Inspection Reports for
Golden Living Point Loma
3223 Duke St, San Diego, CA 92110, United States, CA, 92110
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
9.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
135% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
64% occupied
Based on a March 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 72
Capacity: 113
Deficiencies: 0
Date: Mar 23, 2026
Visit Reason
Licensing Program Analyst Amy Domingo conducted an unannounced Required Annual Inspection to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies observed or cited during the inspection. Resident care, safety measures, and facility conditions met all licensing standards.
Report Facts
Perishable food supply: 2
Non-perishable food supply: 7
Facility capacity: 113
Resident census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during inspection and exit interview |
| Amy Domingo | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 113
Deficiencies: 1
Date: Feb 3, 2026
Visit Reason
The inspection was conducted as an unannounced Case Management - Deficiencies visit triggered by a complaint investigation regarding staff fingerprint clearance and association with the facility.
Complaint Details
During a complaint investigation, it was discovered that Staff #1 worked at the facility without fingerprint clearance and association. Staff #1 was removed from the schedule and terminated. A deficiency and civil penalty were issued.
Findings
The facility allowed Staff #1 to work prior to obtaining fingerprint clearance and association with the facility, which posed an immediate health and safety risk. Staff #1 was removed from the schedule and terminated. A deficiency was issued and a civil penalty assessed.
Deficiencies (1)
Facility allowed Staff #1 to work without fingerprint clearance and association with the facility as required by regulations.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during inspection and named in relation to staff fingerprint clearance deficiency |
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 113
Deficiencies: 0
Date: Feb 3, 2026
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that a resident was touched inappropriately by staff and that staff did not safeguard the resident's personal items.
Complaint Details
The complaint involved allegations of inappropriate sexual touching by staff and failure to safeguard resident's personal items. The allegations were investigated through interviews with staff, residents, and review of records. The complaint was determined to be unsubstantiated.
Findings
The investigation found inconsistent statements and insufficient evidence to support the allegations. Staff and residents denied inappropriate behavior, and the police found no evidence of a crime. The allegation of stolen personal items was also unsubstantiated due to lack of evidence and resident's incapacity to manage valuables.
Report Facts
Facility capacity: 113
Resident census: 73
Complaint control number: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Rocio Granda | Administrator | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 113
Deficiencies: 0
Date: Jan 29, 2026
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff did not ensure a safe environment for a resident, specifically regarding Resident 2 entering Resident 1's room and acting aggressively.
Complaint Details
The complaint was unsubstantiated based on interviews with staff, residents, an outside advocacy source, direct observations, and records review. No evidence supported the claim that Resident 2 acted aggressively or entered other residents' rooms improperly.
Findings
The investigation included interviews, observations, and records review, which found no evidence to substantiate the allegation. Staff reported managing resident behaviors appropriately, and no incident reports or corroborating statements were found. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 113
Census: 73
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Rocio Granda | Administrator | Facility administrator met during the investigation and exit interview |
| Sabel Martinez | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 113
Deficiencies: 0
Date: Jan 29, 2026
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding an allegation that facility staff financially abused a resident.
Complaint Details
The complaint alleged that facility staff financially abused Resident #1 by withdrawing $3400 from their bank account without proper authorization. The investigation revealed that the resident provided verbal authorization and their physical bank card for rent payments, and the facility withdrew payments totaling $2840.14 for rent arrears. The allegation was unsubstantiated due to lack of evidence.
Findings
The investigation found inconsistent statements and insufficient evidence to substantiate the allegation of financial abuse. The resident had authorized rent payments verbally and with their bank card, and the facility withdrew rent payments for outstanding balances with the resident's authorization. The allegation was deemed unsubstantiated.
Report Facts
Capacity: 113
Census: 73
Outstanding rent balance: 2840.14
Alleged missing amount: 3400
Withdrawals on 03/03/25: 1800
Withdrawals on 03/03/25: 1300
Withdrawals on 03/03/25: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation and telephone visit |
| Rocio Granda | Administrator | Facility administrator involved in interviews and discussions during the investigation |
| Lizzette Tellez | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 113
Deficiencies: 0
Date: Jan 20, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not ensure a resident was accorded dignity with other residents.
Complaint Details
The complaint alleged that staff did not ensure resident dignity, specifically that Resident #1 was harassed by their roommate Resident #2, who prohibited Resident #1 from speaking Spanish on the phone. The investigation found no physical altercations or safety concerns, and the allegation was unsubstantiated.
Findings
The investigation included interviews, record reviews, and a brief facility tour. The allegation that staff failed to ensure resident dignity was unsubstantiated due to inconsistent statements and lack of evidence. The administrator was unaware of the incident and offered to relocate the resident and required staff to speak English only to the resident.
Report Facts
Capacity: 113
Census: 73
Room moves: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Rocio Granda | Administrator | Facility administrator interviewed during investigation |
| Lizzette Tellez | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 113
Deficiencies: 1
Date: Jan 16, 2026
Visit Reason
An unannounced Case Management - Deficiencies visit was conducted following a complaint investigation which discovered the facility did not report a resident hospitalization as required by regulations.
Complaint Details
During the complaint investigation, it was substantiated that the facility did not report an incident involving Resident #1's hospitalization as required by Title Regulations.
Findings
The facility failed to report an incident involving a resident's hospitalization, which posed a potential health and safety risk. A Type B deficiency was issued related to reporting requirements.
Deficiencies (1)
Failure to submit a written report to the licensing agency and responsible person within seven days of an incident involving a resident hospitalization.
Report Facts
Residents involved: 1
Total residents: 84
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during inspection and named in deficiency discussion |
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 113
Deficiencies: 3
Date: Jan 16, 2026
Visit Reason
An unannounced complaint investigation was conducted following allegations including neglect resulting in serious bodily injury, failure to assist a resident with showering needs, and failure to address a resident's change in condition.
Complaint Details
The complaint investigation was substantiated for neglect resulting in serious bodily injury, failure to assist with showering, and failure to address change in condition. The allegation that staff did not provide medication as prescribed was unsubstantiated. A $500 immediate civil penalty was assessed for the substantiated violations.
Findings
The investigation substantiated neglect of Resident #1 (R1), who suffered a serious infected wound leading to a below-knee amputation. The facility failed to provide shower assistance, observe and document changes in R1's condition, and provide adequate wound care. Another allegation regarding medication administration was unsubstantiated.
Deficiencies (3)
Licensee did not provide care and supervision to 1 out of 84 residents, posing an immediate health, safety, and personal rights risk.
Licensee did not observe a change in condition for 1 out of 84 residents, posing an immediate health and safety risk.
Licensee did not ensure 1 out of 84 residents received assistance with bathing as documented, posing a potential health, safety, and personal rights risk.
Report Facts
Capacity: 113
Census: 73
Civil penalty amount: 500
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Rocio Granda | Administrator | Facility administrator interviewed during investigation |
| Lizzette Tellez | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 113
Deficiencies: 0
Date: Jan 14, 2026
Visit Reason
A Case Management visit was conducted as an unannounced health and safety check following an Incident Report received on January 13, 2026, regarding inappropriate encounters reported by two residents involving a staff member.
Complaint Details
The visit was triggered by an Incident Report alleging inappropriate encounters by staff #1 with resident #1 and resident #2. The report was received by Community Care Licensing on January 13, 2026. No deficiencies were cited during this visit.
Findings
During the visit, the Licensing Program Analyst toured the facility and reviewed records related to the incident. No deficiencies were cited during the visit, but the Administrator was notified that additional phone calls or visits may be necessary.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during the visit and was notified of the visit purpose and findings. |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 113
Deficiencies: 0
Date: Dec 17, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation of lack of supervision resulting in a resident altercation injury involving two residents.
Complaint Details
The complaint alleged lack of supervision resulting in a resident altercation injury. The allegation was found to be unsubstantiated based on interviews, observations, and records review.
Findings
The investigation found that while a bruise was confirmed on one resident, the origin and timing were inconclusive and the allegation that the other resident caused it was unsubstantiated. Staff conducted an internal investigation and monitored residents appropriately, and interviews with residents and an outside advocacy source did not corroborate the allegation.
Report Facts
Capacity: 113
Census: 73
Attempts to interview resident: 3
Facility visits: 2
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Rocio Granda | Administrator | Facility administrator met during the investigation and exit interview |
| Sabel Martinez | Supervisor named in the report |
Inspection Report
Census: 78
Capacity: 113
Deficiencies: 0
Date: Nov 13, 2025
Visit Reason
The visit was an unannounced Case Management visit regarding the facility's bedridden clearance. The Licensing Program Analyst conducted a health and safety check, interviewed staff and residents, and collected facility records.
