unsubstantiated.
Findings
The Licensing Program Analyst observed the service call system in operation and interviewed staff and residents. The system was found to be functional with calls answered within two minutes, and six out of seven residents confirmed timely responses. The allegation was determined to be unsubstantiated.
Report Facts
Facility capacity: 130
Resident interviews: 6
Total residents interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation and visit |
| Solange Nkafu | Wellness Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 130
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that residents' concerns were ignored by staff at the facility.
Complaint Details
The complaint alleged that staff often ignored residents who requested additional services such as soup or coffee. The investigation included interviews with residents and staff, a physical plant tour, and observation during meal service. The complaint was found unsubstantiated.
Findings
The investigation found that ten out of eleven residents interviewed reported that staff responded to their requests in a timely manner and did not ignore them. Observations during lunch showed staff serving residents appropriately and accommodating requests. The allegation was deemed unsubstantiated.
Report Facts
Residents interviewed: 11
Residents agreeing timely service: 10
Staff observed serving residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Evaluator | Conducted the complaint investigation |
| Solange Nkafu | Wellness Director | Met with LPAs during the investigation |
| Troy Agard | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 130
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that the facility's signal system was not consistently functional, specifically that Resident 1's service call system did not work consistently and staff response times were delayed.
Complaint Details
The complaint alleged that the facility signal system was not consistently functional, with Resident 1's call system failing to work consistently and staff taking a minimum of 25 minutes to respond. The allegation was investigated and found to be unsubstantiated.
Findings
The Licensing Program Analyst observed the facility's service call system and activated Resident 1's call button, which was responded to within two minutes. Interviews with staff and six out of seven residents confirmed timely responses to service calls. No health or safety issues were observed. The allegation was found to be unsubstantiated.
Report Facts
Facility capacity: 130
Resident interviews: 6
Total residents interviewed: 7
Investigation visit duration (hours): 5.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation and visit |
| Solange Nkafu | Wellness Director | Met with Licensing Program Analyst during the investigation |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 130
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that residents' concerns were ignored by staff at the facility.
Complaint Details
The complaint alleged that staff often ignored residents who requested additional services such as soup or coffee. The investigation included interviews with residents and staff, a physical plant tour, and observation during meal service. The complaint was found unsubstantiated.
Findings
The investigation found that 10 out of 11 residents interviewed reported receiving timely service and not being ignored by staff. Observations during lunch showed staff serving residents appropriately and accommodating their requests. The allegation was deemed unsubstantiated.
Report Facts
Residents interviewed: 11
Residents confirming timely service: 10
Staff observed serving residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation |
| Angelica Segovia | Licensing Program Analyst | Conducted the complaint investigation |
| Solange Nkafu | Wellness Director | Met with investigators during the visit |
| Troy Agard | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 130
Deficiencies: 0
Date: Sep 18, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations regarding medication administration, dietary restrictions, and staff response times to resident requests.
Complaint Details
The complaint alleged that staff were not administering medications as prescribed, not ensuring dietary restrictions were met, and not responding timely to resident requests. The investigation found no supporting evidence for these allegations, and they were deemed unsubstantiated.
Findings
Based on interviews, observations, and record reviews, all allegations were found to be unsubstantiated. There was no evidence that staff failed to administer medications as prescribed, meet dietary restrictions, or respond timely to resident requests. No health and safety hazards were noted.
Report Facts
Residents interviewed: 10
Residents census: 104
Facility capacity: 130
Residents interviewed for call button test: 6
Residents interviewed about food quality: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 130
Deficiencies: 0
Date: Sep 18, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations regarding staff assistance with resident ambulation, sufficiency of living accommodations, food quality, and management of resident behaviors.
Complaint Details
The complaint included allegations that staff did not assist residents with ambulation, did not provide sufficient living accommodations, served watered-down juice, and failed to manage a resident's behaviors. Investigations revealed these allegations were unsubstantiated or unfounded, with no evidence supporting the claims.
Findings
All allegations were found to be unsubstantiated or unfounded based on interviews, observations, and record reviews. No health or safety hazards were noted during the visit.
Report Facts
Capacity: 130
Census: 104
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Administrator | Met with Licensing Program Analyst during the investigation |
| Solange Nkafu | Wellness Director | Toured the physical plant with Licensing Program Analyst |
| Karla Garcia | Wellness Assistant | Conducted physical plant tour with Licensing Program Analyst |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 130
Deficiencies: 0
Date: Sep 18, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff were not administering medications as prescribed, not ensuring residents' dietary restrictions were met, and not responding timely to residents' requests for assistance.
Complaint Details
The complaint investigation was triggered by allegations that staff were not administering medications properly, not honoring dietary restrictions, and were slow to respond to resident requests. Interviews with residents, staff, and review of records found no evidence supporting these allegations. The complaint was determined to be unsubstantiated.
Findings
Based on interviews, observations, and record reviews, there was no pertinent information to support the allegations. The complaints regarding medication administration, dietary restrictions, and response times to resident requests were all deemed unsubstantiated at this time.
Report Facts
Residents interviewed: 10
Residents interviewed for food quality: 8
Residents interviewed for call button response: 6
Call response time: 2
Call response time: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Adam Syncheff | Administrator | Met with Licensing Program Analyst during investigation |
| Rena Hirsch | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 130
Deficiencies: 0
Date: Sep 18, 2024
Visit Reason
An unannounced complaint investigation was conducted to investigate allegations that staff do not assist residents with ambulation, do not provide sufficient living accommodations, do not serve food of good quality, and do not assist a resident with managing behaviors.
Complaint Details
The complaint investigation was unannounced and addressed multiple allegations including lack of assistance with ambulation, insufficient living accommodations, poor food quality, and failure to manage a resident's behaviors. The allegations were found to be unsubstantiated or unfounded based on interviews, observations, and record reviews.
Findings
The investigation found no evidence to support the allegations. Interviews, observations, and record reviews indicated that residents are assisted with ambulation, sufficient chairs are available, food quality is adequate, and the alleged resident with behavioral issues was not a current or former resident. All allegations were deemed unsubstantiated or unfounded with no health and safety hazards noted.
