Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not confirmed. However, the facility has had recurring issues with timely staff response to call lights, medication management errors, and maintenance or safety concerns such as unsecured areas and equipment disrepair. The most recent inspection on October 2, 2025, cited a minor deficiency for a dirty dining room floor, showing some ongoing challenges with cleanliness. Previous reports included more serious findings, such as immediate health and safety risks related to medication errors, resident injuries, and staffing shortages, but recent inspections suggest some improvement in these areas. Overall, while some isolated issues persist, the facility appears to be addressing many past deficiencies, though vigilance remains important.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
14.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
255% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
57% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Census: 60
Capacity: 105
Deficiencies: 1
Date: Oct 2, 2025
Visit Reason
An unannounced case management deficiencies inspection was conducted to address observations of the facility.
Findings
The inspection found that the dining room floor was dirty, sticky, and had observable grime and dirt, indicating it was not regularly cleaned. A Type B deficiency was cited for failure to maintain the facility clean, safe, sanitary, and in good repair.
Deficiencies (1)
Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. The floor was visibly dirty with accumulated dirt and grime posing a potential health, safety and personal rights risk to residents in care.
Report Facts
Capacity: 105
Census: 60
Plan of Correction Due Date: Oct 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and signed the report |
| Noel Wolf-Petersen | Licensing Program Analyst | Conducted the inspection |
| Arlene Moreno | Facility staff met during inspection | |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 60
Capacity: 105
Deficiencies: 0
Date: Aug 27, 2025
Visit Reason
The visit was a case management inspection to discuss the status of the appointment of a new administrator and to remind staff of regulatory requirements regarding administrator certification and notification.
Findings
The licensing program analyst met with the interim administrator to review the status of the new administrator's certification application, which was received and is in process of approval. The department outlined required documentation for approval of a new administrator.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arlene Moreno | Interim Administrator | Met with licensing program analyst to discuss appointment of new administrator. |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 105
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff hit and threatened a resident.
Complaint Details
The complaint involved allegations of staff hitting and threatening a resident. The allegations were unsubstantiated based on interviews and lack of evidence.
Findings
The investigation found no corroboration of the allegations after interviews with the resident, their authorized representative, staff, and other residents. The allegations were determined to be unsubstantiated and no deficiencies were cited.
Report Facts
Capacity: 105
Census: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Latrice Ross | Administrator | Facility administrator met during the investigation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 55
Capacity: 105
Deficiencies: 2
Date: May 15, 2025
Visit Reason
The inspection was conducted as a required 1 year annual inspection to evaluate the facility's compliance with health and safety regulations.
Findings
The facility was generally clean, odor-free, and in good repair with proper furniture and lighting. However, three outdoor maintenance storage areas were unsecured, and staff files lacked verification of required annual training including dementia care training.
Deficiencies (2)
Three outdoor maintenance storage areas were left unsecured with items that should be inaccessible to residents.
Unable to verify annual training completion for all staff members, including 20 hours of training with 8 hours of dementia care training.
Report Facts
Water temperature: 117
Staff files reviewed: 6
Plan of Correction Due Date: May 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Arlene Moreno | Facility staff member who met with the Licensing Program Analyst during the inspection. | |
| Latrice Ross | Administrator | Facility administrator named in the report header. |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 105
Deficiencies: 0
Date: Apr 24, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff did not administer a resident's medication resulting in death.
Complaint Details
The allegation of questionable death due to medication non-administration was unsubstantiated based on interviews, police report, and investigation findings.
Findings
The investigation found insufficient evidence to corroborate the allegation. The resident was determined to have died of natural causes, and no deficiencies were cited.
Report Facts
Capacity: 105
Census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Latrice Ross | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 105
Deficiencies: 0
Date: Mar 28, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff did not ensure an adequate temperature was maintained in the facility for residents in care.
Complaint Details
The complaint was unsubstantiated based on interviews and observations. Although some residents felt the temperature was too cold, the evidence did not support the allegation. No deficiencies were cited per California Code of Regulations, TITLE 22.
Findings
The investigation found that the facility maintained temperatures above the minimum requirement of 68 degrees F, with hallways and dining rooms set at 73 degrees F. Interviews with residents were mixed, but overall the allegation was unsubstantiated and no deficiencies were cited.
