Inspection Reports for Golden Living Point Loma
3223 Duke St, San Diego, CA 92110, United States, CA, 92110
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally consistent compliance with regulations. However, there were multiple substantiated deficiencies primarily related to medication management, resident care, documentation, and facility maintenance, including some posing immediate health and safety risks. Notably, the facility received civil penalties totaling $25,000 in 2024 for failures in care and supervision that led to serious resident injuries and a death, and there was a substantiated issue with illegal drug use on the premises in late 2024. The most recent report from October 1, 2025, was a complaint investigation that found no deficiencies and unsubstantiated allegations. This suggests some improvement in recent months, although past serious issues highlight areas of concern.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 78
Capacity: 113
Deficiencies: 0
Oct 1, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not accord resident dignity in their relationship with staff or residents.
Findings
The investigation included interviews, record reviews, and a facility tour. The allegation was found to be unsubstantiated due to inconsistent statements and lack of evidence. The facility addressed the issue by relocating one resident to a private room to avoid further conflict.
Complaint Details
The complaint alleged that staff did not accord resident dignity. The investigation revealed a disagreement between two residents about a bedroom door being open or closed, with no witnessed physical altercation. The allegation was deemed unsubstantiated.
Report Facts
Complaint Control Number: 08-AS-20250611162354
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation and telephone visit. |
| Rocio Granda | Administrator | Facility administrator involved in the investigation and exit interview. |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 113
Deficiencies: 0
Jun 5, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations received on 2021-04-06 regarding medication not given as prescribed, failure to arrange appropriate medical care, and inadequate night staffing.
Findings
The investigation found that the resident was taken to the emergency room and the facility contacted the primary care physician to address medical needs. The resident admitted to refusing prescribed PRN medication. There was insufficient evidence to support inadequate night staffing. The allegations were deemed unsubstantiated.
Complaint Details
The complaint alleged medication was not given as prescribed, the licensee did not arrange appropriate medical care, and the facility was not adequately staffed at night. The investigation found no preponderance of evidence to substantiate these allegations; they were deemed unsubstantiated.
Report Facts
Complaint received date: Apr 6, 2021
Complaint investigation visit date: Jun 5, 2025
Facility census: 76
Facility capacity: 113
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Palado | Licensing Program Analyst | Conducted the complaint investigation |
| Rocio Granda | Administrator | Facility administrator involved in the investigation |
| Stacy Barlow | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 113
Deficiencies: 0
Jun 5, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2021-03-29 alleging that the licensee failed to secure a resident's medication and that facility staff were not properly cleaning a resident's bathroom.
Findings
The investigation found insufficient evidence to support the allegations. Interviews and record reviews indicated that medication was maintained on a medication cart and that the housekeeping schedule was adequate. The allegations were deemed unsubstantiated.
Complaint Details
The complaint was unsubstantiated based on interviews and records reviewed. The allegations regarding medication security and bathroom cleaning were not supported by the evidence.
Report Facts
Capacity: 113
Census: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with during the investigation and named in the report |
| Andrea Palado | Evaluator | Conducted the complaint investigation |
| Stacy Barlow | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 113
Deficiencies: 0
May 23, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that the licensee was not following proper eviction protocols for a resident in care.
Findings
The investigation found that proper 60-day notice was given to the resident due to nonpayment of rent over eight months. Interviews and record reviews did not reveal any concerns about eviction protocols being violated. The complaint was deemed unsubstantiated.
Complaint Details
The complaint alleged that the licensee was not following proper eviction protocols regarding Resident #1. The investigation concluded the allegation was unsubstantiated.
Report Facts
Capacity: 113
Census: 76
Notice period: 60
Nonpayment duration: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Boyles | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Rocio Granda | Administrator | Facility administrator interviewed during investigation |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 77
Capacity: 113
Deficiencies: 0
Mar 21, 2025
Visit Reason
An unannounced required annual inspection was conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be clean, sanitary, and compliant with all regulatory requirements. No deficiencies were observed or cited during the inspection, though a Technical Advisory was issued.
Report Facts
Hot water temperature: 112
Perishable food supply: 2
Non-perishable food supply: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with during inspection and participated in exit interview |
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection visit |
| Robyn Clark | Licensing Program Manager | Named in report header |
Inspection Report
Census: 77
Capacity: 113
Deficiencies: 0
Mar 21, 2025
Visit Reason
Licensing Program Analyst conducted a Case Management - Other visit to review the facility and process a bedridden fire clearance application for one resident.
Findings
The facility was toured with no immediate health or safety issues observed. The facility layout remains consistent with the current floor plans. The fire clearance for one bedridden resident was approved by the Fire Marshall.
Report Facts
Bedridden fire clearance: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during the visit and acknowledged receipt of report and licensing rights |
| Natasha Persaud | Licensing Program Analyst | Conducted the Case Management - Other visit |
| Robyn Clark | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 113
Deficiencies: 0
Feb 6, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff did not safeguard a resident's personal belongings, specifically missing money and clothing of Resident #1.
Findings
The investigation included interviews, record reviews, and facility tours. Conflicting statements were found, and no preponderance of evidence supported the allegation. The complaint was deemed unsubstantiated.
Complaint Details
The complaint alleged staff did not safeguard Resident #1's personal belongings, including money and clothing. Resident #1 provided conflicting statements about missing money. The administrator and staff confirmed no knowledge of missing items. Resident interviews confirmed belongings were not missing or stolen. The allegation was unsubstantiated.
Report Facts
Capacity: 113
Census: 83
Complaint Control Number: 08-AS-20240709163518
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Rocio Granda | Administrator | Facility administrator interviewed regarding the complaint |
| Robyn Clark | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Plan of Correction
Census: 87
Capacity: 113
Deficiencies: 0
Jan 17, 2025
Visit Reason
The visit was conducted as a Plan of Correction (POC) follow-up to verify correction of a previously cited deficiency regarding a resident not having a written order on file for multivitamins.
Findings
The deficiency related to medication orders was corrected prior to the due date through in-service training on medications conducted by the administrator. No new deficiencies were issued during this visit.
Report Facts
Deficiency due date: Feb 5, 2025
Training completion date: Jan 14, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst and responsible for conducting in-service training to correct deficiency |
| Natasha Persaud | Licensing Program Analyst | Conducted the Plan of Correction visit |
| Robyn Clark | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 113
Deficiencies: 2
Jan 8, 2025
Visit Reason
The visit was conducted to issue deficiencies identified during a complaint investigation that concluded on 01/08/2025.
Findings
The facility failed to maintain current documentation for Resident #1, including an outdated Resident Appraisal and lack of a written physician order for an over-the-counter medication, posing potential health and safety risks.
Complaint Details
The visit was triggered by a complaint investigation that identified deficiencies related to Resident #1's documentation and medication orders. The deficiencies were substantiated and cited.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident #1 did not have current written orders on file for an over-the-counter medication. | Type B |
| Resident #1 was not assessed with a reappraisal every 12 months as required. | Type B |
Report Facts
Residents present: 87
Total licensed capacity: 113
Deficiencies cited: 2
Plan of Correction due date: Feb 5, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during inspection and named in findings |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation and inspection |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 113
Deficiencies: 0
Jan 8, 2025
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation regarding an allegation that staff were unable to communicate with residents due to a language barrier.