Findings
No deficiencies were cited during the facility visit. An exit interview was conducted with the Administrator, who was provided with a copy of the report and appeal rights.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during the visit and involved in exit interview. |
| Nacole Patterson | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Sabel Martinez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 77
Capacity: 113
Deficiencies: 0
Date: Nov 5, 2025
Visit Reason
The visit was a case management health and safety visit conducted regarding an incident report received by Community Care Licensing involving a resident and staff.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst toured the facility and reviewed relevant records.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with during the inspection and involved in discussion of the visit purpose. |
| Marisela Garcia-Centeno | Licensing Program Analyst | Conducted the case management visit and inspection. |
| Sabel Martinez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Capacity: 113
Deficiencies: 0
Date: Oct 17, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that facility staff financially abused a resident.
Complaint Details
The complaint alleged that facility staff financially abused a resident by making fraudulent transactions on the resident's bank account. The investigation found suspicious transactions and concerning behavior by some individuals during bank visits, but no facility staff were identified as responsible, and the allegation was unsubstantiated.
Findings
The investigation included interviews with staff, residents' family, and the reporting party, as well as review of records and audit reports. Despite suspicious financial transactions and some concerning observations, there was insufficient evidence to substantiate the allegation of financial abuse by facility staff, resulting in an unsubstantiated finding.
Report Facts
Facility capacity: 113
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Rocio Granda | Administrator | Facility administrator met during the investigation |
| Harpreet Humpal | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 113
Deficiencies: 0
Date: 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.
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.
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.
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: 78
Capacity: 113
Deficiencies: 0
Date: Oct 1, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2025-06-11 alleging that staff did not accord resident dignity in their relationship with staff or residents.
Complaint Details
The complaint alleged staff did not accord resident dignity, specifically involving a disagreement between Resident #1 and Resident #2 about a bedroom door being opened or closed. The investigation found no evidence to substantiate the allegation.
Findings
The investigation included interviews, record reviews, and a brief facility tour. The allegation was found to be unsubstantiated due to inconsistent statements and lack of preponderance of evidence. The facility addressed the issue by relocating one resident to a private room to avoid further conflict.
Report Facts
Complaint Control Number: 08-AS-20250611162354
Capacity: 113
Census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Rocio Granda | Administrator | Facility administrator involved in the investigation |
| Lizzette Tellez | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 113
Deficiencies: 0
Date: Sep 17, 2025
Visit Reason
An unannounced complaint investigation was conducted following an allegation that staff did not provide a safe environment for a resident.
Complaint Details
The complaint alleged that staff did not provide a safe environment for Resident 1. The investigation was unsubstantiated based on interviews with staff and residents, records review, and direct observations.
Findings
The investigation found no preponderance of evidence to prove the alleged violation occurred. Interviews, observations, and records review indicated that the residents involved had verbal altercations initiated by one resident, but no physical altercation or unsafe environment was substantiated.
Report Facts
Capacity: 113
Census: 77
Complaint Control Number: 08-AS-20250909225542
Investigation Duration: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Rocio Granda | Administrator | Facility administrator met during the investigation |
| Andres Barragan | Kitchen Supervisor | Participated in exit interview and received report copy |
| Sabel Martinez | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 113
Deficiencies: 0
Date: Sep 17, 2025
Visit Reason
An unannounced complaint investigation was conducted following an allegation that staff caused bruising to a resident.
Complaint Details
The complaint alleged that staff caused bruising to Resident 1. The allegation was found to be unsubstantiated based on interviews, observations, and records review.
Findings
The investigation included interviews, observations, and records review, concluding that there was insufficient evidence to substantiate the allegation of staff causing bruising to the resident. The resident's bruises were explained by agitation and falls, with fall mitigations in place and hospice involvement.
Report Facts
Capacity: 113
Census: 77
Complaint Control Number: 08-AS-20250910111033
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Rocio Granda | Administrator | Facility administrator met during the investigation |
| Andres Barragan | Kitchen Supervisor | Participated in exit interview and received report copy |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 113
Deficiencies: 0
Date: 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.
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.
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.
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
Date: 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.
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.
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.
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
Date: Jun 5, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2021-04-06 alleging medication not given as prescribed, failure to arrange appropriate medical care, and inadequate night staffing.
Complaint Details
The complaint was unsubstantiated based on interviews and records reviewed. Allegations included medication not given as prescribed, failure to arrange appropriate medical care, and inadequate night staffing. The resident refused PRN medication and was taken to the emergency room. There was insufficient evidence to support inadequate staffing.
Findings
The investigation found insufficient evidence to support the allegations. The resident was taken to the emergency room and the administrator contacted the primary care physician. The resident admitted to refusing prescribed PRN medication. The allegations were deemed unsubstantiated.
Report Facts
Capacity: 113
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with during investigation and contacted for follow-up information |
| Andrea Palado | Licensing Evaluator | Conducted the complaint investigation |
| Stacy Barlow | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 113
Deficiencies: 0
Date: Jun 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on 2021-03-29 regarding failure to secure a resident's medication and improper cleaning of a resident's bathroom.
Complaint Details
The complaint was unsubstantiated based on interviews and records reviewed. No evidence supported the allegations that the licensee failed to secure medication or that staff improperly cleaned a resident's bathroom.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews and records reviewed did not support that medication was left unsecured or that bathroom cleaning was inadequate. The allegations were deemed unsubstantiated.
Report Facts
Capacity: 113
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Facility administrator met during the investigation |
| Andrea Palado | Licensing Evaluator | Conducted the complaint investigation |
| Stacy Barlow | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 113
Deficiencies: 0
Date: 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.
Complaint Details
The complaint alleged that the licensee was not following proper eviction protocols regarding Resident #1. The investigation concluded the allegation was unsubstantiated.
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.
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
Complaint Investigation
Census: 76
Capacity: 113
Deficiencies: 0
Date: May 23, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations that the licensee was not following proper eviction protocols for a resident in care.
Complaint Details
The complaint alleged that the licensee was not following proper eviction protocols regarding a resident. The complaint was investigated and found to be unsubstantiated.
Findings
The investigation found that proper 60-day notice was given to the resident for nonpayment of rent over eight months, and interviews with an outside source revealed no concerns about eviction protocols. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 113
Census: 76
Notice period: 60
Nonpayment period: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Boyles | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Rocio Granda | Administrator | Facility administrator interviewed during the investigation |
| Simon Jacob | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Annual Inspection
Census: 77
Capacity: 113
Deficiencies: 0
Date: 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
Date: 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
Annual Inspection
Census: 77
Capacity: 113
Deficiencies: 0
Date: 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 regulations. No deficiencies were observed or cited during the inspection, though a Technical Advisory was issued.
Report Facts
Days of perishable food present: 2
Days of non-perishable food present: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with during inspection and named in the report. |
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection. |
| Robyn Clark | Supervisor | Named as supervisor in the report. |
Inspection Report
Census: 77
Capacity: 113
Deficiencies: 0
Date: Mar 21, 2025
Visit Reason
Licensing Program Analyst Natasha Persaud conducted a Case Management - Other visit to evaluate the facility and review the application process for a bedridden fire clearance for one resident.
Findings
During the visit, no immediate health or safety issues were observed. The facility's sketches and floor plans were consistent with the current layout. The fire clearance for one bedridden resident was approved by the Fire Marshall on 06/27/2024, and the application process portion related to this has been completed.
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 licensee rights |
| Natasha Persaud | Licensing Program Analyst | Conducted the Case Management - Other visit |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 113
Deficiencies: 0
Date: 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.
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.
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.
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
Complaint Investigation
Census: 83
Capacity: 113
Deficiencies: 0
Date: 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.
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 and noted Resident #1's forgetfulness. The allegation was unsubstantiated after investigation.
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.
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 |
| Rocio Granda | Administrator | Facility administrator interviewed regarding the allegation |
| Robyn Clark | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Plan of Correction
Census: 87
Capacity: 113
Deficiencies: 0
Date: 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
Plan of Correction
Census: 87
Capacity: 113
Deficiencies: 0
Date: Jan 17, 2025
Visit Reason
The visit was a Plan of Correction (POC) inspection conducted 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
Deficiency correction date: Jan 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Named in relation to correction of medication order deficiency and plan of correction |
| Natasha Persaud | Licensing Program Analyst | Conducted the Plan of Correction visit |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 113
Deficiencies: 2
Date: Jan 8, 2025
Visit Reason
The visit was conducted to issue deficiencies identified during a complaint investigation that concluded on 01/08/2025.
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.
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.
Deficiencies (2)
Resident #1 did not have current written orders on file for an over-the-counter medication.
Resident #1 was not assessed with a reappraisal every 12 months as required.
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
Date: 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.
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.
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.
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
Date: 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.
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.
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.
Deficiencies (1)
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.
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: 87
Capacity: 113
Deficiencies: 0
Date: Jan 8, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding an allegation that staff were unable to communicate with residents due to a language barrier.