Report Facts
Capacity: 105
Census: 56
Temperature: 73
Minimum temperature requirement: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Latrice Ross | Administrator | Facility administrator met with Licensing Program Analyst during inspection |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 105
Deficiencies: 0
Date: Mar 14, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations regarding physical plant issues including disrepair of facility doors, heater malfunction, inappropriate removal of garbage bins, and restricted access to the smoking area.
Complaint Details
The complaint was unsubstantiated based on interviews and observations. The department determined there was insufficient evidence to prove the alleged violations occurred.
Findings
The investigation found no substantiation for the allegations. The door to the smoking area had a malfunctioning electronic assist device in the process of being replaced, the heater was functioning properly, and no evidence was found of improper garbage removal. No deficiencies were cited.
Report Facts
Capacity: 105
Census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation |
| Cynthia Tamayo | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Latrice Ross | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Follow-Up
Census: 47
Capacity: 105
Deficiencies: 0
Date: Feb 28, 2025
Visit Reason
An unannounced plan of correction (POC) inspection was conducted to ensure previously cited deficiencies have been corrected as agreed upon by the department and facility representatives.
Findings
All previously cited deficiencies were corrected and the facility was found to be in compliance with title 22 regulations. No deficiencies were observed or cited during this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the unannounced POC inspection |
| Latrice Ross | Administrator | Facility representative met during inspection |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 105
Deficiencies: 0
Date: Jan 31, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 2024-06-24 regarding lack of supervision, disrespect of residents' personal rights, and failure of overnight staff to perform required checks and services.
Complaint Details
The complaint included allegations of lack of supervision resulting in residents disturbing others, residents' personal rights not being respected, and overnight staff not performing required checks and services. The investigation found no preponderance of evidence to substantiate these allegations.
Findings
Based on interviews with staff and residents, the allegations were found to be unsubstantiated. No deficiencies were cited under California Code of Regulations, TITLE 22. The facility demonstrated ongoing efforts to manage resident supervision and care.
Report Facts
Complaint Control Number: 27-AS-20240624165720
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Debra Duval | Administrator | Facility administrator named in report header |
| Latrice Ross | Licensee met with during investigation | |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 105
Deficiencies: 1
Date: Jan 31, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations received on 2024-08-20 regarding resident bathing and staff response to call lights.
Complaint Details
The complaint investigation was triggered by allegations that a resident was not bathed per service agreement and that staff were not responding to call lights in a timely manner. The bathing allegation was unsubstantiated, while the call light response allegation was substantiated.
Findings
The investigation found one allegation unsubstantiated regarding resident bathing per service agreement, and one allegation substantiated regarding staff delays in responding to call lights. The substantiated allegation resulted in a cited deficiency related to failure to provide timely assistance to residents.
Deficiencies (1)
Incidental Medical and Dental Care: The licensee failed to arrange or assist in arranging medical and dental care appropriate to residents' needs, evidenced by delays in staff response to calls for assistance.
Report Facts
Capacity: 105
Census: 53
Deficiency count: 1
Plan of Correction Due Date: Feb 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw the complaint investigation |
| Latrice Ross | Licensee met with during investigation | |
| Debra Duval | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 105
Deficiencies: 4
Date: Oct 17, 2024
Visit Reason
An unannounced complaint investigation was conducted based on allegations received on 06/17/2024 regarding neglect/lack of supervision, physical plant hazards, staff qualifications, and air conditioner disrepair at Greenhaven Estates facility.
Complaint Details
The complaint investigation was substantiated for neglect/lack of supervision, physical plant hazards, and staff qualifications. The allegation regarding improper refund issuance was unfounded.
Findings
The investigation substantiated allegations that a resident was injured by tools used by vendors repairing a non-functional air conditioner in the resident's room, which had been out of service for 18 days. Staff training was insufficient, and the air conditioner repair was delayed. Another complaint regarding improper refund issuance was found to be unfounded.
Deficiencies (4)
Maintenance and Operation: Facility was not clean, safe, sanitary and in good repair; resident sustained injury due to accessible vendor tools.
Basic Services: Resident sustained injury due to being allowed access to a room where repairs were ongoing.
Personal Rights: AC unit was not working and repair was delayed, posing potential health, safety and personal rights risk.
Staff training: Insufficient training hours, including dementia care and first aid certification not reviewed.
Report Facts
Capacity: 105
Census: 47
Deficiencies cited: 4
Training hours observed: 2
Air conditioner non-operational days: 18
Days delay for contracted vendor contact: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw the complaint investigation report |
| Latrice Ross | Facility representative met with during inspection |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 105
Deficiencies: 1
Date: Aug 23, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that a resident did not have hot water in their unit.