Findings
The investigation found that while some staff primarily spoke Spanish and had limited English proficiency, they were able to meet residents' needs and communicate effectively. The night manager and medication technician spoke English, and the language barrier did not affect care or supervision. The allegation was deemed unsubstantiated due to inconsistent statements and lack of evidence.
Complaint Details
The complaint alleged that staff could not communicate with residents due to a language barrier, specifically that night shift staff could not speak English. The investigation found this allegation unsubstantiated.
Report Facts
Complaint Control Number: 08-AS-20241112094804
Capacity: 113
Census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Rocio Granda | Administrator | Facility administrator interviewed during investigation |
| Yahaira Garduno | Office Assistant | Met with during investigation and received report and licensee rights |
| Robyn Clark | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 113
Deficiencies: 1
Jan 8, 2025
Visit Reason
The inspection was conducted to investigate complaints alleging that staff did not repair a wall allowing rodents into the facility and that staff did not ensure chemicals were inaccessible to residents.
Findings
The investigation substantiated that the facility failed to properly repair a hole in a resident's wall, allowing rodent access, and did not promptly contact pest control. The facility corrected the issue after the investigation. The allegation regarding chemicals being accessible to residents was unsubstantiated as the resident ingested a small amount of Lysol but no further medical treatment was required and the facility took corrective actions.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not repair a wall allowing rodents into the facility. It was unsubstantiated that staff did not ensure chemicals were inaccessible to residents. Resident #1 ingested a small amount of Lysol but did not require hospitalization. The facility took corrective actions including repairing the wall, pest control treatment, and securing cleaning supplies.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors. The licensee did not ensure the facility was in good repair for 1 out of 87 residents, posing a potential health and safety risk. | Type B |
Report Facts
Census: 87
Total Capacity: 113
Deficiencies cited: 1
Plan of Correction Due Date: Jan 15, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Robyn Clark | Licensing Program Manager | Oversaw the complaint investigation |
| Rocio Granda | Administrator | Facility administrator involved in interviews and corrective actions |
| Yahaira Garduno | Office Assistant | Met with Licensing Program Analyst during investigation and received report |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 113
Deficiencies: 0
Dec 18, 2024
Visit Reason
Licensing Program Analyst conducted a Case Management - Incident visit following a self-reported incident involving a resident who experienced cardiac arrest during dialysis treatment and was subsequently hospitalized.
Findings
The resident was transported to the hospital after cardiac arrest at the dialysis center and later passed away. The Wellness Director and Administrator reported no prior symptoms observed before the incident. No deficiencies were issued during this visit.
Complaint Details
The visit was triggered by a self-reported incident involving Resident #1 who suffered cardiac arrest at a dialysis center and was admitted to the ICU. The resident passed away on 12/17/24. No deficiencies were found.
Report Facts
Facility capacity: 113
Resident census: 85
Incident date: Dec 10, 2024
Resident death date: Dec 17, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met during inspection and provided information about the resident and incident |
| Diana Rodriguez | Wellness Director | Provided details about the resident's dialysis treatment and condition prior to the incident |
| Natasha Persaud | Licensing Program Analyst | Conducted the Case Management - Incident visit |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 113
Deficiencies: 1
Nov 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations of neglect/lack of supervision resulting in use and sale of illegal drugs within the facility.
Findings
The investigation substantiated the allegation of neglect/lack of supervision related to illegal drug use by multiple residents inside the facility, including possession and use of methamphetamine and marijuana. The administrator failed to enforce policies effectively, did not report confiscated drugs to law enforcement, and no eviction actions were taken despite warnings. The allegation of neglect/lack of supervision resulting in sale of illegal drugs was unsubstantiated due to lack of evidence.
Complaint Details
The complaint investigation was substantiated for neglect/lack of supervision resulting in use of illegal drugs, with evidence including observations, photographs, resident and staff interviews confirming drug use inside the facility. The allegation of neglect/lack of supervision resulting in sale of illegal drugs was unsubstantiated due to insufficient evidence.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Administrator – Qualifications and Duties. The administrator did not carry out the policies of the licensee regarding illegal drug use in the facility, posing an immediate health and safety risk to residents. | Type A |
Report Facts
Capacity: 113
Census: 90
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Named in deficiency related to failure to carry out policies regarding illegal drug use |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Robyn Clark | Licensing Program Manager | Oversaw the complaint investigation |
| Yahaira Garduno | Office Manager Assistant | Met with Licensing Program Analyst during investigation and received report and licensee rights |
Inspection Report
Annual Inspection
Census: 88
Capacity: 113
Deficiencies: 0
Oct 17, 2024
Visit Reason
The inspection was conducted as a Case Management - Annual Continuation visit to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies observed or cited. All safety, sanitation, and equipment standards were met, including proper medication storage and adequate food supplies.
Report Facts
Hot water temperature: 113
Census: 88
Total capacity: 113
Inspection start time: 11.31
Inspection end time: 14.15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Natasha Persaud | Licensing Program Analyst | Conducted the Case Management - Annual Continuation inspection |
Inspection Report
Census: 88
Capacity: 113
Deficiencies: 0
Oct 17, 2024
Visit Reason
The visit was a Case Management - Incident inspection conducted due to a self-reported incident involving a resident and staff member.
Findings
The incident involved allegations that Staff #1 was rough with Resident #1 during care, but interviews with residents and staff provided conflicting statements and no deficiencies were cited. The facility administrator acted appropriately in response to the incident.
Report Facts
Incident date: Oct 9, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Facility administrator who managed the incident and was present during the inspection |
| Natasha Persaud | Licensing Program Analyst | Conducted the Case Management - Incident visit |
| Lizzette Tellez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 85
Capacity: 113
Deficiencies: 0
Sep 26, 2024
Visit Reason
Licensing Program Analyst Natasha Persaud conducted a Case Management-Other visit to issue an amended report.
Findings
No deficiencies were observed during the visit. An exit interview was conducted and Licensee Rights were provided to the Office Assistant.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the Case Management-Other visit. |
| Yahaira Garduno | Office Assistant | Met with Licensing Program Analyst during the visit. |
| Rocio Granda | Administrator | Named as facility administrator. |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 113
Deficiencies: 0
Aug 23, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2021-03-01 regarding the facility's failure to address resident's change in condition, incontinent care needs, general resident care needs, staffing sufficiency, and dietary needs.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews, record reviews, and outside source information indicated that residents' care needs, including wound care, incontinence care, showers, staffing levels, and dietary accommodations, were being met appropriately.
Complaint Details
The complaint was unsubstantiated based on interviews with staff, residents, and outside sources, as well as review of facility records. Allegations included failure to address a resident's wound, inadequate incontinence care for three residents, insufficient staffing, lack of regular showers, and unmet dietary needs for one resident. None of these were corroborated by the investigation.
Report Facts
Staff present: 3.75
Capacity: 113
Census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rocio Grandola | Administrator | Facility administrator present during the investigation and exit interview |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 113
Deficiencies: 0
Aug 20, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff did not ensure residents have access or assistance to required appointments, specifically regarding Resident #1's request for additional physical therapy.