Complaint Details
The complaint alleged that staff were unable to communicate with residents due to a language barrier, specifically noting that night shift staff could not speak English. The investigation found inconsistent statements and no preponderance of evidence to support the allegation. The complaint was unsubstantiated.
Findings
The investigation found that although some staff primarily spoke Spanish and had limited English proficiency with complex questions, the night manager and medication technician spoke English and residents' needs were met. The language barrier did not affect the staff's ability to provide care or communicate with outside agencies. The allegation was deemed unsubstantiated.
Report Facts
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 during investigation and received report and licensee rights |
| Robyn Clark | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 113
Deficiencies: 1
Date: Jan 8, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not repair a wall allowing rodents into the facility and did not ensure chemicals were inaccessible to residents.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not repair a wall allowing rodents into the facility. It was found that the hole under the bathroom sink was not completely repaired, allowing rodent access. The facility did not initially contact pest control upon knowledge of the issue but did so after the Licensing Program Analyst's visit. The allegation that staff did not ensure chemicals were inaccessible to residents was unsubstantiated; Resident #1 ingested a small amount of Lysol but paramedics assessed and did not recommend hospital transport. The facility has since secured cleaning supplies and reassessed the resident's safety.
Findings
The investigation substantiated that staff failed to properly repair a hole in a resident's wall allowing rodent access, posing a potential health and safety risk. The facility eventually repaired the hole and had pest control treat the area. The allegation regarding chemicals being accessible to residents was unsubstantiated after review and interviews.
Deficiencies (1)
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. This requirement is not met as evidenced by the hole in the wall allowing rodent access.
Report Facts
Capacity: 113
Census: 87
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 |
| Rocio Granda | Administrator | Facility administrator interviewed regarding findings and corrective actions |
| Yahaira Garduno | Office Assistant | Met with Licensing Program Analyst during investigation and received report and licensee rights |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 113
Deficiencies: 0
Date: Jan 8, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not ensure a resident was treated with dignity in their relationships with others.
Complaint Details
The complaint alleged that staff did not ensure Resident #1 was treated with dignity by Resident #2, who made inappropriate comments. Interviews and evidence did not support the allegation, and it was unsubstantiated.
Findings
The investigation found inconsistent statements and insufficient evidence to substantiate the allegation. Interviews revealed conflicts between residents but no neglectful actions or staff misconduct. The allegation was deemed unsubstantiated.
Report Facts
Complaint Control Number: 08-AS-20241021145523
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Rocio Granda | Administrator | Met with Licensing Program Analyst during investigation. |
| Yahaira Garduno | Office Assistant | Met with Licensing Program Analyst and received report and licensee rights. |
| Robyn Clark | Supervisor | Supervisor named on report. |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 113
Deficiencies: 2
Date: Jan 8, 2025
Visit Reason
The visit was conducted to issue deficiencies identified during a complaint investigation that concluded on 01/08/2025.
Complaint Details
The visit was complaint-related and deficiencies were identified during the complaint investigation that concluded on 01/08/2025.
Findings
The facility was found to have deficiencies related to Resident #1's records, including an outdated Resident Appraisal and lack of a written order for an over-the-counter medication. These deficiencies posed potential health and safety risks to the resident.
Deficiencies (2)
Failure to have a signed, dated written order from a physician and a label on the medication for every prescription and nonprescription PRN medication.
Failure to ensure residents are assessed every 12 months or when there is a significant change in condition.
Report Facts
Residents present: 87
Total capacity: 113
Deficiencies cited: 2
Plan of Correction due date: Feb 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Named in relation to findings and plan of correction |
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection and authored the report |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 113
Deficiencies: 0
Date: 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.
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.
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.
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
Census: 85
Capacity: 113
Deficiencies: 0
Date: Dec 18, 2024
Visit Reason
Licensing Program Analyst Natasha Persaud conducted a Case Management - Incident visit following a self-reported incident involving a resident who experienced cardiac arrest during dialysis treatment and was hospitalized.
Findings
The facility reported no deficiencies during the visit. The resident was observed prior to dialysis with no symptoms, but later passed away at the hospital. The visit included interviews with the administrator and wellness director, and an exit interview was conducted.
Report Facts
Resident dialysis frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met during inspection and named in report |
| Natasha Persaud | Licensing Program Analyst | Conducted the Case Management - Incident visit |
| Diana Rodriguez | Wellness Director | Met during inspection and provided information about resident |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 113
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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.
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
Complaint Investigation
Census: 90
Capacity: 113
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations of neglect and lack of supervision resulting in the use and sale of illegal drugs within the facility.
Complaint Details
The complaint investigation was substantiated for neglect/lack of supervision resulting in use of illegal drugs, with multiple residents found using illegal drugs inside the facility over a period of time. The allegation of neglect/lack of supervision resulting in sale of illegal drugs was unsubstantiated due to insufficient evidence.
Findings
The investigation substantiated the allegation of neglect/lack of supervision resulting in use of illegal drugs by multiple residents inside the facility, with evidence including photographs, confiscated drugs, and resident and staff interviews. However, the allegation of neglect/lack of supervision resulting in sale of illegal drugs was found to be unsubstantiated due to lack of evidence despite rumors and resident admissions.
Deficiencies (1)
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.
Report Facts
Capacity: 113
Census: 90
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Rocio Granda | Administrator | Named in deficiency related to failure to carry out policies regarding illegal drug use |
| Yahaira Garduno | Office Manager Assistant | Met with evaluator during investigation and received report and licensee rights |
Inspection Report
Annual Inspection
Census: 88
Capacity: 113
Deficiencies: 0
Date: 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
Date: 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
Annual Inspection
Census: 88
Capacity: 113
Deficiencies: 0
Date: Oct 17, 2024
Visit Reason
The inspection was a Case Management - Annual Continuation visit conducted 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 absence of hazards.
Report Facts
Hot water temperature: 113
Perishable food supply: 2
Non-perishable food supply: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during inspection and participated in facility tour |
| Natasha Persaud | Licensing Program Analyst | Conducted the Case Management - Annual Continuation inspection |
Inspection Report
Census: 88
Capacity: 113
Deficiencies: 0
Date: Oct 17, 2024
Visit Reason
The inspection was a Case Management - Incident visit conducted due to a self-reported incident involving a resident and a staff member.
Findings
The investigation found conflicting statements regarding the incident where staff was alleged to be rough with a resident. Interviews with staff and residents indicated no issues, and the facility administrator acted appropriately. No deficiencies were cited.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met during the inspection and acted appropriately with resident care and concerns. |
| Natasha Persaud | Licensing Program Analyst | Conducted the Case Management - Incident visit. |
Inspection Report
Census: 85
Capacity: 113
Deficiencies: 0
Date: 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
Census: 85
Capacity: 113
Deficiencies: 0
Date: 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. |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 113
Deficiencies: 0
Date: 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.
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.
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.
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: 85
Capacity: 113
Deficiencies: 0
Date: Aug 23, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 03/01/2021 regarding the facility's failure to address resident's change in condition, incontinent care needs, resident care needs, staffing sufficiency, and dietary needs.
Complaint Details
The complaint was unsubstantiated based on interviews with staff, residents, and outside sources, as well as review of facility documentation. Allegations included failure to address a resident's change in condition, inadequate incontinent care, insufficient staffing, and unmet dietary needs, none of which were confirmed.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews, record reviews, and outside source information confirmed that resident care needs, including incontinence care, showers, staffing levels, and dietary accommodations, were being met appropriately.
Report Facts
Capacity: 113
Census: 85
Average staff present: 3.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Rocio Grandola | Administrator | Facility administrator present during investigation and exit interview |
| Yahaira Garduno | Assistant Office Manager | Met with Licensing Program Analyst during investigation visit |
| Simon Jacob | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 113
Deficiencies: 0
Date: 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.
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.
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.
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
Date: 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.
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.
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.
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: 87
Capacity: 113
Deficiencies: 0
Date: Aug 20, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff did not ensure residents have access or assistance to required appointments.
Complaint Details
The complaint alleged that staff did not ensure residents had access or assistance to required appointments, specifically that Resident #1 needed additional physical therapy which the facility did not assist with. The investigation revealed that the facility requested additional therapy but the resident's insurance declined it, and the resident is currently receiving therapy through a different agency. The allegation was unsubstantiated.
Findings
The investigation found inconsistent statements and insufficient evidence to support the allegation. The facility complied with regulations and assisted the resident with the request for additional physical therapy. The allegation was deemed unsubstantiated.
Report Facts
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 Manager | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 113
Deficiencies: 0
Date: Aug 20, 2024
Visit Reason
An unannounced complaint investigation was conducted following allegations that staff handled residents in a rough manner and did not treat residents with dignity and respect.