Complaint Details
The complaint was substantiated based on the preponderance of evidence obtained during the investigation regarding the physical plant issue of inadequate hot water temperature.
Findings
The investigation substantiated the complaint, finding that hot water temperatures throughout the facility were below Title 22 regulations, posing a potential health, safety, and personal rights risk to residents.
Deficiencies (1)
Maintenance and Operation: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not met as evidenced by LPA testing hot water temperatures throughout the facility and no residential area recorded a hot water temperature to meet Title 22 regulations.
Report Facts
Hot water temperature: 97
Hot water temperature: 96.6
Hot water temperature: 98.6
Hot water temperature: 95
Deficiency Plan of Correction due date: Aug 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Alex Noel | Facility staff met during inspection | |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 105
Deficiencies: 2
Date: Jul 17, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations of neglect/lack of supervision due to staff not responding to resident pendant calls and physical plant issues related to the facility elevator being in disrepair.
Complaint Details
The complaint investigation was substantiated based on interviews with staff, residents, and a family member, confirming delays in call response times and elevator disrepair issues.
Findings
The investigation substantiated the allegations that staff delays in responding to call pendants resulted in residents waiting for care, sometimes soiling themselves, and that the elevator was shut down in March 2024 due to delayed repairs of the elevator phone system. Deficiencies were cited related to medical and dental care and maintenance and operation of the facility.
Deficiencies (2)
Incidental Medical and Dental Care: The licensee failed to ensure timely response to calls for assistance, resulting in residents' needs not being met promptly.
Maintenance and Operation: The facility failed to maintain the elevator in good repair, resulting in its shutdown due to delayed repairs.
Report Facts
Facility Capacity: 105
Census: 53
Plan of Correction Due Date: Jul 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Debra Duval | Facility representative met during investigation | |
| Benji Doctolero | Administrator | Facility administrator named in report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 105
Deficiencies: 3
Date: Jul 17, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations of neglect and lack of supervision, specifically regarding unmet incontinence needs, delayed response to call buttons, and insufficient staffing to meet resident needs.
Complaint Details
The complaint investigation was substantiated. Allegations included neglect and lack of supervision, specifically unmet incontinence needs, delayed call button responses, and insufficient staffing. Interviews with five staff members, four residents, and a family member supported these findings.
Findings
The investigation substantiated the allegations based on interviews with staff, residents, and a family member, confirming delays in call response times, residents soiling themselves while waiting for assistance, and insufficient staffing levels to meet resident needs. Deficiencies were cited related to medical and dental care arrangements and personnel requirements.
Deficiencies (3)
Incidental Medical and Dental Care: The licensee failed to arrange or assist in arranging medical and dental care appropriate to residents' conditions and needs, evidenced by statements from staff, residents, and family.
Personnel Requirements - General: Facility personnel were insufficient in number and competence to meet resident needs, including responding timely to call lights, posing immediate health, safety, or personal rights risks.
Incidental Medical and Dental Care: Facility staff failed to meet residents' incontinence needs, with residents routinely wet and soiled during overnight shifts when agency staff were used, corroborated by family member statements.
Report Facts
Capacity: 105
Census: 53
Staffing: 6
Deficiency count: 3
Plan of Correction Due Dates: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Debra Duval | Administrator | Met with Licensing Program Analyst during the investigation |
| Benji Doctolero | Administrator | Named as facility administrator in the report header |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 105
Deficiencies: 0
Date: Jul 17, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff did not ensure residents' dietary needs were met.
Complaint Details
The complaint was unsubstantiated based on the investigation. There were no deficiencies cited per California Code of Regulations, TITLE 22.
Findings
The investigation was unable to corroborate the allegations. Interviews and file reviews indicated that the alleged resident was independent in eating and no specific service plans related to diet and eating were found. The complaint was determined to be unsubstantiated.
Report Facts
Capacity: 105
Census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and met with facility administrator |
| Benji Doctolero | Administrator | Facility administrator at time of investigation |
| Debra Duval | Met with Licensing Program Analyst to discuss investigation details | |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Plan of Correction
Census: 57
Capacity: 105
Deficiencies: 1
Date: Jun 20, 2024
Visit Reason
An unannounced Plan of Correction (POC) inspection was conducted to ensure that past deficiencies cited have been corrected.