Findings
The investigation found inconsistent statements and no preponderance of evidence to support the allegation. The facility complied with regulations and assisted Resident #1 with the request for additional physical therapy, but the Home Health agency declined authorization due to the resident reaching maximum rehabilitation potential. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged staff did not ensure residents had access or assistance to required appointments, focusing on Resident #1's need for additional physical therapy. The investigation concluded the allegation was unsubstantiated.
Report Facts
Complaint Control Number: 08-AS-20240709161340
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Rocio Granda | Administrator | Facility administrator interviewed and acknowledged receipt of report and licensee rights. |
| Yahaira Garduno | Office Manager | Met with Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 113
Deficiencies: 0
Aug 20, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff handled residents roughly and did not treat residents with dignity and respect.
Findings
The investigation found inconsistent statements and insufficient evidence to substantiate the allegations. Resident and staff interviews indicated no ongoing issues of rough handling or disrespect, and the allegations were deemed unsubstantiated.
Complaint Details
The complaint alleged that staff handled residents in a rough manner and did not treat residents with dignity and respect. Specific allegations involved Staff #1 and Resident #1 and Resident #2. Interviews and record reviews did not corroborate these claims, and the complaint was unsubstantiated.
Report Facts
Capacity: 113
Census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Rodriguez | Medication Technician | Interviewed regarding allegations and received report and licensing appeal rights |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 113
Deficiencies: 0
Jul 11, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the licensee did not provide a comfortable temperature for residents.
Findings
The investigation found inconsistent statements and insufficient evidence to support the allegation. Observations and interviews indicated that the facility temperature was comfortable, with residents having access to fans and windows open. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that the licensee did not provide a comfortable temperature for residents. The allegation was unsubstantiated after investigation.
Report Facts
Complaint Control Number: 08-AS-20240702095905
Facility Capacity: 113
Census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johnny Laesch | Med Tech | Interviewed during the complaint investigation and received licensing appeal rights |
| Yahaira Garduno | Office Manager/Supervisor | Interviewed during the complaint investigation |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Follow-Up
Census: 92
Capacity: 113
Deficiencies: 1
Jun 26, 2024
Visit Reason
Unannounced case management visit to follow-up on a substantiated case management investigation related to the questionable death of a resident.
Findings
The Department determined that the facility was negligent in providing needed care and supervision to a resident with dementia, which led to the resident's fall and death. A civil penalty of $15,000 was issued for this violation.
Complaint Details
The visit was a follow-up to a substantiated case management investigation regarding the questionable death of a resident. The licensee was found culpable of negligence and cited for a Type A deficiency. A civil penalty was assessed and issued.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Type A deficiency for failure to provide adequate care and supervision to a resident with dementia, resulting in a fatal fall. | Type A |
Report Facts
Civil penalty amount: 15000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met during inspection and acknowledged receipt of appeal rights |
| Natasha Persaud | Licensing Program Analyst | Conducted the case management visit and signed the report |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Follow-Up
Census: 91
Capacity: 113
Deficiencies: 1
Jun 19, 2024
Visit Reason
Unannounced case management visit to follow-up on a substantiated complaint investigation regarding failure to ensure needed medical care for a resident.
Findings
The Department found that the facility neglected to provide emergent medical care after a resident's fall, resulting in a serious bodily injury (hip fracture) that required hospitalization and surgery. A civil penalty of $9,500 was issued for this violation.
Complaint Details
The visit was a follow-up to a substantiated complaint investigation from May 20, 2022, regarding failure to provide needed medical care to a resident who fell and was in extreme pain but was not taken for medical evaluation. The complaint was substantiated.
Severity Breakdown
Type A deficiency: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure needed medical care for a resident after a fall, resulting in untreated hip fracture and serious bodily injury. | Type A deficiency |
Report Facts
Civil penalty amount: 9500
Immediate civil penalty: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yahira Gardunio Ramirez | Office Manager/Supervisor | Met with Licensing Program Analyst during inspection and acknowledged receipt of appeal rights. |
| Carmen Lopez | Licensing Program Analyst | Conducted the unannounced case management visit and signed the report. |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 91
Capacity: 113
Deficiencies: 1
Jun 19, 2024
Visit Reason
An unannounced case management visit was conducted to deliver enhanced civil penalties and to conduct background clearance verification of facility staff.
Findings
A deficiency was cited because Staff #1 did not have a transferred criminal record clearance or was not associated with the facility, posing a potential health, safety, and personal rights risk to all 91 residents in care. An immediate civil penalty of $500 was assessed.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff #1 did not have a transferred criminal record clearance or was associated to the facility as required by Health and Safety Code Section 1569.17(b), posing a potential health, safety and personal rights risk to 91 residents. | Type A |
Report Facts
Civil penalty amount: 500
Residents at risk: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carmen Lopez | Licensing Program Analyst | Conducted the unannounced case management visit and cited the deficiency. |
| Yahira Gardunio Ramirez | Office Manager/Supervisor | Facility representative who granted entry and received the report. |
Inspection Report
Plan of Correction
Census: 92
Capacity: 113
Deficiencies: 0
May 2, 2024
Visit Reason
Unannounced Plan of Correction visit to verify correction of a previously issued deficiency regarding basic services requirements related to resident elopement risks.
Findings
The facility had corrected the previously issued deficiency by installing an operable alarm system that deters residents from leaving unassisted. No deficiencies were observed during this visit.
Report Facts
Capacity: 113
Census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during the Plan of Correction visit and acknowledged receipt of report and licensing rights. |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced Plan of Correction visit. |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 113
Deficiencies: 0
May 2, 2024
Visit Reason
An unannounced complaint investigation was conducted to investigate an allegation that lack of supervision resulted in a resident sustaining injury after being pushed by another resident.
Findings
The investigation found inconsistent statements and insufficient evidence to support the allegation. The incident was observed by staff, and there was no lack of supervision. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that lack of supervision resulted in Resident #1 sustaining injury after being pushed by Resident #2, who exhibited aggressive behavior. The investigation included interviews and record reviews and concluded the allegation was unsubstantiated.
Report Facts
Complaint Control Number: 08-AS-20210818160505
Facility Capacity: 113
Census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Rocio Granda | Administrator | Facility administrator interviewed during investigation |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 113
Deficiencies: 0
May 2, 2024
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation regarding allegations that a resident sustained multiple falls due to neglect, was given wrong medication, and suffered food poisoning from facility food.
Findings
The investigation found inconsistent statements and no preponderance of evidence to support the allegations. Resident and staff interviews, record reviews, and observations did not corroborate the claims, resulting in the allegations being deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on interviews, record reviews, and observations. Allegations included neglect causing falls, medication errors, and food poisoning, none of which were supported by evidence.
Report Facts
Complaint Control Number: 08-AS-20210907104633
Number of allegations: 3
Days between complaint receipt and investigation: 1008
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rocio Granda | Administrator | Facility administrator interviewed during investigation |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 113
Deficiencies: 1
Apr 18, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that lack of supervision resulted in a resident wandering out of the facility.
Findings
The investigation found that the facility did not ensure supervision for one resident who left the facility unassisted, posing a potential health and safety risk. The allegation was substantiated and the facility plans to install door alarms to prevent future incidents.