Complaint Details
The complaint alleged staff handled residents roughly and did not treat residents with dignity and respect. Interviews with residents and staff, including Medication Technician Andrea Rodriguez, revealed no corroboration of these claims. The complaint was unsubstantiated.
Findings
The investigation found inconsistent statements and insufficient evidence to support the allegations. Resident and staff interviews indicated no rough handling or mistreatment, and the allegations were deemed unsubstantiated.
Report Facts
Capacity: 113
Census: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Rodriguez | Medication Technician | Interviewed during complaint investigation and recipient of report and licensee rights |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 113
Deficiencies: 0
Date: 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.
Complaint Details
The complaint alleged that the licensee did not provide a comfortable temperature for residents. The allegation was unsubstantiated after investigation.
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.
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
Complaint Investigation
Census: 92
Capacity: 113
Deficiencies: 0
Date: Jul 11, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the licensee did not provide a comfortable temperature for residents.
Complaint Details
The complaint alleged the licensee did not provide a comfortable temperature for residents. The allegation was investigated and found unsubstantiated.
Findings
The investigation found that the facility maintained a comfortable temperature overall, with some residents reporting being too hot and using fans that were not in use. Staff confirmed provision of fans and ordered portable air conditioning units. The allegation was deemed unsubstantiated due to inconsistent statements and lack of preponderance of evidence.
Report Facts
Capacity: 113
Census: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johnny Laesch | Med Tech | Interviewed during complaint investigation and recipient of licensing rights |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Yahaira Garduno | Office Manager/Supervisor | Interviewed during complaint investigation |
| Lizzette Tellez | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Follow-Up
Census: 92
Capacity: 113
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Type A deficiency for failure to provide adequate care and supervision to a resident with dementia, resulting in a fatal fall.
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: 92
Capacity: 113
Deficiencies: 1
Date: 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.
Complaint Details
The visit was a follow-up on a substantiated case management investigation regarding the questionable death of a resident (R1) due to neglect and lack of supervision. The complaint was substantiated.
Findings
The Department found the licensee culpable of negligence for not providing needed care and supervision to a resident with dementia, resulting in the resident's fall and death. A civil penalty of $15,000 was issued for this violation.
Deficiencies (1)
Type A deficiency for failure to provide needed care and supervision to a resident with dementia.
Report Facts
Civil penalty amount: 15000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Named in relation to the case management investigation and receipt of penalty and appeal rights |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
| Lizzette Tellez | Supervisor | Supervisor named in the report |
Inspection Report
Follow-Up
Census: 91
Capacity: 113
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Failure to ensure needed medical care for a resident after a fall, resulting in untreated hip fracture and serious bodily injury.
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
Date: 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.
Deficiencies (1)
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.
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
Follow-Up
Census: 91
Capacity: 113
Deficiencies: 1
Date: Jun 19, 2024
Visit Reason
An unannounced case management visit was conducted to follow up on a substantiated complaint investigation regarding the facility's failure to ensure needed medical care for a resident.
Complaint Details
The complaint alleged the licensee did not ensure needed medical care for a resident who fell and complained of pain. The allegation was substantiated.
Findings
The investigation confirmed that the facility failed to provide or arrange medical evaluation after a resident's fall, resulting in an untreated hip fracture and serious bodily injury. A civil penalty of $9,500 was issued for this violation.
Deficiencies (1)
Licensee did not ensure needed medical care for a resident after a fall, violating 22 CCR § 87465(g) Incidental Medical and Dental Care.
Report Facts
Civil penalty amount: 9500
Immediate civil penalty amount: 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 inspection |
Inspection Report
Census: 91
Capacity: 113
Deficiencies: 1
Date: Jun 19, 2024
Visit Reason
An unannounced case management visit was conducted to deliver enhanced civil penalties (ECP) and to conduct background clearance observations of facility staff associations with the Licensing Information System.
Findings
A deficiency was cited for Staff #1 not being associated with the facility in the Licensing Information System despite working there, posing a potential health, safety, and personal rights risk to residents. An immediate civil penalty of $500 was assessed.
Deficiencies (1)
Failure to ensure Staff #1 had a transferred criminal record clearance or was associated with the facility as required by CCR 87355.
Report Facts
Civil penalty amount: 500
Residents at risk: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yahira Gardunio Ramirez | Office Manager/Supervisor | Met during the visit and involved in the exit interview. |
| Carmen Lopez | Licensing Program Analyst | Conducted the unannounced case management visit and cited the deficiency. |
| Jennifer Lott | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Plan of Correction
Census: 92
Capacity: 113
Deficiencies: 0
Date: 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
Date: 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.
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.
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.
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
Date: 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.
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.
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.
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: 0
Date: May 2, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that lack of supervision resulted in a resident sustaining injury.
Complaint Details
The complaint alleged that lack of supervision resulted in Resident #1 sustaining injury when Resident #2 pushed Resident #1, causing a fractured hip. The investigation included interviews and record reviews and concluded the allegation was unsubstantiated.
Findings
The investigation found inconsistent statements and insufficient evidence to substantiate the allegation. Staff were present and observed the incident, and the facility had made accommodations and attempted to find alternative placement for the aggressive resident. The allegation was deemed unsubstantiated.
Report Facts
Facility capacity: 113
Census: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Rocio Granda | Administrator | Facility administrator met during investigation and named in findings |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 113
Deficiencies: 0
Date: May 2, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that a resident sustained multiple falls due to neglect, was given wrong medication, and consumed facility food resulting in food poisoning.
Complaint Details
The complaint investigation was unsubstantiated based on interviews, record reviews, and observations. Allegations included neglect causing falls, wrong medication administration, and food poisoning from facility food, none of which were supported by evidence.
Findings
The investigation found inconsistent statements and no preponderance of evidence to support the allegations. Resident records and staff interviews did not confirm falls or medication errors, and no food poisoning was linked to facility food. The allegations were deemed unsubstantiated.
Report Facts
Complaint Control Number: 8
Capacity: 113
Census: 92
Hospital visits: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Rocio Granda | Administrator | Facility administrator met during investigation |
Inspection Report
Plan of Correction
Census: 92
Capacity: 113
Deficiencies: 0
Date: May 2, 2024
Visit Reason
The visit was an unannounced Plan of Correction (POC) inspection 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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during the Plan of Correction visit and named in relation to the deficiency correction. |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced Plan of Correction visit. |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 113
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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.
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
Date: 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.
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.
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.
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
Complaint Investigation
Census: 92
Capacity: 113
Deficiencies: 1
Date: 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.
Complaint Details
The complaint was substantiated. It involved a resident who wandered out of the facility unassisted, resulting in a fall and hospital transport. Staff were unaware the resident had left as they were assisting other residents. The facility's doors lock from outside at night but not from inside due to safety reasons.
Findings
The investigation substantiated the allegation that one resident left the facility unassisted, resulting in a fall and hospital transport without injury. The facility did not ensure adequate supervision, posing a potential health and safety risk. The administrator plans to purchase door alarms and relocated the resident to a secured memory unit.
Deficiencies (1)
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 supervise Resident #1 who left the facility unassisted.
Report Facts
Census: 92
Total Capacity: 113
Deficiencies cited: 1
Plan of Correction Due Date: May 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Evaluator | Conducted the complaint investigation |
| Rocio Granda | Administrator | Facility administrator interviewed regarding the incident and findings |
| Adilene Ramirez | Staff member interviewed during investigation and received report and licensee rights | |
| Lizzette Tellez | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 113
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
An unannounced complaint investigation was conducted following allegations that staff did not assist a resident with feeding and that the facility smelled of mold.
Complaint Details
The complaint was unsubstantiated after investigation. Allegations included staff not assisting a resident with feeding and the presence of mold odor causing sickness. Evidence did not support these claims.
Findings
The investigation found the allegations unsubstantiated. Resident and staff interviews confirmed the resident was able and preferred to feed themselves, and no mold was observed or smelled during the visit or prior inspections.
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 during investigation |
Inspection Report
Census: 91
Capacity: 113
Deficiencies: 0
Date: 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
Date: 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.
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.
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.
Deficiencies (1)
The licensee did not give medications as prescribed to 1 out of 91 residents, posing an immediate health and safety risk.
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: 91
Capacity: 113
Deficiencies: 1
Date: Apr 2, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that medications were not given as prescribed and a medication error resulting in injury for Resident #1.
Complaint Details
The complaint investigation was substantiated for the allegation that medications were not given as prescribed to Resident #1, including dispensing a medication causing an allergic reaction despite hospital documentation. The allegation of medication error resulting in injury was unsubstantiated.
Findings
The investigation substantiated that medications were not given as prescribed to Resident #1, posing an immediate health and safety risk. The facility continued dispensing a medication causing an allergic reaction despite hospital documentation. Another allegation of medication error resulting in injury was unsubstantiated due to lack of evidence linking the fall to medication.