Findings
The inspection found that while most issues such as light fixtures were corrected, the kitchen storage closet door remained unlocked with sharp knives accessible to residents, posing an immediate health and safety risk. Due to this being the second violation within 12 months, an immediate civil penalty was issued.
Deficiencies (1)
Kitchen storage was not locked, containing multiple drawers of sharp knives accessible to residents, posing an immediate health, safety, or personal rights risk.
Report Facts
Capacity: 105
Census: 57
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Debra Duval | Administrator | Facility administrator met during inspection |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager and Supervisor |
Inspection Report
Annual Inspection
Census: 57
Capacity: 105
Deficiencies: 0
Date: Jun 20, 2024
Visit Reason
The inspection was conducted as a continuation of the required one-year annual inspection begun on 2024-05-24.
Findings
No deficiencies were cited during the inspection. Most resident files were complete except one requiring an updated LIC 602 form which was over a year old and needed renewal.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and file review. |
| Debra Duval | Administrator | Met with Licensing Program Analyst during the inspection and facility tour. |
Inspection Report
Annual Inspection
Census: 62
Capacity: 105
Deficiencies: 9
Date: May 24, 2024
Visit Reason
The inspection was conducted as a required 1 year annual inspection to evaluate the facility's compliance with health and safety regulations.
Findings
The facility was generally clean and in good repair, but several deficiencies were noted including unsecured cleaning supplies and sharp objects accessible to residents, missing health screenings and certifications in staff files, improper glove disposal, non-slip mats missing in memory care showers, and several lights out in common areas.
Deficiencies (9)
Cleaning supplies and sharp objects accessible to residents in activity room, laundry room, and kitchen storage area.
Kitchen storage not locked containing multiple drawers of sharp knives accessible to residents.
Five out of six staff files lacked required CPR and first aid training certificates.
Several gloves disposed of improperly in common area drawers and furniture.
Several common area hallway lights were out and not working as designed.
Two out of four memory care showers lacked non-slip mats or strips on floors.
Staff files not fully accessible to licensing program analyst for review.
Four out of six staff files lacked required health screenings and TB tests.
No documentation of hands-on training for staff as required for dementia care and other training.
Report Facts
Staff files reviewed: 6
Staff files non-compliant: 5
Staff files non-compliant: 4
Memory care showers without non-slip mats: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debra Duval | Administrator | Met with Licensing Program Analyst during inspection and involved in facility evaluation |
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Supervisor of the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 105
Deficiencies: 1
Date: Apr 11, 2024
Visit Reason
The inspection was conducted on 04/11/2024 during an unrelated complaint investigation to assess compliance with food service temperature regulations.
Complaint Details
The visit was conducted while investigating an unrelated complaint. Specific substantiation status is not stated.
Findings
The licensing program analyst observed refrigerator temperatures and logs showing temperatures exceeding the maximum allowed 40 degrees Fahrenheit, with some readings as high as 45 degrees, posing a potential health, safety, and personal rights risk to residents.
Deficiencies (1)
Refrigerators were observed with temperatures recorded over 40 degrees F on several dates, some as high as 45 degrees, violating Title 22 regulations.
Report Facts
Deficiency Plan of Correction Due Date: Apr 15, 2024
Facility Capacity: 105
Census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and observed deficiencies |
| Czarrina A Camilon-Lee | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Census: 61
Capacity: 105
Deficiencies: 0
Date: Mar 8, 2024
Visit Reason
An unannounced case management inspection was conducted to gather additional information regarding control of property and change of administrator.
Findings
The Licensing Program Analyst met with the executive director and confirmed the submission of requested documents to confirm the appointment of a new administrator. An exit interview was conducted and a copy of the report was left at the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Del Dosso | Executive Director | Met with Licensing Program Analyst during inspection to discuss recent changes and confirm appointment of new administrator. |
| Kevin Gould | Licensing Program Analyst | Conducted the unannounced case management inspection. |
Inspection Report
Census: 52
Capacity: 105
Deficiencies: 0
Date: Feb 8, 2024
Visit Reason
An unannounced case management inspection was conducted to gather additional information regarding control of property and facility name change.