Report Facts
Capacity: 130
Census: 104
Number of residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Adam Syncheff | Administrator | Met with Licensing Program Analyst during investigation |
| Solange Nkafu | Wellness Director | Participated in physical plant tour during investigation |
| Karla Garcia | Wellness Assistant | Participated in physical plant tour during investigation |
Inspection Report
Annual Inspection
Census: 106
Capacity: 130
Deficiencies: 0
Date: Sep 13, 2024
Visit Reason
The inspection was conducted as a continuation of the required 1 Year Annual Inspection to evaluate compliance with licensing requirements.
Findings
The facility was observed to be in compliance with safety, cleanliness, and staff record requirements. No immediate health and safety hazards were found during the inspection.
Report Facts
Staff files reviewed: 8
Resident rooms inspected: 8
Hot water temperature: 107.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Facility representative met during inspection and named in the report |
| Raymond Comer | Licensing Program Analyst | Licensing evaluator conducting the inspection |
| Eva Miller | Supervisor | Supervisor named in the report |
Inspection Report
Annual Inspection
Census: 106
Capacity: 130
Deficiencies: 0
Date: Sep 13, 2024
Visit Reason
The inspection visit was conducted as a continuation of the required 1 Year Annual Inspection to evaluate compliance with licensing requirements.
Findings
The inspection found no immediate health and safety hazards. Fire detection and protection systems, laundry, common areas, resident bedrooms, bathrooms, and outdoor areas were observed to be in good condition and compliant with safety standards. Staff records were complete and current.
Report Facts
Staff files reviewed: 8
Fire extinguisher last service date: Jul 16, 2024
Hot water temperature: 107.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Facility representative met during inspection and mentioned in exit interview |
| Raymond Comer | Licensing Program Analyst | Conducted the inspection and signed the report |
| Eva Miller | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 106
Capacity: 130
Deficiencies: 0
Date: Sep 12, 2024
Visit Reason
An unannounced annual inspection of the facility was conducted by Licensing Program Analyst Raymond Comer to evaluate compliance with licensing requirements.
Findings
The facility was inspected for physical plant conditions, infection control, fire safety, kitchen cleanliness, medication storage, common areas, and resident records. Overall, the facility was found to be clean, well-maintained, and compliant with required protocols, although the annual inspection was not fully completed due to time constraints and will be finished at a later date.
Report Facts
Residents receiving hospice care: 3
Bedridden residents: 1
Hospice waiver capacity: 30
Fire clearance capacity: 122
Additional bedridden capacity: 8
Resident files reviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Facility Administrator | Met with Licensing Program Analyst during inspection and received copy of report |
| Raymond Comer | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Eva Miller | Supervisor | Supervisor named on report |
Inspection Report
Annual Inspection
Census: 106
Capacity: 130
Deficiencies: 0
Date: Sep 12, 2024
Visit Reason
An unannounced annual inspection was conducted by Licensing Program Analyst Raymond Comer to evaluate the facility's compliance with licensing requirements.
Findings
The facility was inspected for cleanliness, safety, infection control, kitchen conditions, medication storage, and resident records. No deficiencies or violations were noted, but the annual inspection was not completed due to time constraints and will be finished at a later date.
Report Facts
Residents receiving hospice care: 3
Bedridden residents: 1
Resident files reviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Facility Administrator | Met with Licensing Program Analyst during inspection and received copy of report |
| Raymond Comer | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 130
Deficiencies: 0
Date: Sep 6, 2024
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation that staff was unlawfully evicting a resident while in care.
Complaint Details
The complaint alleged that staff was unlawfully evicting a resident while in care. The investigation included interviews, document reviews, and a physical plant tour. The allegation was found to be unsubstantiated.
Findings
The investigation found no sufficient information to verify the allegation of unlawful eviction. The resident had received eviction notices due to default of payment, but the facility indicated no intention to evict. The allegation was unsubstantiated and no immediate health or safety hazards were noted.
Report Facts
Capacity: 130
Census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the complaint investigation and subsequent visit |
| Naira Margaryan | Licensing Program Manager | Conducted initial investigation and is listed as supervisor |
| Adam Syncheff | Executive Director | Met with Licensing Program Analyst during investigation |
| Rena Hirsch | Administrator | Spoke with Licensing Program Manager during initial visit |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 130
Deficiencies: 0
Date: Sep 6, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff was unlawfully evicting a resident while in care.
Complaint Details
The complaint alleged that staff unlawfully evicted a resident while in care. The investigation included interviews, document reviews, and a physical plant tour. It was found that the resident's responsible party had payment issues due to the pandemic, but eviction procedures were communicated and no unlawful eviction occurred. The allegation was unsubstantiated.
Findings
The investigation found no sufficient information to verify the allegation of unlawful eviction. The resident had received a 30-day eviction notice due to default of payment, but the facility and owner indicated no intention to evict. The allegation was unsubstantiated and no immediate health or safety hazards were noted.
Report Facts
Facility capacity: 130
Resident census: 104
Eviction notice period: 30
Date complaint received: Oct 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted complaint investigation and visit |
| Naira Margaryan | Licensing Program Manager | Oversaw complaint investigation |
| Adam Syncheff | Executive Director | Met with Licensing Program Analyst during investigation |
| Rena Hirsch | Executive Director | Spoke with Licensing Program Manager during initial investigation |
| Adam Zenou | Facility Owner | Spoke with Licensing Program Analyst by phone regarding complaint |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 130
Deficiencies: 0
Date: Jul 30, 2024
Visit Reason
An unannounced complaint investigation was conducted to investigate the allegation that staff do not accurately manage residents' medications, specifically that staff do not track or record residents' expired medications.
Complaint Details
The complaint alleging inaccurate management of residents' medications, including failure to track or record expired medications, was investigated and found to be unsubstantiated.