Complaint Details
The complaint was substantiated. It involved a resident who left the facility unassisted and sustained a fall but no injuries. Staff were unaware the resident left as they were assisting other residents. The facility provides 24-hour supervision but was unable to monitor the front door after hours. The resident was relocated to a secured memory unit and a security system is planned to alert staff when doors are opened in the evening.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Basic services requirements. Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by failure to ensure supervision for 1 out of 92 residents, posing a potential health and safety risk. | Type B |
Report Facts
Resident census: 92
Total capacity: 113
Deficiency count: 1
Plan of Correction due date: May 16, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rocio Granda | Administrator | Facility administrator interviewed regarding the incident and findings |
| Adilene Ramirez | Staff member interviewed and received licensee rights during exit interview | |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 113
Deficiencies: 0
Apr 18, 2024
Visit Reason
An unannounced complaint investigation was conducted based on allegations that staff did not assist a resident with feeding and that the facility smelled of mold.
Findings
The investigation found inconsistent statements and insufficient evidence to substantiate the allegations. Resident interviews, staff interviews, and records confirmed the resident was able to feed themselves and preferred to do so, and no mold was observed or smelled during the visit or previous visits.
Complaint Details
The complaint was unsubstantiated. Allegations included staff not assisting a resident with feeding and the facility smelling of mold. Investigations included interviews, record reviews, and multiple visits with no evidence supporting the allegations.
Report Facts
Capacity: 113
Census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Rocio Granda | Administrator | Facility administrator interviewed during investigation |
| Adilene Ramirez | Staff member interviewed and met with during investigation | |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 91
Capacity: 113
Deficiencies: 0
Apr 2, 2024
Visit Reason
The visit was a Case Management - Incident visit triggered by a self-reported incident involving Resident #1 who was hospitalized for chest pain and subsequently threatened harm to themselves and others upon discharge back to the facility.
Findings
No deficiencies were issued during the visit. The administrator implemented increased status checks and held meetings with the resident and staff to ensure safety.
Report Facts
Census: 91
Total Capacity: 113
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Named in relation to the incident and safety measures implemented |
| Monica Cordova | Business Office Manager | Met with Licensing Program Analysts and received Licensee Rights |
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection visit |
| Ryan Fulton | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 113
Deficiencies: 1
Apr 2, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that medications were not given as prescribed and a medication error resulting in injury for Resident #1.
Findings
The investigation substantiated that medications were dispensed to Resident #1 despite knowledge of a new allergy, posing an immediate health and safety risk. Another allegation of medication error resulting in injury was unsubstantiated due to lack of evidence linking the fall to medication.
Complaint Details
The complaint investigation was substantiated for medications not given as prescribed, with missing signatures on Medication Administration Records and continued dispensing of a medication causing an allergic reaction. The allegation of medication error resulting in injury was unsubstantiated due to inconsistent statements and lack of evidence.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee did not give medications as prescribed to 1 out of 91 residents, posing an immediate health and safety risk. | Type A |
Report Facts
Census: 91
Total Capacity: 113
Deficiencies cited: 1
Plan of Correction Due Date: Apr 3, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Named in relation to complaint investigation and findings |
| Monica Cordova | Business Office Manager | Met with Licensing Program Analysts during investigation and received Licensee Rights |
| Natasha Persaud | Licensing Program Analyst | Conducted complaint investigation |
| Ryan Fulton | Licensing Program Analyst | Conducted complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 113
Deficiencies: 0
Mar 19, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations of lack of supervision resulting in a resident altercation and staff verbally abusing a resident.
Findings
The investigation found inconsistent statements and insufficient evidence to substantiate the allegations. The resident altercation was determined to have been resolved years ago, and no recent altercations or verbal abuse were confirmed. The allegations were deemed unsubstantiated.
Complaint Details
The complaint involved allegations of lack of supervision leading to a resident altercation and verbal abuse by staff. The investigation concluded the allegations were unsubstantiated due to lack of corroborating evidence.
Report Facts
Complaint Control Number: 08-AS-20240312090659
Capacity: 113
Census: 88
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Rodriguez | Medication Technician | Met with Licensing Program Analyst during investigation and signed receipt of licensee rights |
| Rocio Granda | Administrator | Facility administrator involved in investigation and provided information about staff scheduling and resident safety |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 113
Deficiencies: 0
Feb 29, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 10/16/2020 regarding staff response times and an illegal eviction at the facility.
Findings
The investigation found no corroborating evidence to support the allegations of illegal eviction or untimely staff response to resident care needs. Interviews with staff, residents, and outside sources indicated the resident was never evicted and care needs were addressed timely.
Complaint Details
The complaint alleged that staff did not respond timely to assist a resident and that there was an illegal eviction. The allegations were found to be unsubstantiated after investigation.
Report Facts
Capacity: 113
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liliana Silveira | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Rocio Granda | Administrator | Facility administrator met during the investigation and exit interview |
| Jennifer Lott | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 89
Capacity: 113
Deficiencies: 0
Feb 28, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate the facility's compliance with licensing regulations.
Findings
The Licensing Program Analyst conducted a tour, reviewed staff and client records, and interviewed staff and clients. Due to time constraints, a return visit is needed to complete the annual inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during the inspection and participated in the exit interview. |
| Yahaira Garduno | Assistant Manager | Joined the Licensing Program Analyst and Administrator during the inspection. |
| Juliana Barfield | Licensing Program Analyst | Conducted the unannounced annual inspection visit. |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager in the report. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 113
Deficiencies: 0
Feb 28, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the facility did not refill prescriptions in a timely manner, did not arrange transportation services to meet resident needs, and that facility staff was unable to communicate effectively with residents and/or emergency personnel.
Findings
The investigation included interviews, record reviews, and facility tours, and found no evidence to substantiate the allegations. Staff assisted residents with medication management and transportation, and communication issues were related to hearing impairments or accents rather than language barriers. The allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on interviews with residents and staff, record reviews, and observations. The Department found no evidence that residents missed medications or medical appointments due to transportation or communication issues. Staff provided assistance with medication refills and transportation, and language barriers did not impede emergency communication.
Report Facts
Complaint Control Number: 08-AS-20201007102549
Facility Capacity: 113
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Rocio Granda | Administrator | Facility administrator who was met during the visit and participated in the exit interview |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 113
Deficiencies: 1
Feb 26, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that facility staff did not administer medications as prescribed to a resident.
Findings
The investigation substantiated that facility staff failed to administer prescribed medications to resident R1 for multiple days, posing a potential health risk. The facility had run out of Nortriptyline and did not timely order medication refills, resulting in medication omissions from January 29 to February 18, 2024.
Complaint Details
The complaint was substantiated based on interviews, record reviews, and outside sources. The allegation that staff did not administer medications as prescribed was found valid. The resident's medical condition was negatively affected due to lack of medication.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff did not administer medications as prescribed, violating CCR 87465(C)(2) regarding incidental medical and dental care. | Type B |
Report Facts
Days medication not administered: 9
Resident count: 89
Plan of Correction due date: Mar 26, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marisela Garcia-Centeno | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Rocio Granda | Administrator | Facility administrator involved in investigation and plan of correction |
| Denise Powell | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 113
Deficiencies: 1
Feb 23, 2024
Visit Reason
The visit was a case management inspection conducted to cite deficiencies observed during a complaint visit that were unrelated to the complaint allegations.