Findings
The Licensing Program Analyst met with the executive director to discuss recent changes at the facility, transition to a new management group, and provided required documents for a name change. Plans were made to submit control of property information and name change request documents to the department by 2/16/24.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Del Dosso | Executive Director | Met with Licensing Program Analyst during inspection and discussed facility changes and name change process. |
| Kevin Gould | Licensing Program Analyst | Conducted the unannounced case management inspection. |
Inspection Report
Census: 53
Capacity: 105
Deficiencies: 1
Date: Jan 5, 2024
Visit Reason
An unannounced case management visit was conducted to address concerns regarding facility change of ownership and to ensure the health and safety of residents in care.
Findings
The visit found that the facility had changed its business signage and a new management company was added to the license without notification to the Department. Deficiencies were cited related to failure to notify the department of the sale of the property and loss of control of the property, posing immediate health, safety, and personal rights risks to residents.
Deficiencies (1)
Sale of licensed facility; resulting issuance of new license; procedure: Except as provided in subdivision (e), the property and business shall not be transferred until the buyer qualifies for a license or provisional license within the appropriate provisions of this chapter. This requirement was not met as evidenced by the Licensee not notifying the department of the sale of the property and no longer having control of the property which poses an immediate health, safety and personal rights risk to residents in care.
Report Facts
Capacity: 105
Census: 53
Plan of Correction Due Date: Jan 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tung Truong | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Alexandria Noel | Business Director | Met with Licensing Program Analyst during the visit and discussed transfer of property requirements |
| Peggy Oneil | Regional Director of Operation | Spoke with Licensing Program Analyst regarding purchase of property from foreclosure sale |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 105
Deficiencies: 0
Date: Dec 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate an allegation that facility staff did not ensure that residents are provided care in a timely manner.
Complaint Details
The complaint was that facility staff did not ensure timely care for residents. The allegation was found to be unfounded, meaning it was false or without reasonable basis, and the complaint was dismissed.
Findings
The investigation found that although there were staff call outs, additional staff were available to assist with resident care needs. Based on interviews and observation, the allegation was deemed unfounded and no deficiencies were observed or cited.
Report Facts
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager in the report |
| Benji Doctolero | Administrator | Facility administrator mentioned in relation to the investigation |
| Alexanderia Noel | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 105
Deficiencies: 2
Date: Dec 14, 2023
Visit Reason
This is a case management visit regarding an incident report received at Community Care Licensing involving Resident #1 who was missing from the facility for approximately 2 hours without staff knowledge.
Complaint Details
The visit was triggered by a complaint incident report regarding Resident #1 being returned by police after being missing from the facility for approximately 2 hours. The preponderance of evidence standard was met.
Findings
The investigation revealed that Resident #1 was AWOL from the facility for about 2 hours due to the exit door alarm being turned off during maintenance, posing an immediate health and safety risk to residents. Staff failed to ensure the facility was secure and safe.
Deficiencies (2)
Care of Persons with Dementia: Facility staff failed to ensure the continued safety of residents if they wander away from the facility; Resident #1 was AWOL for approximately 2 hours.
Care of Persons with Dementia: The licensee failed to have an auditory device or other staff alert feature to monitor exits, as alarms were not working during the time Resident #1 eloped.
Report Facts
Plan of Correction Due Date: Dec 15, 2023
Plan of Correction In-Service Due Date: Dec 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the inspection and investigation |
| Stephen Richardson | Licensing Program Manager | Supervised the inspection |
| Adriana Vue | Interim Assisted Living Director (LVN) | Facility staff met during the inspection |
Inspection Report
Census: 49
Capacity: 105
Deficiencies: 1
Date: Dec 14, 2023
Visit Reason
The visit was an unannounced case management inspection focused on deficiencies, including a review of administrator changes and compliance with licensing requirements.
Findings
The inspection found that the facility lacked a qualified and currently certified administrator or a designated substitute on file with the Community Care Licensing, posing an immediate health and safety risk to residents.
Deficiencies (1)
Administrator - Qualifications and Duties: The facility did not have a qualified and currently certified administrator on premises or a designated substitute accountable for management and administration.
Report Facts
Capacity: 105
Census: 49
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the inspection and signed the report |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection |
| Benji Doctolero | Administrator | Previous Administrator no longer working at the facility |
| Adriana Vue | Interim Assisted Living Director (LVN) | Met with Licensing Program Analyst during the visit |
| Bradley Boyer | Executive Chef/Culinary Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 105
Deficiencies: 0
Date: Dec 14, 2023
Visit Reason
The inspection was conducted to investigate complaints alleging staff stealing a resident's money, staff being rough with a resident, and staff neglect resulting in a resident fall.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Victoria Brown. Interviews with staff, residents, and review of documentation led to the conclusion that the allegations were unfounded and the complaint was dismissed.