Findings
The Licensing Program Analyst observed the medication room, conducted interviews with staff, and reviewed medication records and destruction logs. No discrepancies were found, and all expired medications were properly tracked, recorded, and scheduled for bio-hazard disposal. The allegation was unsubstantiated and no deficiencies were cited.
Report Facts
Residents audited: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 130
Deficiencies: 0
Date: Jul 30, 2024
Visit Reason
An unannounced complaint investigation was conducted to investigate the allegation that staff do not accurately manage residents' medications, specifically that staff do not track or record residents' expired medications.
Complaint Details
The complaint alleged that staff do not accurately manage residents' medications by failing to track or record expired medications. The investigation found no discrepancies and the allegation was unsubstantiated.
Findings
The Licensing Program Analyst observed the medication room as clean, organized, and secure, conducted an audit of medications for sixteen residents with no discrepancies found, reviewed medication destruction records with no discrepancies, and interviewed staff who confirmed proper tracking and destruction of expired medications. The allegation was unsubstantiated and no deficiencies were cited.
Report Facts
Residents audited: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Adam Syncheff | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 130
Deficiencies: 4
Date: Jul 16, 2024
Visit Reason
This was an unannounced complaint investigation visit triggered by a complaint received on 2024-02-15 concerning multiple allegations including bed bugs, lack of housekeeping services, failure to provide transportation to appointments, unmet dietary needs, and failure to safeguard residents' personal belongings.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to prevent bed bugs, inadequate housekeeping, failure to provide transportation, unmet dietary needs, and failure to safeguard personal belongings. The facility was found noncompliant in several areas posing immediate health and safety risks.
Findings
The investigation substantiated multiple allegations: presence of bed bugs despite pest control efforts, inadequate housekeeping services with unsanitary resident rooms, failure to provide timely transportation resulting in missed appointments and hospitalizations, dietary needs generally met but improper control of one resident's food by another without legal authority, and failure to safeguard residents' personal belongings with reports of missing items. One allegation regarding uncomfortable environment due to heating/cooling was unsubstantiated.
Deficiencies (4)
Presence of bed bugs in resident rooms and failure to maintain clean and sanitary conditions.
Failure to provide timely transportation to residents causing missed appointments and hospitalizations.
Failure to safeguard residents' personal belongings, with multiple reports of missing items.
Allowing a resident (R2) to make food decisions on behalf of another resident (R1) without legal authority, interfering with personal rights.
Report Facts
Capacity: 130
Census: 106
Deficiency count: 4
POC Due Date: Jul 17, 2024
POC Due Date: Nov 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Huma Rahimi | Licensing Evaluator | Conducted the complaint investigation and authored the report |
| Adam Syncheff | Executive Director | Facility representative interviewed during investigation |
| Nichelle Gillyard | Supervisor | Supervisor overseeing the licensing evaluation |
| Rena Hirsch | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 130
Deficiencies: 4
Date: Jul 16, 2024
Visit Reason
This was an unannounced complaint investigation visit triggered by allegations received on 02/15/2024 regarding staff not preventing bed bugs, not providing housekeeping services, not transporting residents to appointments, not meeting dietary needs, and not safeguarding residents' personal belongings.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to prevent bed bugs, inadequate housekeeping, failure to provide transportation leading to missed appointments and hospitalizations, failure to meet dietary needs due to unauthorized control of food, and failure to safeguard personal belongings. One allegation about uncomfortable environment was unsubstantiated.
Findings
The investigation substantiated multiple allegations including presence of bed bugs, inadequate housekeeping services, failure to provide timely transportation causing missed appointments and hospitalizations, failure to meet dietary needs due to unauthorized control of resident's food by another resident, and failure to safeguard residents' personal belongings. One allegation regarding providing a comfortable environment was unsubstantiated.
Deficiencies (4)
Maintenance and Operation: Facility was not clean, safe, sanitary, and in good repair due to bed bugs and unsanitary resident rooms.
Incidental Medical and Dental Care: Failure to provide timely transportation to residents causing hospitalization.
Safeguards for Resident Cash, Personal Property, and Valuables: Failure to safeguard residents' personal belongings, with multiple items reported missing.
Personal Rights: Allowing a resident (R2) to make dietary decisions for another resident (R1) without legal authority.
Report Facts
Capacity: 130
Census: 106
Deficiency count: 4
Plan of Correction Due Dates: Jul 17, 2024
Plan of Correction Due Dates: Nov 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Executive Director | Met with Licensing Program Analysts during investigation and provided information |
| Huma Rahimi | Licensing Program Analyst | Conducted the complaint investigation |
| Nichelle Gillyard | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 130
Deficiencies: 2
Date: Jun 28, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that the licensee/administrator made misleading representation of the facility.
Complaint Details
The complaint alleged that the licensee/administrator made misleading representation of the facility by operating as Savant and staff representing themselves as employees of Savant. The allegation was substantiated based on observations and interviews.
Findings
The investigation found that the facility had changed its name and signage to Savant West Hollywood Senior Living without following appropriate protocol with the licensing department. Staff were observed representing themselves as employees of Savant, and the allegation of misleading representation was substantiated.
Deficiencies (2)
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met.
Licensee changed name and signage to building without following appropriate protocol with the CCLD, posing potential risks to residents in care.
Report Facts
Capacity: 130
Census: 109
Plan of Correction Due Date: Jul 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Met during investigation and interview |
| Naira Margaryan | Licensing Program Manager | Supervisor involved in complaint intake and investigation |
| Tihesha Smith | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 130
Deficiencies: 2
Date: Jun 28, 2024
Visit Reason
An unannounced complaint investigation was conducted to investigate allegations that the licensee/administrator made misleading representations of the facility, including operating under a different name and staff representing themselves as employees of another entity.
Complaint Details
The complaint alleged that the licensee/administrator made misleading representation of the facility by operating as Savant and staff representing themselves as employees of Savant. The allegation was substantiated based on interviews, observations of signage and staff clothing, and confirmation that the name change paperwork had not been approved by the licensing department.
Findings
The investigation found sufficient evidence to substantiate the allegation that the licensee/administrator made misleading representations by changing the facility name and signage without proper approval and staff wearing clothing advertising a different facility name, posing potential risks to residents.