Deficiencies (1)
The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by failure to give medications as prescribed to 1 out of 91 residents, posing an immediate health and safety risk.
Report Facts
Capacity: 113
Census: 91
Deficiencies cited: 1
Plan of Correction Due Date: Apr 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met during investigation and named in report |
| Monica Cordova | Business Office Manager | Met during investigation and received report and licensee rights |
| Natasha Persaud | Licensing Evaluator | Conducted complaint investigation |
| Ryan Fulton | Licensing Program Analyst | Conducted complaint investigation |
| Lizzette Tellez | Supervisor | Supervisor overseeing investigation |
Inspection Report
Census: 91
Capacity: 113
Deficiencies: 0
Date: Apr 2, 2024
Visit Reason
The visit was a Case Management - Incident visit conducted due to a self-reported incident involving a resident who was hospitalized for chest pain and subsequently refused to return to the facility, threatening harm to themselves and others.
Findings
During the visit, Licensing Program Analysts toured the facility, reviewed records, and interviewed staff and residents. The administrator implemented increased status checks and held meetings to ensure the resident's safety. No deficiencies were issued during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Named in relation to the incident involving Resident #1 and safety measures implemented. |
| Monica Cordova | Business Office Manager | Met with Licensing Program Analysts during the visit and received Licensee Rights. |
| Natasha Persaud | Licensing Program Analyst | Conducted the Case Management - Incident visit. |
| Ryan Fulton | Licensing Program Analyst | Conducted the Case Management - Incident visit. |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 113
Deficiencies: 0
Date: 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.
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.
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.
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: 88
Capacity: 113
Deficiencies: 0
Date: Mar 19, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations of lack of supervision resulting in a resident altercation and staff verbally abusing a resident.
Complaint Details
The complaint involved allegations of lack of supervision leading to a resident altercation and staff verbally abusing a resident. The investigation found the altercation occurred years ago and was resolved, and no curse words were witnessed during the alleged verbal abuse incident. The allegations were unsubstantiated.
Findings
The investigation found no substantiated evidence to support the allegations. The resident altercation was historical and resolved, with no recent incidents. The verbal abuse allegation was not corroborated by witnesses, and inconsistent statements led to the allegations being deemed unsubstantiated.
Report Facts
Capacity: 113
Census: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Rodriguez | Medication Technician | Completed the visit with Licensing Program Analyst during the investigation |
| Rocio Granda | Administrator | Facility administrator involved in the investigation |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 113
Deficiencies: 0
Date: 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.
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.
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.
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
Complaint Investigation
Census: 89
Capacity: 113
Deficiencies: 0
Date: Feb 29, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 10/16/2020 regarding staff not responding timely to assist a resident and an illegal eviction.
Complaint Details
The complaint involved allegations that staff did not respond timely to assist a resident and that the facility attempted an illegal eviction. The investigation was unsubstantiated due to lack of corroborating evidence.
Findings
The investigation found no corroborating evidence to support the allegations. Interviews with staff, residents, and outside sources revealed that the resident was never evicted and that care needs were addressed in a timely manner. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 113
Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liliana Silveira | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rocio Granda | Administrator | Met with the evaluator during the investigation and exit interview |
| Jennifer Lott | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Annual Inspection
Census: 89
Capacity: 113
Deficiencies: 0
Date: 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
Date: 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.
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.
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.
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: 89
Capacity: 113
Deficiencies: 0
Date: Feb 28, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate 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 not able to communicate with residents and/or emergency service personnel.
Complaint Details
The complaint was unsubstantiated based on interviews and records review. Allegations included untimely prescription refills, inadequate transportation arrangements, and communication difficulties. The Department found no evidence supporting these claims.
Findings
The investigation included interviews with residents, staff, and review of records. The evidence did not 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.
Report Facts
Capacity: 113
Census: 89
Complaint Control Number: 08-AS-20201007102549
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rocio Granda | Administrator | Facility administrator met during the visit and participated in exit interview |
Inspection Report
Annual Inspection
Census: 89
Capacity: 113
Deficiencies: 0
Date: Feb 28, 2024
Visit Reason
Licensing Program Analyst Juliana Barfield conducted an unannounced visit to conduct a Required Annual Inspection of the facility.
Findings
During the visit, the analyst toured the facility, reviewed staff and client records, and interviewed staff and clients. Due to time constraints, a return visit is needed to complete the annual inspection. An exit interview was conducted with the Administrator.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Administrator present during the inspection and exit interview. |
| Yahaira Garduno | Assistant Manager | Assistant Manager present during the inspection. |
| Juliana Barfield | Licensing Program Analyst | Conducted the unannounced annual inspection visit. |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 113
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Facility staff did not administer medications as prescribed, violating CCR 87465(C)(2) regarding incidental medical and dental care.
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: 91
Capacity: 113
Deficiencies: 1
Date: 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.
Complaint Details
The complaint alleging failure to administer medications as prescribed was substantiated based on interviews, record reviews, and outside sources. The allegation was found valid by the preponderance of evidence standard.
Findings
The investigation substantiated that facility staff failed to administer Nortriptyline and another medication as prescribed to resident R1, resulting in a potential health risk. The facility ran out of medication and did not timely order refills, and staff did not perform adequate follow-up to ensure medication management.
Deficiencies (1)
Facility staff did not administer medications as prescribed, posing a potential health risk to 1 of 89 residents in care.
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 discussion of findings and plan of correction |
| Denise Powell | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 113
Deficiencies: 1
Date: 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.
Complaint Details
The visit was triggered by a complaint, but the deficiencies cited 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.
Deficiencies (1)
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.
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
Date: 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.
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.
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.
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
Census: 89
Capacity: 113
Deficiencies: 0
Date: Feb 23, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 10/06/2020 regarding failure to reposition a resident and failure to maintain a resident's room temperature within regulation.
Complaint Details
The complaint involved allegations that facility staff failed to reposition a resident leading to pressure wounds, and that the facility did not maintain the resident's room temperature within regulation. The investigation found these allegations unsubstantiated based on interviews, records, and observations.
Findings
The investigation, including interviews, records review, and direct observations, 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 temperature records and observations did not confirm a failure to maintain room temperature within regulation. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 113
Census: 89
Temperature range: 66.9
Temperature range: 97
Temperature range: 68
Temperature range: 88.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Mina Ramirez | Caregiving Supervisor | Interviewed during the investigation and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 113
Deficiencies: 1
Date: Feb 23, 2024
Visit Reason
Licensing Program Analyst Rebecca Ruiz conducted an announced case management visit to cite deficiencies observed during a complaint visit that are unrelated to the complaint allegations.
Complaint Details
Deficiencies cited were observed during a complaint visit but are unrelated to the complaint allegations.
Findings
The facility was found to have a staff member (S1) working without proper association and without a transferred criminal background clearance, posing an immediate safety risk to residents. A civil penalty of $500 was issued.
Deficiencies (1)
Failure to ensure that Staff 1's criminal background clearance was transferred to the facility prior to working, violating CCR 87355(e)(2).
Report Facts
Civil penalty amount: 500
Residents at risk: 97
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 | Participated in exit interview and acknowledged receipt of report |
| Lizzette Tellez | Supervisor | Named as supervisor in the report |
Inspection Report
Complaint Investigation
Capacity: 113
Deficiencies: 0
Date: Feb 21, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that residents were financially abused while in care.
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.
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.
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
Capacity: 113
Deficiencies: 0
Date: Feb 21, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that residents were financially abused while in care.
Complaint Details
The complaint alleged that Resident #1 and Resident #2 were financially abused, including theft of cash, wallets, and debit/credit cards. Investigations found conflicting statements from residents and confirmed that cards were stolen outside the facility. Staff and other residents denied theft. Both residents had locks on their drawers and physician reports indicated they could leave unassisted. The complaint was unsubstantiated.
Findings
The investigation revealed inconsistent statements and no preponderance of evidence to support the allegations of financial abuse. The allegations were deemed unsubstantiated after interviews and record reviews.
Report Facts
Facility capacity: 113
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Yahaira Garduno | Medication Technician Supervisor | Met with the Licensing Program Analyst during the investigation and received the report and licensee rights |
| Lizzette Tellez | Supervisor | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 113
Deficiencies: 0
Date: 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.
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.
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.
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: 89
Capacity: 113
Deficiencies: 0
Date: Feb 8, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to address allegations that staff were not providing adequate service to a resident in care.
Complaint Details
The complaint alleged that staff were not providing adequate service to a resident. The investigation included interviews, facility tour, and records review. The allegation was unsubstantiated as no witnesses or evidence supported the claim.
Findings
The investigation found that staff provide various services to residents and assist them when needed. Interviews with staff and review of records revealed no evidence supporting the allegation. The complaint was determined to be unsubstantiated.