Findings
The investigation found no preponderance of evidence to support the allegations. The complaint was deemed unfounded, meaning the allegations were false or without reasonable basis, and no deficiencies were cited.
Report Facts
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Benji Doctolero | Administrator | Previous Administrator interviewed during investigation |
| Adriana Vue | Interim Assisted Living Director (LVN) | Met with during the investigation |
| Stephen Richardson | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 105
Deficiencies: 1
Date: Nov 3, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations including night shift staff sleeping, staff handling residents roughly causing bruising, inappropriate use of children to care for residents, maintenance of expired medications, medication accessibility to residents, and questionable death.
Complaint Details
The complaint investigation was substantiated for the allegation of night shift staff sleeping, meaning the allegation was valid based on the preponderance of evidence. Other allegations were unsubstantiated or unfounded. The substantiated allegation required a plan of correction with an estimated completion of 90 days.
Findings
The allegation of night shift staff sleeping was substantiated based on a photo and interviews, posing an immediate health and safety risk. Other allegations including rough handling causing bruising, use of children to care for residents, maintenance of expired medications, and medication accessibility were unsubstantiated due to lack of preponderance of evidence. The allegation of questionable death was unfounded as it was investigated under a different complaint and dismissed.
Deficiencies (1)
Observation of the Resident: The licensee shall ensure that residents are regularly observed. This requirement was not met as staff were confirmed sleeping during their shift, posing an immediate health and safety risk.
Report Facts
Capacity: 105
Census: 55
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation |
| Alexandria Noel | Business Office Manager/Administrator | Met with Licensing Program Analyst during the investigation |
| Kayla Davis | Administrator | Facility administrator named in the report |
| Benji Doctolero | Administrator | Identified staff member sleeping in photo related to substantiated allegation |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 105
Deficiencies: 0
Date: Oct 6, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2023-06-29 alleging that staff did not seek timely medical attention for a resident.
Complaint Details
The complaint alleged that staff did not seek timely medical attention for a resident. After investigation, the allegation was found to be unfounded, meaning it was false or without reasonable basis.
Findings
The investigation found that the resident was sent to the hospital twice for swallowing and breathing issues, with staff providing appropriate care and assistance. The allegation was deemed unfounded with no violations cited during the visit.
Report Facts
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Stephen Richardson | Licensing Program Manager | Named in report as Licensing Program Manager |
| Benji Doctolero | Administrator | Met with Licensing Program Analyst during investigation |
| Kayla Davis | Administrator | Previous Administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 105
Deficiencies: 2
Date: Sep 8, 2023
Visit Reason
The visit was conducted to obtain information regarding an Incident Report about a medication error involving a resident receiving a double dose of medication.
Complaint Details
The visit was complaint-related due to a medication error incident report. The preponderance of evidence standard was met confirming the medication error and lack of medical attention.
Findings
The investigation confirmed that a medication error occurred where a resident received a double dose in the morning and was not provided medical attention despite reporting feeling unwell. Staff involved were interviewed, and corrective actions including termination and in-service training were taken.
Deficiencies (2)
Medication was not administered as prescribed to resident #1, confirmed by documentation and interviews.
Resident #1 advised staff of feeling overmedicated but did not receive medical attention after the medication error.
Report Facts
Census: 52
Total Capacity: 105
Medication doses given: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the investigation and inspection |
| Benji Doctolero | Administrator | Facility administrator notified of the medication error |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 51
Capacity: 105
Deficiencies: 0
Date: Sep 7, 2023
Visit Reason
The visit was an unannounced Case Management visit conducted by Licensing Program Analyst Victoria Brown to address the immediate exclusion order for staff member S1.
Findings
No deficiencies were observed or cited during the visit. The facility was informed and agreed that staff member S1 is immediately excluded from employment or presence on the premises.
Report Facts
Capacity: 105
Census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Benji Doctolero | Administrator | Met with Licensing Program Analyst during the visit and discussed staff exclusion |
| Victoria Brown | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Stephen Richardson | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 105
Deficiencies: 0
Date: Sep 7, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff do not respond to residents’ call buttons in a timely manner.
Complaint Details
The complaint was related to staff response time to call buttons. Interviews and observations revealed residents were unhappy about staff layoffs but there was no care or supervision issue. The allegation was deemed unfounded.