Deficiencies (2)
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met.
Based on observation and interviews the Licensee changed name and signage to building without following appropriate protocol with the CCLD. This poses a potential risks to residents in care.
Report Facts
Capacity: 130
Census: 109
Deficiencies cited: 2
Plan of Correction Due Date: Jul 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Met during investigation and involved in findings regarding misleading representation |
| Tihesha Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Oversaw complaint intake and investigation |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 130
Deficiencies: 0
Date: Jun 16, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility did not safeguard a resident's personal belongings.
Complaint Details
The complaint alleged that the facility did not safeguard resident #1's personal belongings, including a passport and computer. The allegation was deemed unsubstantiated due to lack of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegation that the facility failed to safeguard residents' personal belongings. Interviews with staff and residents indicated that belongings were stored in residents' rooms and no confirmed missing items were found.
Report Facts
Capacity: 130
Census: 109
Staff interviewed: 5
Residents interviewed: 6
Residents total: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tihesha Smith | Licensing Program Analyst | Conducted the complaint investigation visit |
| Naira Margaryan | Supervisor | Supervisor overseeing the investigation |
| Rena Hirsch | Administrator | Facility administrator not present during visit |
| Solange Nkafu | Wellness Director | Met with during the investigation visit |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 130
Deficiencies: 0
Date: Jun 16, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility did not safeguard a resident's personal belongings.
Complaint Details
The complaint alleged that Resident #1's passport and computer were missing after returning to the facility on 01/04/2024. Interviews with staff and residents revealed no evidence supporting the allegation. The complaint was deemed unsubstantiated.
Findings
The investigation found insufficient evidence to substantiate the allegation that the facility failed to safeguard residents' personal belongings. Interviews with staff and residents indicated that belongings were stored in residents' rooms and no confirmed missing items were found.
Report Facts
Capacity: 130
Census: 109
Staff interviewed: 5
Residents interviewed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tihesha Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation |
| Solange Nkafu | Wellness Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 130
Deficiencies: 1
Date: May 9, 2024
Visit Reason
This was an unannounced complaint investigation visit conducted to investigate multiple allegations including issues with residents' call buttons, staff response times, communication barriers, incontinence care, odor control, and adherence to residents' care plans.
Complaint Details
The complaint investigation was substantiated for the allegation that staff do not ensure that residents have a working call button. Other allegations including staff response time to call buttons, communication barriers, incontinence care, odor control, and following care plans were unsubstantiated.
Findings
The investigation substantiated that the residents' call buttons were not consistently working, posing a potential health and safety risk. Other allegations regarding staff response times, communication barriers, incontinence care, odor control, and care plan adherence were unsubstantiated based on interviews and observations.
Deficiencies (1)
Based on interviews and observations, the residents' call buttons were not in working order which poses a potential health, safety and personal rights risk to residents in care.
Report Facts
Residents interviewed: 11
Staff interviewed: 3
Average call button response time: 7
Capacity: 130
Census: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Nirjara Acharya | Regional Director | Met with Licensing Program Analyst during investigation |
| Naira Margaryan | Supervisor | Supervisor overseeing the investigation |
| Rena Hirsch | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 130
Deficiencies: 1
Date: May 9, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations including non-functioning call buttons, delayed response to call buttons, communication barriers, incontinence care, odor issues, and failure to follow resident care plans.
Complaint Details
The complaint investigation was substantiated for the allegation that staff do not ensure that residents have a working call button. Other allegations including staff not answering call buttons timely, communication barriers, incontinence care, odor issues, and failure to follow care plans were unsubstantiated.
Findings
The investigation substantiated the allegation that the call button system was not consistently functioning, posing a potential health and safety risk. Other allegations including delayed response to call buttons, communication barriers, incontinence care, odor issues, and failure to follow care plans were found to be unsubstantiated based on interviews and observations.
Deficiencies (1)
87303 Maintenance and Operation (a): The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by; Based on interviews and observations, the residents' call buttons were not in working order which poses a potential health, safety and personal rights risk to residents in care.
Report Facts
Census: 109
Total Capacity: 130
Response Time: 7
Residents Interviewed: 11
Staff Interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation |
| Nirjara Acharya | Regional Director | Met with Licensing Program Analyst during the inspection |
| Rena Hirsch | Administrator | Facility administrator mentioned in report header |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 130
Deficiencies: 0
Date: Feb 27, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff do not prevent residents from entering other residents' rooms and do not prevent inappropriate interactions between residents.
Complaint Details
The complaint involved allegations that staff failed to prevent Resident #2 from entering Resident #1's room and saying inappropriate things, and that Resident #1 was being sexually harassed by Resident #2. After interviews with staff and residents, the allegations were determined to be unsubstantiated.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with staff and residents indicated that the interactions between the residents in question were consensual and no inappropriate behavior was verified. No health and safety hazards were noted during the visit.
Report Facts
Capacity: 130
Census: 106
Number of staff interviewed: 3
Number of residents interviewed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Evaluator | Conducted the complaint investigation |
| Adam Syncheff | Executive Director | Met with Licensing Evaluator during the investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 130
Deficiencies: 0
Date: Feb 27, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that insufficient staffing caused food served to residents to be cold.
Complaint Details
The complaint alleging insufficient staffing causing cold food was investigated and found unsubstantiated based on staff interviews, observations, and resident feedback.
Findings
The investigation found that there were sufficient servers during meals, including staff from Memory Care and Assisted Living units assisting with serving. Interviews with residents indicated that food was served on time or within five minutes. The allegation was deemed unsubstantiated.
Report Facts
Servers scheduled per meal: 3
Memory Care residents: 35
Memory Care servers: 4
Assisted Living residents served trays: 15
Residents served in dining area: 50
Residents served in dining area: 55
Residents interviewed: 11
Residents reporting timely food service: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Executive Director | Met with Licensing Program Analysts during investigation and confirmed staffing details |
| Jose Gary Tan | Licensing Evaluator | Conducted the complaint investigation |
| Liezel Dela Cerra | Licensing Program Analyst | Conducted the complaint investigation |
| Troy Agard | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 130
Deficiencies: 0
Date: Feb 27, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff did not prevent a resident from entering another resident's room and did not prevent inappropriate interactions between residents.