Report Facts
Capacity: 113
Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tiffany Holmes | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rocio Granda | Administrator | Facility administrator interviewed during the investigation |
| Simon Jacob | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 113
Deficiencies: 0
Date: 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.
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.
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.
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: 94
Capacity: 113
Deficiencies: 0
Date: Oct 30, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 08/13/2020 regarding medication mishandling, room temperature, facility disrepair, insect presence, food service adequacy, and lighting sufficiency at the facility.
Complaint Details
The complaint investigation was unsubstantiated based on interviews, record reviews, and observations. Allegations included staff mishandling medication, uncomfortable room temperature, facility disrepair, presence of insects, inadequate food service, and insufficient lighting. No evidence supported these claims.
Findings
The investigation found no evidence to substantiate any of the allegations. Reviews of resident medication records, facility tours, staff and outside source interviews revealed no discrepancies or concerns regarding medication handling, room temperature, facility condition, insect presence, food service, or lighting. All allegations were deemed unsubstantiated.
Report Facts
Capacity: 113
Census: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Domingo | Licensing Evaluator | Conducted the complaint investigation and delivered findings |
| Yahaira Garduno | Med Tech Supervisor | Met with evaluator during investigation and received report copy |
| Maya S. Mnoyan | Administrator | Facility administrator present during investigation |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 113
Deficiencies: 2
Date: 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.
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.
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.
Deficiencies (2)
The licensee did not ensure medications were given as prescribed for 1 out of 79 residents, posing a potential health and safety risk.
Items that pose a danger were accessible to 1 out of 79 residents, posing a potential health and safety risk.
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: 90
Capacity: 113
Deficiencies: 2
Date: Sep 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including resident medications not given as prescribed and resident accessibility to dangerous items.
Complaint Details
The complaint investigation was substantiated for allegations that resident medications were not given as prescribed and that a resident had access to dangerous items. The allegations related to 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.
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. Another set of allegations regarding lack of supervision, incontinent care, medical care assistance, and safeguarding personal items were found unsubstantiated.
Deficiencies (2)
The licensee did not ensure medications were given as prescribed for 1 out of 79 residents, posing a potential health and safety risk.
Items that pose a danger were accessible to 1 out of 79 residents, posing a potential health and safety risk.
Report Facts
Missed medication doses: 19
Residents in care: 79
Plan of Correction Due Date: Oct 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation. |
| Ruth Granda | Business Office Assistant | Met with the evaluator and involved in findings related to medication and storage deficiencies. |
| Rocio Granda | Administrator | Interviewed regarding resident access to dangerous items and medical care. |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 113
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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.
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: 91
Capacity: 113
Deficiencies: 1
Date: 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.
Complaint Details
The complaint was substantiated based on interviews and record review. The facility admitted no telephone services were available after business hours. The administrator is working with Verizon to have phones operable 24 hours with voicemail monitored hourly.
Findings
The investigation found the allegation substantiated; the facility telephone was not operable at night after business hours, posing a potential safety risk to residents. The administrator confirmed ongoing efforts with Verizon to restore 24-hour telephone service with voicemail monitored hourly by staff.
Deficiencies (1)
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 in care, posing a potential safety risk.
Report Facts
Census: 91
Total Capacity: 113
Deficiency 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 complaint investigation |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 113
Deficiencies: 0
Date: 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.
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.
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.
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: 87
Capacity: 113
Deficiencies: 0
Date: Jul 26, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 03/22/2023 alleging inadequate food service, unmet residents' care needs, lack of incontinence care, lack of criminal record clearances for staff, and insufficient staff training.
Complaint Details
The complaint investigation was unsubstantiated for allegations including inadequate food service, unmet residents' care needs, and lack of incontinence care. The complaint was unfounded regarding staff lacking criminal record clearances and required training. The Department found no evidence to support the allegations after inspection, interviews, and record review.
Findings
The investigation found insufficient evidence to substantiate the allegations. Observations, interviews, and record reviews indicated adequate food service, timely and accommodating staff care, proper incontinence care, current criminal background clearances for staff, and required staff training. The allegations were deemed unsubstantiated or unfounded.
Report Facts
Facility capacity: 113
Census: 87
Staff clearance percentage: 64
Staff records reviewed: 6
Employees randomly selected for clearance review: 37
Total employees: 58
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 | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 113
Deficiencies: 0
Date: 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.
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.
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.
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: 89
Capacity: 113
Deficiencies: 0
Date: Jul 21, 2023
Visit Reason
An unannounced complaint investigation visit 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.
Complaint Details
The complaint was unsubstantiated. The resident was non-compliant with wound care and medical treatment, and the facility made efforts to provide care and encourage hospital visits. The wounds were chronic venous stasis ulcers, not new pressure injuries.
Findings
The investigation found that the resident had venous stasis wounds, not pressure injuries, and was non-compliant with wound care instructions. The facility consistently encouraged the resident to seek medical treatment and attempted to arrange increased wound care, but the resident refused some treatments. The allegations were deemed unsubstantiated due to lack of evidence supporting neglect or failure by the facility.
Report Facts
Capacity: 113
Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rocio Granda | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 113
Deficiencies: 0
Date: 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.
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.
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.
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: 85
Capacity: 113
Deficiencies: 0
Date: 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.
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 revealed the facility notified the responsible party as required, and the visitor did not contract the virus. The allegation was unsubstantiated.
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 physician of the COVID-19 positive resident. The allegation was deemed unsubstantiated.
Report Facts
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 |
| Rocio Granda | Administrator | Provided information regarding COVID-19 notification procedures |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 113
Deficiencies: 0
Date: 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.
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.
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.
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
Date: 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.
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.
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.
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
Complaint Investigation
Census: 86
Capacity: 113
Deficiencies: 0
Date: Mar 22, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-10-21 alleging that the licensee did not meet the needs of a resident.
Complaint Details
The complaint alleged that the licensee did not meet the needs of a resident. The investigation found inconsistent statements and no preponderance of evidence to support the allegations. The complaint was deemed unsubstantiated.
Findings
The investigation included interviews, record reviews, and a facility tour. The findings concluded that the allegations were unsubstantiated as the facility was meeting the resident's needs, and issues were related to the resident's physicians and family circumstances rather than the facility.
Report Facts
Capacity: 113
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Monica Cordoba | Business Manager | Met with the Licensing Program Analyst during the investigation |
| Rocio Granda | Administrator | Interviewed regarding resident's condition and family visits |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 113
Deficiencies: 0
Date: Mar 22, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that staff did not seek timely treatment for a resident, did not respond promptly to assist residents, and that the administrator did not allow a resident to return after discharge from a skilled nursing facility.
Complaint Details
The complaint involved allegations that staff failed to seek timely treatment for Resident #1, did not respond promptly to resident assistance calls, and that the administrator prevented the resident from returning after discharge from a skilled nursing facility. The investigation concluded these allegations were unsubstantiated.
Findings
The investigation found inconsistent statements and insufficient evidence to substantiate the allegations. The resident received timely treatment starting October 2, 2022, and was under skilled nursing facility care from October to December 2022. Staff response times were generally timely, and the administrator confirmed the resident was allowed to return to the facility. The allegations were deemed unsubstantiated.
Report Facts
Capacity: 113
Census: 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 investigator and facility representative during investigation |
| Rocio Granda | Administrator | Facility administrator involved in interviews and findings |
Inspection Report
Census: 85
Capacity: 113
Deficiencies: 1
Date: 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.
Deficiencies (1)
Independent resident medications, including controlled substances, were not secured as required, posing a potential health risk to 1 out of 85 residents.
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
Date: 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.
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.
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.
Deficiencies (1)
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.
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: 85
Capacity: 113
Deficiencies: 1
Date: Feb 14, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 10/14/2020 regarding changes to a resident's room accommodations without amending the admissions agreement and failure to safeguard resident's personal belongings.
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.
Findings
The investigation substantiated that the facility changed a resident's room without proper notification or amending the admissions agreement, posing a personal rights risk. The allegation that the facility failed to safeguard the resident's personal belongings was unsubstantiated due to inconsistent evidence.
Deficiencies (1)
Licensee did not notify Resident 1 or amend the admission agreement when changing Resident 1’s room, violating admissions agreement requirements.
Report Facts
Deficiencies cited: 1
Capacity: 113
Census: 85
Plan of Correction Due Date: Mar 16, 2023
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Hamilton | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rocio Granda | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Census: 85
Capacity: 113
Deficiencies: 1
Date: Feb 14, 2023
Visit Reason
The visit was an unannounced case management visit to discuss medication management for independent residents.
Findings
The Licensing Program Analyst observed that not all independent residents had a secured area to store their medications, resulting in a cited deficiency related to medication security.