Findings
The investigation found that the allegation was unfounded, meaning it was false or without reasonable basis. No deficiencies were observed or cited during the visit.
Report Facts
Estimated Days of Completion: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Benji Doctolero | Administrator | Facility administrator interviewed during investigation |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 45
Capacity: 105
Deficiencies: 1
Date: Aug 9, 2023
Visit Reason
The visit was conducted to ensure there is an Administrator on file with the Department following the departure of the previous Administrator and to review related documentation.
Findings
The Licensing Program Analyst found that required documentation for the designee and new Administrator was incomplete, unsigned, and not submitted in a timely manner. The facility roster was not updated to reflect the current Administrator. A deficiency was cited related to Administrator qualifications and duties.
Deficiencies (1)
Administrator - Qualifications and Duties: The facility did not have a qualified and currently certified Administrator on file, and required documentation was not submitted timely, posing a potential health and safety risk to residents.
Report Facts
Deficiency count: 1
Plan of Correction Due Date: Aug 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Benji Doctolero | Administrator | Current Administrator present during visit |
| Kayla Davis | Administrator | Previous Administrator listed on staff roster |
| Jessica Del Aguila | Licensee representative unaware that documents had not been submitted | |
| Victoria Brown | Licensing Program Analyst | Conducted the inspection visit |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 105
Deficiencies: 1
Date: Aug 9, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff did not provide a refund to the responsible party.
Complaint Details
The complaint was substantiated. The allegation was that staff did not provide a refund to the responsible party. The refund amount was $6,760.13 and had not been issued at the time of the investigation but was to be sent via certified mail.
Findings
The investigation found that a refund of $6,760.13 was owed due to a mistake on a ledger and had not yet been issued but would be sent out from the corporate office. The allegation was substantiated based on evidence and admissions from facility representatives.
Deficiencies (1)
Failure to issue refund within 15 days after resident's belongings were removed, violating termination of admission agreement requirements.
Report Facts
Refund amount: 6760.13
Estimated days of completion: 30
Census: 45
Total capacity: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation |
| Jessica Del Aguila | Regional Vice President, Senior Living Tarantino Properties, Inc. | Interviewed during investigation; provided information about refund and ledger mistake |
| Bridget Botez | Business Office Manager | Previous staff who mentioned the refund amount to the family |
| Benji Doctolero | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Census: 46
Capacity: 105
Deficiencies: 0
Date: Jul 17, 2023
Visit Reason
The visit was an unannounced case management follow-up to review two incident reports involving missing money and missing credit cards reported in October 2022.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst reviewed the facility's theft and loss procedures and requested copies of police reports related to the incidents.
Report Facts
Missing money amount: 135
Incident date: Oct 20, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the case management visit and reviewed incident reports |
| Alexandria Rodriguez | Regional Nurse | Met with Licensing Program Analyst during the visit |
| Kayla Davis | Administrator | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 105
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations received on 2023-02-16 regarding resident care, safety, staffing, and facility conditions at Greenhaven Estates.
Complaint Details
The complaint included multiple allegations such as failure to follow resident's prescribed diet, mold in resident rooms, inadequate staffing, lack of training for resident transfers, delayed response to call pendents, failure to ensure resident safety resulting in injuries, failure to notify POA of hospitalization, false statements, unsafe resident rooms with tripping hazards, electrical issues, failure to report incidents to CCL, unexplained rent increases, failure to notify POA and resident of probationary license, and failure to provide fire drill instructions. All allegations were found to be unfounded.
Findings
The complaint was found to be unfounded after investigation, with no deficiencies observed. The allegations were determined to be false or without reasonable basis, and the complaint was dismissed.
Report Facts
Capacity: 105
Census: 49
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation and delivered the unfounded finding |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Kayla Davis | Administrator | Facility administrator met during the investigation |
Inspection Report
Census: 51
Capacity: 105
Deficiencies: 1
Date: Jun 28, 2023
Visit Reason
The visit was an unannounced case management follow-up to an incident report regarding a resident finding a thumb tack in a bowl of fruit.
Findings
The facility was cited for a violation of food service requirements after a resident was served food that was not safe for consumption, posing an immediate health and safety risk. The investigation found thumb tacks used in the kitchen area where food was served.