Complaint Details
The complaint involved allegations that Resident #2 entered Resident #1's room and said inappropriate things, and that Resident #1 was being sexually harassed by Resident #2. After interviewing three staff members and eleven residents, the allegations were found to be unsubstantiated.
Findings
Based on interviews with staff and residents, there was insufficient evidence to verify the allegations. All interviewed residents and most staff stated that interactions were consensual and no inappropriate behavior was observed. The allegations were determined to be unsubstantiated.
Report Facts
Staff interviewed: 3
Residents interviewed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Executive Director | Met with during the complaint investigation |
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 130
Deficiencies: 0
Date: Feb 27, 2024
Visit Reason
The inspection visit was conducted to investigate a complaint alleging that due to insufficient staffing, the food served to residents gets cold.
Complaint Details
The complaint was unsubstantiated after investigation. The allegation was that insufficient staffing caused food to be served cold, but evidence showed adequate staffing and timely food service.
Findings
The investigation found that there are three servers scheduled at every meal, with additional staff assisting in serving, and interviews with residents indicated that most received food on time. Based on the gathered information, the allegation was deemed unsubstantiated.
Report Facts
Servers scheduled per meal: 3
Memory Care residents: 35
Memory Care servers: 4
Assisted Living residents served trays: 15
Residents served in dining area: 50
Residents interviewed: 11
Residents reporting timely food service: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation |
| Liezel Dela Cerra | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Executive Director | Interviewed during the investigation |
| Troy Agard | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 130
Deficiencies: 1
Date: Feb 20, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that staff did not prevent a resident from spitting on surfaces in common areas.
Complaint Details
The complaint alleged that staff did not prevent Resident #1 from spitting on surfaces in common areas. The allegation was substantiated based on interviews with ten residents and six staff members, observations, and record review. One citation was issued related to this allegation.
Findings
The investigation substantiated the allegation that Resident #1 was spitting on floors, napkins, bowls, and common areas, and staff did not adequately prevent this behavior. Interviews with residents and staff confirmed the behavior, and the facility had attempted redirection despite language barriers. The resident is ambulatory with no mental issues.
Deficiencies (1)
The facility failed to ensure one resident was clean and sanitary at all times, posing potential health, safety, or personal rights risks. Floor surfaces in bath, laundry, and kitchen areas were not maintained in a clean, sanitary, and odorless condition.
Report Facts
Residents interviewed: 10
Staff interviewed: 6
Citation count: 1
Plan of Correction due date: Mar 7, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Executive Director | Met with Licensing Program Analyst during the investigation |
| Gina Saucedo | Licensing Program Analyst | Conducted the complaint investigation |
| Troy Agard | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 130
Deficiencies: 0
Date: Feb 8, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation of unlawful eviction at the facility.
Complaint Details
The complaint alleged unlawful eviction. The investigation revealed a 30-day eviction notice was issued on 01/25/2024 for failure to pay rent totaling $2,767.05 and room and board charges of $1,398.07. The resident was still residing at the facility and denied the eviction allegation. The complaint was unsubstantiated.
Findings
The investigation found that the eviction notice was issued due to failure to pay rent and room and board charges. The resident was advised to vacate within 30 days but was still living at the facility at the time of the visit. The resident denied the allegation, stating they checked into a hotel voluntarily. The allegation was deemed unsubstantiated.
Report Facts
Rent owed: 2767.05
Room and Board charges: 1398.07
Capacity: 130
Census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Huma Rahimi | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Syncheff | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 130
Deficiencies: 0
Date: Feb 8, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation of unlawful eviction at the facility.
Complaint Details
The complaint alleged unlawful eviction of a resident. The eviction notice was for a 30-day notice issued on 01/25/2024 due to unpaid rent totaling $2,767.05 and additional room and board charges of $1,398.07. The resident denied the allegation and stated they voluntarily left to stay at a hotel. The allegation was unsubstantiated.
Findings
The investigation found that the eviction notice was issued for failure to pay rent, but the resident was still living at the facility and denied the allegation, stating they checked into a hotel. The allegation was deemed unsubstantiated based on interviews, record review, and observation.
Report Facts
Unpaid rent amount: 2767.05
Additional room and board charges: 1398.07
Capacity: 130
Census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Administrator | Met with Licensing Program Analyst during investigation |
| Huma Rahimi | Licensing Program Analyst | Conducted the complaint investigation |
| Nichelle Gillyard | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 130
Deficiencies: 0
Date: Jan 16, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff were not addressing residents' health conditions while in care.
Complaint Details
The complaint alleged that Resident #1 was being treated poorly by the caregiver and that their health conditions were worsening daily. The investigation found no substantiation of these claims.
Findings
The investigation included interviews with staff and residents, review of facility records, and a physical plant tour. All interviewed residents and staff denied mistreatment, and the allegation was deemed unsubstantiated based on gathered information.
Report Facts
Residents interviewed: 12
Staff interviewed: 3
Facility capacity: 130
Census: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Jessica Perez | Wellness Director | Met with Licensing Program Analyst during investigation. |
| Rena Hirsch | Administrator | Facility administrator named in report header. |
| Troy Agard | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 130
Deficiencies: 0
Date: Jan 16, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff were not addressing residents' health conditions while in care.
Complaint Details
The complaint alleged that Resident #1 was being treated poorly and that their health conditions were worsening. The investigation found that Resident #1 was admitted with hospice and home health services, and staff logs documented relevant care activities. Interviews with staff and 12 residents confirmed respectful care was provided. The allegation was unsubstantiated.
Findings
The investigation included interviews with staff and residents, review of facility records, and a physical plant tour. All interviewed residents and staff denied mistreatment, and the allegation was deemed unsubstantiated based on gathered information.