Findings
The licensee failed to ensure that an individual (Staff 1) working at the facility had a transferred criminal background clearance prior to working, posing an immediate safety risk to all 97 residents. A deficiency was cited regarding staff association and a civil penalty of $500 was issued.
Complaint Details
The visit was triggered by a complaint, but the deficiencies cited were unrelated to the complaint allegations.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that Staff 1's criminal background clearance was transferred to the facility prior to working, posing an immediate safety risk to 97 residents. | Type A |
Report Facts
Civil penalty amount: 500
Residents at risk: 97
Facility capacity: 113
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the case management visit and cited deficiencies |
| Diana Rodriguez | Wellness Director | Met with Licensing Program Analyst during the visit |
| Mina Ramirez | Caregiver Supervisor | Received the exit interview and report copies |
| Lizzette Tellez | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 113
Deficiencies: 0
Feb 23, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that facility staff failed to reposition a resident and did not maintain the resident's room temperature within regulation.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff attempted to reposition the resident but were restricted by the resident's Responsible Party, and the facility maintained appropriate temperature control measures. The allegations were determined to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to reposition a resident leading to pressure wounds and failure to maintain the resident's room temperature within regulation. Interviews, records review, and direct observations did not corroborate these allegations.
Report Facts
Facility capacity: 113
Resident census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mina Ramirez | Caregiving Supervisor | Met with during inspection and involved in interviews |
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 113
Deficiencies: 0
Feb 21, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that residents were financially abused while in care.
Findings
The investigation revealed inconsistent statements and no preponderance of evidence to support the allegations. The allegations were deemed unsubstantiated after interviews and record reviews.
Complaint Details
The complaint alleged financial abuse involving theft of cash, wallets, and debit/credit cards from residents. Resident #1 reported theft of $400 and wallets with conflicting statements. Resident #2 reported stolen debit/credit cards both in the community and at the facility. Interviews and evidence did not corroborate the allegations, and no fraudulent activity was found on accounts.
Report Facts
Facility capacity: 113
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yahaira Garduno | Medication Technician Supervisor | Met with Licensing Program Analyst during investigation and received Licensee Rights |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 113
Deficiencies: 0
Feb 8, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not providing adequate service to a resident in care.
Findings
The investigation found that staff provide several services to residents including cleaning, assistance, and showering. Interviews with staff and residents indicated that staff assist residents as needed and perform rounds to meet resident needs. The allegation that staff were not providing adequate service was unsubstantiated.
Complaint Details
The complaint alleged that staff were not providing adequate service to a resident. Interviews revealed no witnesses to support the allegation. Resident 1 had past incidents of missing items but did not report lack of staff assistance. The complaint was unsubstantiated.
Report Facts
Complaint Control Number: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tiffany Holmes | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rocio Granda | Administrator | Facility administrator met with during investigation |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 113
Deficiencies: 0
Oct 30, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations including medication mishandling, uncomfortable room temperature, facility disrepair, presence of insects, inadequate food service, and insufficient lighting in resident rooms.
Findings
The investigation found no evidence to substantiate any of the allegations. Observations, interviews, and record reviews indicated that medication was handled properly, room temperatures were comfortable, the facility was well maintained and free of insects, food service was adequate, and lighting was sufficient.
Complaint Details
The complaint investigation was unsubstantiated based on interviews, record reviews, and observations. No violations were confirmed regarding medication mishandling, room temperature, facility disrepair, insects, food service, or lighting.
Report Facts
Capacity: 113
Census: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Domingo | Licensing Program Analyst | Conducted the complaint investigation |
| Yahaira Garduno | Med Tech Supervisor | Met with Licensing Program Analyst during investigation and participated in exit interview |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 113
Deficiencies: 2
Sep 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including medications not given as prescribed and resident access to dangerous items.
Findings
The investigation substantiated that medications were not given as prescribed to one resident and that one resident had access to items posing a danger. Other allegations related to lack of supervision, incontinent care, medical care assistance, and safeguarding personal items were unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations that medications were not given as prescribed and that a resident had access to dangerous items. Other allegations including lack of supervision resulting in injury, failure to provide incontinent care, failure to assist or arrange medical care, and failure to safeguard personal items were unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The licensee did not ensure medications were given as prescribed for 1 out of 79 residents, posing a potential health and safety risk. | Type B |
| Items that pose a danger were accessible to 1 out of 79 residents, posing a potential health and safety risk. | Type B |
Report Facts
Missed medication doses: 19
Residents in care: 79
Facility capacity: 113
Current census: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Ruth Granda | Business Office Assistant | Met with the Licensing Program Analyst during the investigation and agreed to staff training for medication administration and storage of dangerous items. |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 113
Deficiencies: 1
Aug 16, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility telephone was in disrepair and not operable after business hours.
Findings
The investigation substantiated that the facility did not have operable telephone service at night for all 91 residents, posing a potential safety risk. The facility was working with Verizon to restore 24-hour telephone service with voicemail monitored hourly by staff.
Complaint Details
The complaint was substantiated based on interviews and record review. The allegation was that the facility telephone was not operable after business hours, which was confirmed during the investigation.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Telephones. All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility. This requirement is not met as evidenced by the facility not having operable telephone service at night for 91 out of 91 residents, posing a potential safety risk. | Type B |
Report Facts
Census: 91
Total Capacity: 113
Deficiency Type Count: 1
Plan of Correction Due Date: Aug 18, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Named in relation to the telephone service deficiency and investigation |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 113
Deficiencies: 0
Jul 26, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 03/22/2023 alleging inadequate food service, unmet residents' care needs, lack of incontinence care, staff lacking criminal record clearances, and insufficient staff training.
Findings
The investigation found insufficient evidence to substantiate the allegations. Observations, interviews, and record reviews indicated that food service was adequate, residents' care needs were met, incontinence care was provided appropriately, staff had proper criminal background clearances, and required training was completed. The allegations were deemed unsubstantiated or unfounded.
Complaint Details
The complaint included allegations that the facility did not provide adequate food service, staff did not meet residents' care needs, staff did not provide incontinence care, staff lacked criminal record clearances, and staff did not receive required training. The investigation concluded these allegations were unsubstantiated or unfounded.
Report Facts
Capacity: 113
Census: 87
Staff with criminal record clearances: 37
Total staff randomly selected: 58
Percentage of staff cleared: 64
Number of staff training records reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst and participated in exit interviews |
| Marisela Garcia-Centeno | Licensing Program Analyst | Conducted the complaint investigation visit |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 113
Deficiencies: 0
Jul 21, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that a resident developed multiple pressure injuries due to neglect, that facility staff did not arrange medical care, and did not observe changes in the resident's condition.
Findings
The investigation found that the resident had venous stasis wounds, not pressure injuries, and was non-compliant with wound care and medical treatment. The facility made efforts to arrange care and hospital visits, but the resident often refused treatment. The allegations were deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint was unsubstantiated. The resident developed venous stasis wounds, not pressure injuries. The resident was non-compliant with wound care and medical treatment. The facility attempted to arrange medical care and hospital visits, but the resident refused. The facility was not found neglectful.