Deficiencies (1)
Independent resident medications, including controlled substances, were not secured in a safe and locked place, posing a potential health risk to 1 out of 85 residents.
Report Facts
Residents at risk: 1
Deficiency count: 1
Plan of Correction due date: Feb 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Hamilton | Licensing Program Analyst | Conducted the unannounced case management visit and cited the deficiency |
| Rocio Granda | Administrator | Met with Licensing Program Analyst and acknowledged the deficiency |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 113
Deficiencies: 0
Date: 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.
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.
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.
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: 0
Date: Jan 17, 2023
Visit Reason
The inspection visit was conducted to investigate a complaint alleging that staff does not properly assist a client while in care, specifically regarding prescription medication.
Complaint Details
The complaint alleged that facility staff did not properly assist a client in care by withholding or failing to administer prescription medication. The investigation found no corroborating evidence, and the complaint was unsubstantiated.
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.
Report Facts
Capacity: 113
Census: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Pena | Licensing Program Analyst | Conducted the complaint investigation |
| Rocio Granda | Administrator | Met with the evaluator and discussed findings |
| Simon Jacob | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 113
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
The licensee retained a resident requiring assistance with diabetic medication management without having a skilled professional on staff to assist with injections.
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: 1
Date: 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.
Complaint Details
The complaint alleged the facility was retaining a resident requiring a higher level of care. The allegation was substantiated based on interviews, record reviews, and observations indicating the resident was unable to safely manage insulin injections and blood sugar checks without skilled professional assistance.
Findings
The investigation substantiated that Resident #1 requires a higher level of care due to inability to manage their diabetes medications and blood sugar checks independently. The facility lacks a skilled professional to assist with insulin injections, posing a potential health and safety risk.
Deficiencies (1)
Failure to ensure a resident requiring assistance with diabetic medication management received appropriate skilled professional care, posing a potential health and safety risk.
Report Facts
Capacity: 113
Census: 83
Deficiency count: 1
Plan of Correction Due Date: Jan 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during investigation and named in findings regarding lack of skilled professional on staff |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 113
Deficiencies: 2
Date: 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.
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.
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.
Deficiencies (2)
The licensee did not assist with self-administered medications for Resident #1, posing an immediate health and safety risk.
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.
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: 83
Capacity: 113
Deficiencies: 2
Date: 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.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to provide medications as prescribed and failure to maintain a clean and safe resident room. The investigation included interviews, record reviews, and observations. Civil penalties were assessed for repeat violations within 12 months.
Findings
The investigation substantiated that the facility failed to provide Resident #1 with prescribed medications as documented in the Medication Administrative Records, posing an immediate health and safety risk. Additionally, the facility did not maintain Resident #1's room in a clean, safe, and sanitary condition, with issues such as missing floor tiles and a towel rack barely held by screws. Both deficiencies were repeat violations within a 12-month period and civil penalties were assessed.
Deficiencies (2)
The licensee did not assist with self-administered medications for Resident #1, resulting in missed doses and inaccurate medication records.
The licensee did not provide a clean, safe, sanitary, and well-maintained environment for Resident #1's room, including missing floor tiles and a towel rack barely held by screws.
Report Facts
Capacity: 113
Census: 83
Deficiencies cited: 2
Plan of Correction Due Dates: 11302022
Plan of Correction Due Dates: 12272022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Perla Barragan | Care Coordinator | Named in relation to medication administration and room condition findings |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Rocio Granda | Administrator | Interviewed regarding medication and room condition findings |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 113
Deficiencies: 0
Date: 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.
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.
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.
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
Complaint Investigation
Census: 82
Capacity: 113
Deficiencies: 0
Date: 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.
Complaint Details
The complaint alleged that Resident #1 was unable to attend a dental appointment scheduled for 11/10/22 because staff failed to hold/stop medications as required. The facility confirmed medication was not held due to lack of a written physician's order. The allegation was unsubstantiated.
Findings
The investigation found that the facility did not have a current written physician's order to hold/stop the resident's medications, and the medications were administered as prescribed. The allegation was deemed unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 113
Census: 82
Complaint Control Number: 08-AS-20221109160427
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Evaluator | Conducted the complaint investigation |
| Rocio Granda | Administrator | Facility administrator involved in the investigation |
| Lizzette Tellez | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Census: 86
Capacity: 113
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failure to ensure resident appraisals were on file for 3 out of 86 residents, which is required to meet residents' care needs.
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
Date: 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: 86
Capacity: 113
Deficiencies: 0
Date: Oct 11, 2022
Visit Reason
An unannounced Case Management - Incident visit was conducted to review four self-reported incidents including two elopements and two thefts involving residents.
Findings
The facility followed required elopement procedures for the two residents who eloped, and no injuries were sustained. No deficiencies were issued based on the inspection.
Report Facts
Incidents reported: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Facility Administrator met during the inspection and was involved in discussion of visit purpose |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
| Lizzette Tellez | Supervisor | Supervisor named on the report |
Inspection Report
Census: 86
Capacity: 113
Deficiencies: 1
Date: 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 observed and cited due to the facility not having current resident appraisals on file for 3 out of 86 residents, which poses a health and safety risk. The administrator acknowledged the oversight and plans to complete the reappraisals and submit proof of correction.
Deficiencies (1)
Failure to ensure resident appraisals were on file for 3 out of 86 residents, violating reappraisal requirements.
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 acknowledged oversight regarding resident appraisals. |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced Case Management - Legal/Non-Compliance visit and authored the report. |
| Lizzette Tellez | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Census: 85
Capacity: 113
Deficiencies: 0
Date: 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
Census: 85
Capacity: 113
Deficiencies: 0
Date: 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 Resident #2 falling and sustaining an injury.
Findings
No deficiencies were cited at this time in the areas evaluated during the inspection. The Licensing Program Analyst toured the facility, requested records, and interviewed staff and residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
| Andrea Zamorano | Manager Assistant | Met with Licensing Program Analyst during the visit and discussed the purpose of the visit. |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 113
Deficiencies: 2
Date: 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.
Complaint Details
The complaint investigation was substantiated based on observations and interviews confirming the allegations regarding hot water temperature and malfunctioning shower knobs.
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.
Deficiencies (2)
Faucets used by residents did not maintain hot water temperature between 105 and 120 degrees F, with temperatures rising up to 128 degrees F.
Bathroom shower faucets were not maintained in operating condition, with faulty knobs that did not adjust water flow properly.
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
Complaint Investigation
Census: 84
Capacity: 113
Deficiencies: 2
Date: Sep 9, 2022
Visit Reason
An unannounced complaint investigation was conducted due to allegations that facility showers did not maintain hot water temperature and bathing facilities were not maintained in operating condition.
Complaint Details
The complaint was substantiated. The allegations included failure to maintain hot water temperature and bathing facilities not being maintained in operating condition. The investigation confirmed these issues during the unannounced visit.
Findings
The investigation found that the hot water temperature in the shower of Room 41 was inconsistent, rising above the regulated 105-120 degrees F range, reaching up to 128 degrees F, posing a safety risk. Additionally, the shower knobs in Room 41 were faulty and did not operate correctly, preventing proper water flow control and shutoff.
Deficiencies (2)
Faucets used by residents did not maintain hot water temperature within the regulated range of 105-120 degrees F.
Bathroom shower faucets were not maintained in operating condition, with faulty knobs that did not adjust water flow properly.
Report Facts
Residents affected: 1
Plan of Correction Due Date: 7
Plan of Correction Due Date: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Discussed allegations and findings with Licensing Program Analyst; acknowledged receipt of report and licensing rights. |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced complaint investigation and documented findings. |
| Lizzette Tellez | Supervisor | Supervisor overseeing the complaint investigation. |
Inspection Report
Census: 86
Capacity: 113
Deficiencies: 0
Date: 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
Census: 86
Capacity: 113
Deficiencies: 0
Date: Jun 22, 2022
Visit Reason
An unannounced Case Management Visit was conducted to follow up on a self-reported incident involving a resident who was absent without leave from the facility.
Findings
The resident returned unharmed on their own the day after being reported absent. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management Visit. |
| Lizzette Tellez | Supervisor | Named as supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 113
Deficiencies: 0
Date: 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.
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.
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.
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
Date: 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.
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.
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.
Deficiencies (4)
Licensee did not telephone 911 to obtain medical treatment for Resident #1 after unwitnessed falls resulting in serious bodily injury (hip fracture).
Licensee did not assist Resident #1 with prescribed medications upon admission.
Licensee did not notify Resident #1's responsible party after multiple falls.
Staff did not provide assistance with Resident #1's fall risk needs identified in pre-admission appraisal, resulting in bruising due to falls.
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: 82
Capacity: 113
Deficiencies: 0
Date: 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 name-calling resulting in humiliation and that staff restricted a resident's right to associate with another resident.