Report Facts
Facility capacity: 130
Resident census: 100
Number of staff interviewed: 3
Number of residents interviewed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation |
| Jessica Perez | Wellness Director | Met with Licensing Program Analyst during investigation |
| Troy Agard | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 130
Deficiencies: 0
Date: Dec 28, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that staff unlawfully evicted a resident.
Complaint Details
The allegation that staff unlawfully evicted a resident was unsubstantiated based on interviews and record review.
Findings
The investigation found insufficient evidence to verify the allegation that staff unlawfully evicted a resident. The resident in question was currently in a mental health facility and will not be readmitted due to posing an immediate danger to self and others. No health and safety hazards were noted during the visit.
Report Facts
Capacity: 130
Census: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Evaluator | Conducted the complaint investigation |
| Adam Syncheff | Executive Director | Met with Licensing Program Analysts during the investigation |
| Naira Margaryan | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 130
Deficiencies: 0
Date: Dec 28, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that staff unlawfully evicted a resident.
Complaint Details
The allegation that staff unlawfully evicted a resident was unsubstantiated based on interviews and record review.
Findings
The investigation found insufficient information to verify the allegation. Staff stated the resident is currently in a mental health facility and will not be readmitted due to posing an immediate danger to self and others. No health and safety hazards were noted.
Report Facts
Capacity: 130
Census: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Syncheff | Executive Director | Met with during the investigation and explained the reason for the visit |
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation |
| Christopher Alemoh | Licensing Program Analyst | Conducted the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Named in report signature and oversight |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 130
Deficiencies: 0
Date: Nov 29, 2023
Visit Reason
An unannounced complaint investigation was conducted to investigate allegations that staff did not properly address multiple residents' falls at the facility.
Complaint Details
The complaint alleged that staff did not properly address multiple residents' falls. The allegation was unsubstantiated after review of incident reports and staff interviews. The facility reported multiple fall incidents over recent months, and staff stated that increased falls correlated with increased census. Precautions such as bed adjustments, obstacle removal, medication review, and increased monitoring were confirmed.
Findings
The investigation found that three residents experienced multiple falls, but the facility staff took all necessary precautions and measures to mitigate falls. Based on record review and interviews, there was insufficient evidence to verify the allegation, and it was determined to be unsubstantiated. No health and safety hazards were noted during the visit.
Report Facts
Fall incidents: 3
Fall incidents: 11
Fall incidents: 5
Fall incidents: 6
Resident census increase: 48
Resident census: 96
Facility capacity: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rina Hirsch | Executive Director | Met with Licensing Program Analyst during investigation and discussed allegations |
| Abeye Duguma | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Naira Margaryan | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 130
Deficiencies: 0
Date: Nov 29, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff did not properly address multiple residents' falls at the facility.
Complaint Details
The complaint alleged that staff did not properly address multiple residents' falls. The allegation was unsubstantiated after investigation.
Findings
The investigation found that three residents experienced multiple falls, but all available measures and precautions were exercised by the facility. Staff stated that the increase in falls correlated with the census increase. Based on record review and interviews, there was not enough information to verify the allegation, and it was deemed unsubstantiated. No health and safety hazards were noted.
Report Facts
Fall incidents reported: 3
Fall incidents reported: 11
Fall incidents reported: 5
Fall incidents reported: 6
Facility census increase: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rina Hirsch | Executive Director | Met with Licensing Program Analyst during investigation |
| Naira Margaryan | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 130
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation that the facility refused to accept a resident back from the hospital upon discharge.
Complaint Details
The complaint alleged that staff refused to accept resident back from hospital. The allegation was deemed unsubstantiated based on interviews and record review during the visit.
Findings
The investigation found that the allegation was unsubstantiated as the resident was scheduled to be released from the hospital on the day of the visit and the administrator confirmed acceptance of the resident upon release.
Report Facts
Capacity: 130
Census: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rena Hirsch | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 130
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit following a complaint received on 2023-09-29 alleging that staff refused to accept a resident back from the hospital.
Complaint Details
The complaint alleged that staff refused to accept Resident #1 back from the hospital. The investigation found this allegation unsubstantiated based on interviews and record review.
Findings
The Licensing Program Analyst conducted interviews, document reviews, and a physical plant tour. The allegation was found to be unsubstantiated as the resident was scheduled for release and the administrator confirmed acceptance of the resident upon release.
Report Facts
Complaint Control Number: 31-AS-20230929161909
Facility Capacity: 130
Census: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rena Hirsch | Administrator | Met with Licensing Program Analyst and confirmed acceptance of resident |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 130
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff were not maintaining the facility in a clean condition, not ensuring the facility was free from pests, and not ensuring residents had air conditioning.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included unclean conditions, pest infestation, and lack of air conditioning. Interviews with nine residents and staff, document review, and physical inspection found no supporting evidence for the allegations.
Findings
The investigation found the facility to be generally clean with no evidence of pest infestation, including bed bugs. Residents reported regular cleaning and no issues with air conditioning. The allegations were deemed unsubstantiated based on interviews, observations, and document reviews.
Report Facts
Residents interviewed: 9
Capacity: 130
Census: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rena Hirsch | Executive Director | Met with Licensing Program Analysts during the investigation and provided information about facility operations. |
| Jose Gary Tan | Licensing Evaluator | Conducted the complaint investigation. |
| Gina Saucedo | Licensing Program Analyst | Assisted in conducting the complaint investigation. |
| Troy Agard | Supervisor | Supervisor overseeing the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 130
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not maintaining the facility in a clean condition, not ensuring the facility was free from pests, and not ensuring residents had air conditioning.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included unclean facility conditions, presence of pests (bed bugs), and issues with air conditioning. Interviews with nine residents and staff, physical inspections, and record reviews did not support the allegations.
Findings
The investigation found the facility to be generally clean, with no evidence of pest infestation, and air conditioning functioning properly with residents reporting no issues. Based on interviews, observations, and record reviews, the allegations were deemed unsubstantiated at this time.