Report Facts
Capacity: 113
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Rocio Granda | Administrator | Facility administrator interviewed during investigation |
| Lizzette Tellez | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 113
Deficiencies: 0
Apr 5, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding an allegation that the facility was not following COVID-19 guidelines, specifically related to notifying a visitor who came into contact with a resident diagnosed with COVID-19.
Findings
The investigation found inconsistent statements and insufficient evidence to support the allegation. The facility followed its Mitigation Plan by notifying the responsible party and resident's physician, and there was no indication that the visitor contracted the virus. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged the facility did not notify a visitor who came into contact with a resident diagnosed with COVID-19. The investigation concluded the allegation was unsubstantiated as the facility followed notification guidelines and no evidence showed the visitor contracted the virus.
Report Facts
Facility capacity: 113
Census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Monica Cordoba | Business Manager | Met with Licensing Program Analyst during investigation and received report |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 113
Deficiencies: 0
Mar 22, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 10/21/2021 regarding the facility's alleged failure to meet the needs of a resident.
Findings
The investigation included interviews, record reviews, and a facility tour. It was found that the resident was sad and wanted more family visits but denied suicidal ideations. The facility was meeting the resident's needs, and the issues were related to difficulties in obtaining medical information due to lack of conservatorship. The allegations were deemed unsubstantiated due to inconsistent statements and lack of evidence.
Complaint Details
The complaint alleged that the licensee did not meet the needs of a resident. The investigation found no evidence to support the allegation, and it was unsubstantiated.
Report Facts
Complaint Control Number: 08-AS-20211021152316
Facility Capacity: 113
Census: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Monica Cordoba | Business Manager | Met with Licensing Program Analyst during investigation and received report |
| Rocio Granda | Administrator | Interviewed regarding resident's condition and family visitation |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 113
Deficiencies: 0
Mar 22, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations including staff not seeking timely treatment for a resident, delayed staff response to resident assistance calls, and the administrator allegedly not allowing a resident to return after discharge from a skilled nursing facility.
Findings
The investigation found inconsistent statements and insufficient evidence to substantiate the allegations. Resident #1 received prevention treatment on 10/02/22, was hospitalized on 10/05/22, and transferred to a skilled nursing facility until 12/28/22. Staff response times were generally timely, and the administrator stated the resident was allowed to return, contrary to outside source claims.
Complaint Details
The complaint was unsubstantiated. Allegations included delayed treatment for Resident #1's rash, slow staff response to assistance calls, and refusal to allow Resident #1 to return after discharge from a skilled nursing facility. Investigation revealed no preponderance of evidence to support these claims.
Report Facts
Capacity: 113
Staff per hallway: 3
Staff response time: 5
Staff response time maximum: 10
Alleged delayed response time: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Monica Cordoba | Business Manager | Met with Licensing Program Analyst during investigation |
| Rocio Granda | Administrator | Interviewed regarding allegations and facility operations |
| Lizzette Tellez | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Census: 85
Capacity: 113
Deficiencies: 1
Feb 14, 2023
Visit Reason
The visit was an unannounced case management visit to discuss medication management for independent residents, including a review of resident records and interviews with the Administrator.
Findings
The Licensing Program Analyst observed that not all independent residents had a secured area to store their medications, including controlled substances, posing a potential health risk to one resident out of 85 in care. A deficiency was cited related to medication storage.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Independent resident medications, including controlled substances, were not secured as required, posing a potential health risk to 1 out of 85 residents. | Type B |
Report Facts
Residents in care: 85
Total capacity: 113
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Hamilton | Licensing Program Analyst | Conducted the inspection and cited the deficiency |
| Rocio Granda | Administrator | Interviewed during the inspection and participated in exit interview |
| Denise Powell | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 113
Deficiencies: 1
Feb 14, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-10-14 regarding allegations that the facility changed a resident's room accommodations without amending the admissions agreement and did not safeguard a resident's personal belongings.
Findings
The investigation substantiated that the facility changed a resident's room without proper notice or amending the admissions agreement, posing a personal rights risk. The allegation that the facility did not safeguard the resident's personal belongings was unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility changed a resident's room accommodations without amending the admissions agreement. The allegation that the facility did not safeguard the resident's personal belongings was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to comply with all applicable terms and conditions set forth in the admission agreement, including modifications and attachments, specifically not notifying or amending the admission agreement when changing a resident's room. | Type B |
Report Facts
Residents in care: 75
Capacity: 113
Census: 85
Plan of Correction Due Date: Mar 16, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Hamilton | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Denise Powell | Licensing Program Manager | Oversaw the complaint investigation. |
| Rocio Granda | Administrator | Facility administrator met during the investigation and exit interview. |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 113
Deficiencies: 0
Jan 17, 2023
Visit Reason
The inspection visit was conducted to investigate a complaint alleging that facility staff did not properly assist a client in care, specifically regarding prescription medication.
Findings
The investigation included staff and client interviews, record reviews, and virtual and onsite visits. No evidence was found to support the allegation, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff did not properly assist a client with prescription medication. After investigation, including interviews and record reviews, the allegation was found unsubstantiated due to lack of evidence.
Report Facts
Capacity: 113
Census: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Pena | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rocio Granda | Administrator | Facility administrator met with the investigator and received the report |
| Simon Jacob | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 113
Deficiencies: 1
Dec 20, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the facility was retaining a resident who requires a higher level of care.
Findings
The investigation substantiated that Resident #1 requires a higher level of care due to inability to self-administer insulin injections and blood sugar checks. The facility lacks a skilled professional to assist with injections, posing a potential health and safety risk.
Complaint Details
The complaint alleged the facility was retaining Resident #1 who requires a higher level of care due to uncontrolled diabetes and inability to self-administer insulin and blood sugar checks. The allegation was substantiated based on interviews, record reviews, and observations.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee retained a resident requiring assistance with diabetic medication management without having a skilled professional on staff to assist with injections. | Type B |
Report Facts
Resident census: 83
Total capacity: 113
Deficiency count: 1
Plan of Correction due date: Jan 17, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Named in interviews regarding the facility's lack of skilled professional and resident care |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 113
Deficiencies: 2
Nov 29, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff were not giving resident medication as prescribed and that the licensee did not maintain the resident's room in a clean, safe, or sanitary condition, as well as allegations regarding diabetic diet provision and room temperature.
Findings
The investigation substantiated that the facility failed to provide Resident #1 with prescribed medications as required and did not maintain the resident's room in a clean, safe, and sanitary condition, posing immediate and potential health and safety risks. However, allegations regarding failure to provide a diabetic diet and maintain a comfortable room temperature were unsubstantiated.