Complaint Details
The complaint was unsubstantiated. Allegations included staff failing to protect a resident from humiliation due to name-calling and restricting a resident's right to associate with another. Evidence did not support these claims.
Findings
The investigation found insufficient evidence to support the allegations. The resident was not protected from name-calling by another resident who was intoxicated, but staff took appropriate actions. Staff did not prevent residents from associating with each other, as confirmed by interviews and facility records. The allegations were found to be unsubstantiated.
Report Facts
Capacity: 113
Census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Esther Miller | Licensing Program Analyst | Conducted the complaint investigation visit |
| Monica Cordoba | Manager Assistance | Facility representative who met with the investigator |
| Rocio Granda | Administrator | Facility administrator mentioned in the report |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 113
Deficiencies: 4
Date: 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.
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 investigation confirmed these issues through record reviews and interviews.
Findings
The investigation substantiated that the facility failed to obtain medical treatment for a resident after multiple falls, did not administer prescribed medications promptly, failed to notify the resident's responsible party about incidents, and did not implement fall prevention measures. The resident suffered a hip fracture requiring surgery, and the facility did not follow proper protocols including calling 911 or contacting the primary care physician.
Deficiencies (4)
Licensee did not telephone 911 to obtain medical treatment for Resident #1 after unwitnessed falls that resulted in serious bodily injury (hip fracture).
Licensee did not assist Resident #1 with prescribed medications upon admission to the facility.
Licensee did not notify Resident #1’s responsible party after multiple falls.
Staff did not provide assistance with Resident #1’s fall risk needs identified in pre-admission appraisal, resulting in bruising due to falls.
Report Facts
Civil penalty amount: 500
Resident census: 82
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 Evaluator | Conducted the complaint investigation and authored the report. |
| Denise Powell | Supervisor | Supervisor overseeing the complaint investigation. |
| Monica Cordoba | Manager Assistance | Facility representative met during the investigation and received report and appeal rights. |
| Maya S. Mnoyan | Administrator | Facility administrator mentioned in the report. |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 113
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
The licensee did not ensure one resident received their medications timely, resulting in missed doses over nine days.
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
Date: 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.
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.
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.
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
Date: 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.
Complaint Details
The visit was triggered by a complaint investigation. Deficiencies were substantiated related to resident #1's care and medical records.
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.
Deficiencies (2)
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.
Licensee did not ensure 1 out of 84 residents had a medical assessment within one year of admission; the assessment was outdated.
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
Complaint Investigation
Census: 84
Capacity: 113
Deficiencies: 0
Date: May 18, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that the facility was in disrepair, specifically concerning a resident's doorknob being broken and not locking.
Complaint Details
The complaint alleging the facility was in disrepair was investigated and found to be unfounded, meaning the allegation was false, could not have happened, and/or was without reasonable basis.
Findings
The investigation found that the doorknob was never broken and always worked. One resident had difficulty unlocking the door due to a medical condition. The facility replaced the doorknob within three days with a handle-style knob to accommodate the resident. The complaint was determined to be unfounded.
Report Facts
Complaint Control Number: 8
Complaint Control Number Full: 08-AS-20220308080259
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Rocio Granda | Administrator | Facility administrator interviewed during investigation |
| Lizzette Tellez | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 113
Deficiencies: 1
Date: May 18, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff did not ensure a resident's medication was refilled in a timely manner, that residents' room was not large enough to allow easy passage between beds, and that staff interfered with a resident's reasonable access to the telephone.
Complaint Details
The complaint investigation was substantiated regarding medication refill delays for Resident #1, who missed doses in February and March 2022 due to delayed medication pickups and miscommunication about refills. The allegations about room size and telephone access interference were unsubstantiated.
Findings
The investigation substantiated that one resident did not receive medications timely as prescribed, missing a total of nine days of medication doses, posing an immediate health and safety risk. The allegations regarding the residents' room size and staff interference with telephone access were found unsubstantiated due to inconsistent statements and lack of corroborating evidence.
Deficiencies (1)
The licensee did not ensure one (1) out of 84 residents received their medications timely, resulting in the resident missing medications for a total of 9 days.
Report Facts
Resident census: 84
Total capacity: 113
Medication doses missed: 9
Residents sharing bedroom: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Rocio Granda | Administrator | Facility administrator involved in interviews and exit interview |
| Lizzette Tellez | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 113
Deficiencies: 2
Date: 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.
Complaint Details
The visit was triggered by a complaint investigation concerning deficiencies in resident care and record keeping. The complaint was substantiated by findings of inadequate supervision and outdated medical assessments.
Findings
Deficiencies were found related to one resident whose medical assessment was not current within one year of admission and who was allowed to leave the facility unassisted despite physician restrictions, posing health and safety risks.
Deficiencies (2)
Failure to provide basic services and supervision by allowing a resident to leave the facility unassisted contrary to physician's report.
Failure to obtain a current medical assessment within one year of admission for a resident.
Report Facts
Residents present: 84
Total licensed capacity: 113
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rocio Granda | Administrator | Named in relation to findings about resident supervision and medical assessment compliance |
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection and issued deficiencies |
| Lizzette Tellez | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Census: 83
Capacity: 113
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failure to complete a Resident Appraisal for 1 out of 83 residents, last appraisal dated 11/29/2018.
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
Complaint Investigation
Census: 83
Capacity: 113
Deficiencies: 1
Date: Apr 29, 2022
Visit Reason
The visit was conducted as a Case Management - Incident follow-up to an incident report involving a resident who left the facility and was hospitalized. The purpose was to review the incident and related records.
Complaint Details
The visit was complaint-related, following a self-reported incident where Resident #1 left the facility and was hospitalized. The complaint was substantiated by the finding of a missing current Resident Appraisal.
Findings
The facility failed to have a current Resident Appraisal on file for one resident, which posed a potential health and safety risk. A deficiency was cited related to this failure.
Deficiencies (1)
Failure to complete a Resident Appraisal for 1 out of 83 residents, not meeting the requirement for annual or condition-change appraisals.
Report Facts
Residents present: 83
Total licensed capacity: 113
Deficiencies cited: 1
Plan of Correction due date: May 27, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yahaira Garduno | Medication Technician Supervisor | Met during visit and received report and licensee rights |
| Rocio Granda | Administrator | Contacted by telephone regarding incident and agreed to complete resident appraisal |
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection visit |
| Lizzette Tellez | Supervisor | Supervisor named in report |
Inspection Report
Annual Inspection
Census: 78
Capacity: 113
Deficiencies: 0
Date: 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
Annual Inspection
Census: 78
Capacity: 113
Deficiencies: 0
Date: Mar 16, 2022
Visit Reason
Licensing Program Analyst Natasha Persaud conducted 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. The visit also included evaluation of the facility's mitigation plan and was conducted in conjunction with a Legal/Non-compliance visit.
Findings
No deficiencies were observed during the visit. The Licensing Program Analyst interviewed the Administrator, conducted a walk-through of the facility, and discussed compliance with various regulations. An exit interview was conducted and relevant documents were provided to the Administrator.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced annual required licensing inspection |
| Rocio Granda | Administrator | Met with Licensing Program Analyst during inspection |
| John Rante | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Census: 78
Capacity: 113
Deficiencies: 0
Date: 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: 78
Capacity: 113
Deficiencies: 0
Date: Jan 19, 2022
Visit Reason
The Department conducted an on-site technical assistance visit 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, concluding with a debriefing.
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 walkthrough. |
| Rocio Granda | Administrator | Facility administrator who received report and licensee rights via electronic mail. |
Inspection Report
Census: 81
Capacity: 113
Deficiencies: 0
Date: 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
Census: 81
Capacity: 113
Deficiencies: 0
Date: 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 the Licensee and regional licensing staff to address facility concerns.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Participated in the meeting with the Licensee to discuss facility concerns. |
| Denise Powell | Licensing Program Manager | Participated in the meeting with the Licensee to discuss facility concerns. |
| John Rante | Supervisor | Supervisor overseeing the licensing evaluation. |
| Dan Salceda | Licensee met with licensing staff during the visit. | |
| Rocio Granda | Administrator | Facility Administrator present during the meeting. |
| Perla Barragan | Care Coordinator | Participated in the meeting with the Licensee and licensing staff. |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 113
Deficiencies: 0
Date: 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.
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.
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.
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: 82
Capacity: 113
Deficiencies: 0
Date: Sep 24, 2021
Visit Reason
The visit was an unannounced Case Management - Incident inspection triggered by a self-reported incident involving alleged abuse of multiple memory care residents by a staff member.
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.
Findings
During the visit, the Licensing Program Analyst toured the facility, requested records, and interviewed staff and residents. No deficiencies were issued at this time.
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 | Supervisor | Named as supervisor in the report. |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 113
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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.
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 |
Viewing
Loading inspection reports...