Report Facts
Capacity: 130
Census: 99
Residents interviewed: 9
Pest control inspections: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rena Hirsch | Executive Director | Met with during investigation and interviewed regarding air conditioning and facility conditions |
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation |
| Gina Saucedo | Licensing Program Analyst | Conducted the complaint investigation |
| Troy Agard | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 130
Deficiencies: 2
Date: Sep 19, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-08-11 regarding staff not ensuring residents had equal share of space in the room and other allegations.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not ensure equal sharing of space between residents. Other allegations including emotional blackmail, failure to replace medication, uncomfortable environment, and not safeguarding personal belongings were unsubstantiated.
Findings
The allegation that staff did not ensure equal sharing of living space between residents was substantiated based on observations and interviews. Other allegations including emotional blackmail, failure to replace medication, uncomfortable environment, and not safeguarding personal belongings were unsubstantiated.
Deficiencies (2)
Facility did not ensure Resident #1 had sufficient room available to accommodate with comfort and safety as they were not allowed equal living space and refrigerator access in the bedroom.
Facility did not ensure Resident #1 had access to individual storage space for private use.
Report Facts
Capacity: 130
Census: 99
Number of staff interviewed: 4
Number of residents interviewed: 9
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rina Hirsch | Executive Director | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 130
Deficiencies: 2
Date: Sep 19, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations received on 2023-08-11 regarding resident space sharing, emotional blackmail, medication replacement, comfort environment, and safeguarding of personal belongings.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not make sure resident had equal share of space in the room. Other allegations including emotional blackmail, failure to replace medication, uncomfortable environment, and not safeguarding personal belongings were unsubstantiated.
Findings
The allegation that staff did not ensure equal sharing of living space was substantiated with deficiencies cited related to personal accommodations and personal rights. All other allegations including emotional blackmail, medication replacement, comfortable environment, and safeguarding personal belongings were unsubstantiated based on interviews and observations. No health and safety hazards were noted during the visit.
Deficiencies (2)
Facility did not ensure Resident #1 had sufficient room available to accommodate with comfort and safety as they were not allowed equal living space and refrigerator access in the bedroom.
Facility did not ensure Resident #1 had access to individual storage space for private use.
Report Facts
Capacity: 130
Census: 99
Deficiencies cited: 2
Plan of Correction Due Dates: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation |
| Rina Hirsch | Executive Director | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 130
Deficiencies: 0
Date: Sep 18, 2023
Visit Reason
The complaint investigation visit was conducted to investigate an allegation that staff were mismanaging resident medication, specifically that Resident 1 was not provided their pain medication for approximately three days.
Complaint Details
The complaint alleged that staff were mismanaging resident medication. After investigation, including interviews and record review, the allegation was deemed unsubstantiated.
Findings
The investigation included staff and resident interviews and a review of resident records. It was found that the delay in medication refill was due to waiting for doctor verification with the pharmacy. Resident 1 was informed and understood the process. The allegation of medication mismanagement was unsubstantiated.
Report Facts
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cava | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Nijara Acharya | Regional Administrator | Met with the evaluator during the investigation. |
| Jessica Perez | Wellness Director | Provided information regarding medication refill process. |
| Eva Miller | Supervisor | Named as supervisor on the report. |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 130
Deficiencies: 0
Date: Sep 18, 2023
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations that staff were mismanaging resident medication.
Complaint Details
The complaint alleged staff mismanagement of resident medication. The allegation was investigated and found unsubstantiated based on interviews and record review confirming proper refill procedures.
Findings
The investigation found that Resident 1's pain medication was delayed due to pending doctor authorization for a refill, but the medication was eventually provided as prescribed. Interviews with other residents revealed no complaints about medication management. The allegation was deemed unsubstantiated.
Report Facts
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cava | Licensing Program Analyst | Conducted the complaint investigation visit |
| Nijara Acharya | Regional Administrator | Met with during investigation |
| Jessica Perez | Wellness Director | Met with during investigation and provided information about medication refill |
| Eva Miller | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 130
Deficiencies: 0
Date: Sep 6, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 08/30/2023 regarding staff not preventing physical altercations between residents and the facility not providing a menu for residents in care.
Complaint Details
The complaint investigation was unsubstantiated. Allegation #1 involved a minor incident between two residents with no physical altercation confirmed. Allegation #2 regarding menu provision was disproven by observations and resident interviews.
Findings
The investigation found that the allegation of staff not preventing physical altercations was unsubstantiated as the incident involved a minor scratch with no further medical attention required and no ongoing issues. The allegation that the facility does not provide a menu was also unsubstantiated, as menus were observed posted in multiple locations and residents confirmed receiving menus in newsletters.
Report Facts
Census: 99
Total Capacity: 130
Staff interviewed: 2
Residents interviewed: 9
Menus observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tuesday Cabiness | Licensing Program Analyst | Conducted the complaint investigation and met with the Administrator |
| Rena Hirsch | Administrator | Facility Administrator met during the investigation |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 130
Deficiencies: 0
Date: Sep 6, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that facility staff were not preventing residents from engaging in physical altercations and that the facility did not provide a menu for residents in care.
Complaint Details
The complaint was unsubstantiated. Allegation #1 involved a minor incident between two residents with no physical altercation confirmed. Allegation #2 regarding menus was disproven by observations and resident reports.
Findings
The investigation found the allegation of staff not preventing physical altercations unsubstantiated, as the incident involved a minor scratch with no further incidents and appropriate actions taken. The allegation regarding lack of menus was also unsubstantiated, as menus were observed posted in multiple locations and provided in monthly newsletters.
Report Facts
Census: 99
Total Capacity: 130
Number of staff interviewed: 2
Number of residents interviewed: 9
Number of menus observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rena Hirsch | Administrator | Met with Licensing Program Analyst during the investigation |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the complaint investigation |
| Troy Agard | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Census: 88
Capacity: 130
Deficiencies: 0
Date: Jul 28, 2023
Visit Reason
The visit was an office type evaluation related to a Change of Ownership (CHOW) application, involving a COMP II interview to verify the applicant and administrator's understanding of community care facility licensing laws and regulations.