Complaint Details
The complaint investigation was substantiated for failure to provide prescribed medications and maintain a safe and sanitary environment for Resident #1. The allegations regarding diabetic diet provision and room temperature were unsubstantiated. Civil penalties were assessed for repeat violations within a 12-month period.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| The licensee did not assist with self-administered medications for Resident #1, posing an immediate health and safety risk. | Type A |
| The licensee did not provide a clean, safe, sanitary, and well-maintained environment for Resident #1's room, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 113
Census: 83
Deficiencies cited: 2
Plan of Correction Due Date: Nov 30, 2022
Plan of Correction Due Date: Dec 27, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Perla Barragan | Care Coordinator | Interviewed during investigation and involved in plan of correction |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
| Rocio Granda | Administrator | Interviewed regarding findings and unaware of medication and room issues |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 113
Deficiencies: 0
Nov 15, 2022
Visit Reason
An unannounced complaint investigation was conducted following an allegation that a resident was unable to attend a dental appointment due to staff negligence in holding/stopping medications as required.
Findings
The investigation found that although the Medication Technician Supervisor confirmed the medications would be held/stopped, the facility did not have a current written physician's order to do so. Staff continued to administer medications as prescribed. The allegation was deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that Resident #1 was unable to attend a dental appointment on 11/10/22 because the facility failed to hold/stop medications as required. The investigation found no preponderance of evidence to substantiate the allegation.
Report Facts
Census: 82
Total Capacity: 113
Complaint Control Number: 08-AS-20221109160427
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Rocio Granda | Administrator | Facility administrator interviewed during investigation |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 86
Capacity: 113
Deficiencies: 1
Oct 11, 2022
Visit Reason
The visit was an unannounced Case Management - Legal/Non-Compliance inspection to ensure ongoing compliance with regulations and laws and to ensure the health and safety of residents in care.
Findings
A deficiency was cited due to the facility's failure to have current resident appraisals on file for 3 out of 86 residents, which poses a health and safety risk. The administrator was informed and understands the regulations discussed during the visit.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure resident appraisals were on file for 3 out of 86 residents, which is required to meet residents' care needs. | Type B |
Report Facts
Residents without current appraisals: 3
Census: 86
Total capacity: 113
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during inspection and was debriefed on regulations |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced inspection visit |
| Lizzette Tellez | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 86
Capacity: 113
Deficiencies: 0
Oct 11, 2022
Visit Reason
The visit was an unannounced Case Management - Incident inspection conducted to review and discuss four self-reported incidents at the facility, including two elopements and two theft incidents.
Findings
No deficiencies were issued during the inspection. The facility followed required procedures for the elopements, and incidents were investigated with no injuries reported.
Report Facts
Incidents reported: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Facility Administrator met with Licensing Program Analyst during the inspection and received the report and appeal rights |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
| Lizzette Tellez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 85
Capacity: 113
Deficiencies: 0
Sep 23, 2022
Visit Reason
An unannounced Case Management - Incident visit was conducted to investigate two self-reported incidents: one involving theft related to Resident #1 and another involving a fall injury to Resident #2.
Findings
No deficiencies were cited at the time of the inspection in the areas evaluated during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Zamorano | Manager Assistant | Met with Licensing Program Analyst during the visit and discussed the purpose of the inspection. |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
| Lizzette Tellez | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 113
Deficiencies: 2
Sep 9, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that facility showers did not maintain hot water temperature and that bathing facilities were not maintained in operating condition.
Findings
The investigation substantiated that the hot water temperature in the shower of Room 41 was inconsistent and exceeded regulated limits, and that the shower knobs were faulty and did not operate correctly, posing immediate and potential health and safety risks to residents.
Complaint Details
The complaint investigation was substantiated based on observations and interviews confirming the allegations regarding hot water temperature and malfunctioning shower knobs.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Faucets used by residents did not maintain hot water temperature between 105 and 120 degrees F, with temperatures rising up to 128 degrees F. | Type A |
| Bathroom shower faucets were not maintained in operating condition, with faulty knobs that did not adjust water flow properly. | Type B |
Report Facts
Residents affected: 1
Deficiency Type A Plan of Correction Due Date: Sep 10, 2022
Deficiency Type B Plan of Correction Due Date: Sep 16, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Facility Administrator involved in discussions and exit interview |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 86
Capacity: 113
Deficiencies: 0
Jun 22, 2022
Visit Reason
Unannounced Case Management Visit to follow up on a self-reported unusual incident involving a resident absent without leave (AWOL).
Findings
The resident who was absent without leave returned unharmed on 06-18-2022. No deficiencies were cited during the visit.
Report Facts
Capacity: 113
Census: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management Visit |
| Lizzette Tellez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 113
Deficiencies: 0
May 20, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that facility staff did not protect a resident from humiliation and restricted a resident's right to associate with another resident.
Findings
The investigation found insufficient evidence to support the allegations. The complaint was determined to be unsubstantiated, with facility records and interviews indicating that staff took appropriate actions and did not prevent residents from associating.
Complaint Details
The complaint involved allegations that staff did not protect Resident 1 from being humiliated by another resident and that staff restricted Resident 3 from associating with Resident 1. The investigation found these allegations unsubstantiated based on facility records, staff interviews, and outside sources.
Report Facts
Capacity: 113
Census: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Esther Miller | Licensing Program Analyst | Conducted the complaint investigation visit |
| Denise Powell | Licensing Program Manager | Oversaw the complaint investigation |
| Monica Cordoba | Manager Assistance | Facility representative who met with the investigator |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 113
Deficiencies: 4
May 20, 2022
Visit Reason
An unannounced complaint investigation was conducted following allegations of staff neglect resulting in serious injury, medication not administered according to physician's orders, unexplained bruising, and failure to report incidents to the resident's authorized representative.
Findings
The investigation substantiated the allegations that the facility failed to obtain medical treatment for a resident after multiple falls, did not administer prescribed medications timely, did not notify the resident's responsible party about falls, and failed to implement fall prevention measures. The resident sustained a hip fracture requiring surgery, and the facility was cited for multiple deficiencies.
Complaint Details
The complaint investigation was substantiated. Allegations included staff neglect causing serious injury, medication errors, unexplained bruising, and failure to report incidents to the resident's authorized representative. The resident experienced multiple falls, was not sent for medical evaluation, and sustained a hip fracture. Medication was not administered as prescribed, and the responsible party was not notified.
Severity Breakdown
Type A: 1
Type B: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Licensee did not telephone 911 to obtain medical treatment for Resident #1 after unwitnessed falls resulting in serious bodily injury (hip fracture). | Type A |
| Licensee did not assist Resident #1 with prescribed medications upon admission. | Type B |
| Licensee did not notify Resident #1's responsible party after multiple falls. | Type B |
| Staff did not provide assistance with Resident #1's fall risk needs identified in pre-admission appraisal, resulting in bruising due to falls. | Type B |
Report Facts
Civil penalty amount: 500
Resident census: 82
Total facility capacity: 113
Plan of Correction due dates: May 23, 2022
Plan of Correction due dates: Jun 20, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Esther Miller | Licensing Program Analyst | Conducted the complaint investigation. |
| Denise Powell | Licensing Program Manager | Oversaw the complaint investigation. |
| Monica Cordoba | Manager Assistance | Facility representative who met with the investigator and received report and rights. |
| Maya S. Mnoyan | Administrator | Facility administrator mentioned in report header. |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 113
Deficiencies: 1
May 18, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including failure to ensure timely medication refills for a resident, inadequate room size for easy passage between beds, and staff interfering with resident telephone access.
Findings
The investigation substantiated that one resident did not receive medications timely as prescribed, missing doses over nine days, posing an immediate health and safety risk. Allegations regarding room size and telephone access were found unsubstantiated due to insufficient evidence and inconsistent statements.
Complaint Details
The complaint investigation was substantiated regarding medication delays for Resident #1, who missed doses due to delayed medication refills and lack of timely assistance from staff. Allegations about inadequate room size and staff interference with telephone access were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee did not ensure one resident received their medications timely, resulting in missed doses over nine days. | Type A |
Report Facts
Resident census: 84
Total capacity: 113
Missed medication days: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met during investigation and named in findings |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 113
Deficiencies: 0
May 18, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was in disrepair due to a resident's doorknob being broken and not locking.
Findings
The investigation found that the doorknob was never broken and the facility was not in disrepair. One resident had difficulty opening the lock due to a medical condition, and the facility replaced the doorknob with a handle within three days to accommodate this issue. The complaint was determined to be unfounded.
Complaint Details
The complaint alleged the facility was in disrepair because a resident's doorknob was broken and did not lock for three months, raising concerns about theft. The investigation found the allegation to be unfounded.
Report Facts
Complaint Control Number: 08-AS-20220308080259
Capacity: 113
Census: 84
Investigation duration: 15
Doorknob replacement timeframe: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during investigation and provided information about the doorknob issue |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 113
Deficiencies: 2
May 18, 2022
Visit Reason
The visit was an unannounced Case Management – Deficiency inspection conducted to issue deficiencies identified during a complaint investigation regarding resident care and record accuracy.
Findings
Deficiencies were found related to failure to provide basic services by allowing a resident to leave unassisted despite physician restrictions, and failure to have a current medical assessment within one year for a resident. These deficiencies posed health and safety risks to residents.
Complaint Details
The visit was triggered by a complaint investigation. Deficiencies were substantiated related to resident #1's care and medical records.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee did not provide basic services for 1 out of 84 residents by allowing the resident to leave the facility unassisted, contrary to physician's report. | Type A |
| Licensee did not ensure 1 out of 84 residents had a medical assessment within one year of admission; the assessment was outdated. | Type B |
Report Facts
Residents present: 84
Total licensed capacity: 113
Deficiencies cited: 2
Plan of Correction Due Dates: Type A due 05/19/2022, Type B due 06/15/2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met during inspection and discussed deficiencies |
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection and signed the report |
| Lizzette Tellez | Licensing Program Manager | Named as supervisor and licensing program manager |
Inspection Report
Census: 83
Capacity: 113
Deficiencies: 1
Apr 29, 2022
Visit Reason
The visit was a Case Management - Incident visit conducted to follow up on a self-reported incident involving a resident who left the facility and was hospitalized. The purpose was to review the incident and related records.
Findings
The facility failed to complete a current Resident Appraisal for one resident, with the last appraisal dated 11/29/2018. This deficiency was cited as it poses a potential health and safety risk to the resident in care.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to complete a Resident Appraisal for 1 out of 83 residents, last appraisal dated 11/29/2018. | Type B |
Report Facts
Residents present: 83
Total licensed capacity: 113
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yahaira Garduno | Medication Technician Supervisor | Met during the visit and received the report and Licensee Rights |
| Rocio Granda | Administrator | Contacted via telephone to discuss the incident |
| Natasha Persaud | Licensing Program Analyst | Conducted the Case Management - Incident visit and authored the report |
| Lizzette Tellez | Licensing Program Manager | Supervisor overseeing the visit |
Inspection Report
Annual Inspection
Census: 78
Capacity: 113
Deficiencies: 0
Mar 16, 2022
Visit Reason
The visit was an unannounced annual required licensing inspection to verify compliance with statutes, regulations, and other written requirements relevant to protecting the health of residents and staff, including infection control practices.
Findings
No deficiencies were observed during the visit. The inspection included evaluation of the facility's mitigation plan, infection control, and compliance with various California Code of Regulations related to resident care and rights.
Report Facts
Capacity: 113
Census: 78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during inspection |
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection |
| John Rante | Licensing Program Manager | Named in report header |
Inspection Report
Census: 78
Capacity: 113
Deficiencies: 0
Jan 19, 2022
Visit Reason
The visit was conducted to provide technical assistance and to evaluate the facility's mitigation plan including disinfection, testing, vaccination, screening protocols, and use of personal protective equipment (PPE).
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst interviewed the Wellness Director and conducted a walkthrough of the facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Ruiz | Licensing Program Analyst | Conducted the technical assistance visit and evaluation. |
| Diana Rodriguez | Wellness Director | Interviewed during the visit and participated in the exit interview. |
| Rocio Granda | Administrator | Received the report and Licensee Rights via electronic mail. |
Inspection Report
Census: 81
Capacity: 113
Deficiencies: 0
Nov 17, 2021
Visit Reason
The visit was initiated by the Licensee to discuss facility concerns during a Case Management meeting.
Findings
No deficiencies were issued during this visit. The meeting involved licensing staff and facility representatives discussing concerns.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Salceda | Licensee met with licensing staff during the visit. | |
| Rocio Granda | Administrator | Facility Administrator present during the meeting. |
| Perla Barragan | Care Coordinator | Care Coordinator present during the meeting. |
| Natasha Persaud | Licensing Program Analyst | Licensing staff member conducting the visit. |
| Icela Estrada | Regional Manager | Licensing staff member conducting the visit. |
| Denise Powell | Licensing Program Manager | Licensing staff member conducting the visit. |
| John Rante | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 113
Deficiencies: 0
Sep 24, 2021
Visit Reason
The visit was an unannounced Case Management - Incident inspection triggered by a self-reported incident involving alleged abuse by a staff member of multiple memory care residents.
Findings
During the visit, the Licensing Program Analyst toured the facility, reviewed records, and interviewed staff and residents. No deficiencies were issued at this time.
Complaint Details
The complaint involved Staff #1 allegedly abusing multiple memory care residents. The complaint was self-reported on 09/13/21. No deficiencies were issued.
Report Facts
Capacity: 113
Census: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during the visit and involved in the exit interview |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
| John Rante | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 113
Deficiencies: 1
Nov 12, 2020
Visit Reason
The inspection visit was conducted to investigate a death report received on April 9, 2020, concerning resident #1 who passed away due to a fall.
Findings
The investigation found that staff failed to update the resident's care plan after discharge from a skilled nursing facility, resulting in inadequate supervision and assistance. The resident fell twice on the day of the incident, ultimately sustaining a fatal traumatic brain injury. The licensee was found culpable of negligence.
Complaint Details
The visit was complaint-related due to a death report. The preponderance of evidence standard was met, and the licensee was found culpable of negligence resulting in the resident's death.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not conduct a reappraisal when resident #1 was discharged from a skilled nursing facility to Golden Living Health Management, posing an immediate health and safety risk. | Type A |
Report Facts
Residents in care: 66
Capacity: 113
Census: 74
Plan of Correction Due Date: Nov 26, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Lott | Licensing Program Analyst | Conducted the inspection and investigation |
| Denise Powell | Licensing Program Manager | Supervisor overseeing the inspection |
| Dan Salceda | Licensee met with Licensing Program Analyst during the visit | |
| Maya S. Mnoyan | Administrator | Facility administrator named in report header |
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