Findings
The applicant and administrator demonstrated understanding of facility operation, admission policies, staffing requirements and training, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness. Identification was verified and required documentation was obtained.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Menachem Ginsburg | Administrator | Named as facility administrator |
| Adam Zenou | Licensee/Administrator | Participant in COMP II interview |
| Rena Hirsch | Licensee/Administrator | Participant in COMP II interview |
| Maria Ejaz | Licensing Evaluator | Conducted evaluation and signed report |
| Jude De La Concepcion | Supervisor | Supervisor overseeing evaluation |
Inspection Report
Original Licensing
Census: 88
Capacity: 130
Deficiencies: 0
Date: Jul 28, 2023
Visit Reason
The visit was conducted as part of a change of ownership (CHOW) application process for licensing evaluation of the facility.
Findings
The applicant and administrator participated in a COMP II interview to verify understanding of community care facility licensing laws, including facility operation, admission policies, staffing requirements, health conditions, emergency preparedness, complaints reporting, and pre-licensing readiness.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Menachem Ginsburg | Administrator | Named as facility administrator |
| Adam Zenou | Licensee/Administrator | Participant in COMP II interview |
| Rena Hirsch | Licensee/Administrator | Participant in COMP II interview |
| Jude De La Concepcion | Licensing Program Manager | Named as licensing program manager |
| Maria Ejaz | Licensing Program Analyst | Named as licensing program analyst |
Inspection Report
Capacity: 130
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
The visit was an unannounced office meeting held to discuss the pending application for a change of ownership for the Garden of Palms LA facility and to review management actions taken to improve the facility.
Findings
The report summarizes discussions about management efforts including contracting staffing agencies, hiring a Wellness Director, executing a new dining contract, and working with a consultant to ensure regulatory conformity. Open communication with the regional office was advised.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Zenou | CEO | Discussed facility management and pending application during the office meeting. |
| Moises Bercovich | CEO | Discussed facility management and pending application during the office meeting. |
| Angela Kendrick | Regional Manager | Led the office meeting and advised on communication with the regional office. |
| Reyna Lacey | Regional Manager | Participated in the office meeting. |
| Hao Nguyen | Bureau Chief | Participated in the office meeting. |
Inspection Report
Capacity: 130
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
An office meeting was held to discuss the pending application for a change of ownership for the Garden of Palms LA facility and to review management efforts and regulatory conformity.
Findings
The meeting covered the facility's history, staffing improvements including hiring a Wellness Director and contracting staffing agencies, a new dining contract, and working with a consultant to ensure regulatory compliance. Open communication with the regional office was encouraged.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Zenou | CEO | Met during the office meeting and discussed facility management and pending application. |
| Moises Bercovich | CEO | Met during the office meeting and discussed facility management and pending application. |
| Angela Kendrick | Regional Manager | Led the office meeting and advised on communication with the regional office. |
| Reyna Lacey | Regional Manager | Participated in the office meeting. |
| Hao Nguyen | Bureau Chief | Participated in the office meeting. |
Inspection Report
Original Licensing
Census: 87
Capacity: 130
Deficiencies: 0
Date: Jul 14, 2023
Visit Reason
An unannounced prelicensing visit was conducted due to a change of ownership and to complete Component III orientation for licensure of the facility.
Findings
The facility was found compliant with regulations including safety, maintenance, operational requirements, cleanliness, medication storage, and food safety. No corrections were needed at the time of the visit.
Report Facts
Capacity: 130
Census: 87
Number of inspected bedrooms: 12
Number of bedridden residents allowed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rema Hirsch | Executive Director | Met with LPAs during the inspection and participated in the facility tour |
| John Garcia III | Director of Maintenance | Participated in the facility tour for compliance with safety and maintenance |
| Jose Gary Tan | Licensing Evaluator | Conducted the inspection and signed the report |
| Troy Agard | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Original Licensing
Census: 87
Capacity: 130
Deficiencies: 0
Date: Jul 14, 2023
Visit Reason
An unannounced prelicensing visit was conducted due to a change of ownership and to perform Component III orientation for the facility Garden of Palms LA.
Findings
The facility was found to be compliant with regulations including safety, maintenance, operational requirements, cleanliness, medication storage, and food safety. No corrections were needed at the time of the visit.
Report Facts
Licensed capacity: 130
Current census: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rema Hirsch | Executive Director | Met with Licensing Program Analysts during the inspection and participated in the facility tour |
| John Garcia III | Director of Maintenance | Participated in the physical plant tour for compliance with safety, maintenance, and operational requirements |
Inspection Report
Census: 76
Capacity: 130
Deficiencies: 0
Date: May 18, 2023
Visit Reason
The visit was an office type evaluation related to a Change of Ownership (CHOW) application for the facility.
Findings
The applicant/administrator participated in a COMP II interview to verify understanding of community care facility licensing laws, including facility operation, admission policies, staffing requirements, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Menachem Ginsburg | Administrator | Named as facility administrator. |
| Adam Zenou | Applicant/Administrator | Participated in COMP II interview and confirmed understanding of licensing laws. |
| Maria Ejaz | Licensing Evaluator | Conducted licensing evaluation and signed report. |
| Jude De La Concepcion | Supervisor | Named as supervisor overseeing the evaluation. |
Inspection Report
Census: 76
Capacity: 130
Deficiencies: 0
Date: May 18, 2023
Visit Reason
The visit was an office type evaluation involving the applicant/administrator's participation in COMP II to verify understanding of community care facility licensing laws and readiness for licensing.
Findings
The applicant/administrator demonstrated understanding of licensing laws, facility operation, admission policies, staffing requirements, emergency preparedness, complaints reporting, and pre-licensing readiness during the COMP II interview.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Zenou | applicant/administrator | Participated in COMP II interview and confirmed understanding of licensing laws. |
| Jude De La Concepcion | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Maria Ejaz | Licensing Program Analyst | Named as Licensing Program Analyst on the report. |
Report
February 20, 2024
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