Deficiencies (1)
General Food Service Requirements: The total daily diet shall be of the quality and quantity necessary to meet residents' needs and be served in a safe and healthful manner. This requirement was not met as a resident was served food that was not safe for consumption, posing an immediate health and safety risk.
Report Facts
Capacity: 105
Census: 51
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Davis | Administrator | Met with Licensing Program Analyst during the visit and involved in incident investigation |
| Vincent Moleski | Licensing Program Analyst | Conducted the case management visit and inspection |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 51
Capacity: 105
Deficiencies: 0
Date: Jun 8, 2023
Visit Reason
The inspection was an unannounced Required - 1 Year visit to evaluate the facility's compliance with licensing regulations.
Findings
No deficiencies were observed or cited during the inspection. The facility met all regulatory requirements including safety, medication storage, and environmental conditions.
Report Facts
Licensed capacity: 105
Current census: 51
Hospice waiver capacity: 12
Hospice residents: 4
Temperature inside facility: 77
Hot water temperature: 112.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Davis | Administrator | Met with Licensing Program Analyst during inspection and assisted with the visit |
| Victoria Brown | Licensing Program Analyst | Conducted the Required - 1 Year unannounced inspection |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 51
Capacity: 105
Deficiencies: 0
Date: Mar 8, 2023
Visit Reason
The visit was an unannounced Case Management visit to ensure that the care home is meeting the terms and conditions of its probationary license effective from 6/18/2020 to 6/18/2023.
Findings
No deficiencies were observed or cited during the visit. The facility was found to be in compliance with regulations including staff training, medication audits, safety inspections, and environmental conditions.
Report Facts
Hospice residents: 6
Bedridden residents allowed: 4
Hospice residents allowed: 12
Temperature inside facility: 74
Hot water temperature room 158: 114.8
Hot water temperature room 145: 113.5
Administrator certificate expiration date: Jan 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Davis | Administrator | Met with Licensing Program Analyst during the visit and named in the report |
| Victoria Brown | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 105
Deficiencies: 4
Date: Feb 24, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-01-30 regarding multiple allegations including incontinent needs not being met, call lights not being answered timely, staff disrespectfulness, and unmet medical needs.
Complaint Details
The complaint investigation was substantiated based on interviews with residents and staff, review of medical and service plans, and observation of facility practices. The preponderance of evidence standard was met for all allegations.
Findings
The investigation substantiated the allegations that incontinent care was delayed causing urinary accidents, call lights were not answered timely, staff were disrespectful to residents, and medical needs were not properly met due to lack of authorization for PRN treatments. The Administrator was aware and took action by terminating two staff members.
Deficiencies (4)
Failure to provide timely incontinence care resulting in urinary accidents.
Failure to respond timely to call lights despite them working.
Staff were disrespectful to residents during assistance with daily living activities.
Provision of PRN medication assistance without physician authorization.
Report Facts
Estimated Days of Completion: 90
Capacity: 105
Census: 51
Plan of Correction Due Date: Apr 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Davis | Administrator | Facility Administrator aware of incidents and involved in corrective actions |
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 105
Deficiencies: 2
Date: Nov 16, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-06-01 regarding a resident with an unknown wound on the back and the facility retaining a resident beyond their level of care.
Complaint Details
The complaint investigation was substantiated for two allegations: a resident had an unknown wound on the back that progressed to a stage 3 pressure injury, and the facility retained a resident beyond their level of care for approximately one month. The other allegations regarding admission of a resident outside the scope of care and feeding needs were unsubstantiated.
Findings
The investigation substantiated that a resident had a stage 3 pressure injury on the back that progressed while in the facility, and the facility retained the resident beyond their licensed level of care for about one month. Another allegation that the facility admitted a resident outside the scope of care and that a resident had to be fed all meals was found to be unsubstantiated.
Deficiencies (2)
Stage 3 and 4 pressure injuries were not prevented or properly managed, posing an immediate health and safety risk.
Failure to ensure residents receive care, supervision, and services that meet their individual needs, including retaining a resident beyond the facility's level of care.
Report Facts
Capacity: 105
Census: 52
Deficiencies cited: 2
Investigation dates: Jun 1, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Ivey-Canady | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation |
| Kayla Davis | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 105
Deficiencies: 1
Date: Nov 16, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-06-02 regarding allegations including a resident sustaining a pressure injury while in care.
Complaint Details
The complaint investigation was substantiated for the allegation that a resident sustained a pressure injury while in care. Other allegations including medication not administered as prescribed, staff forcing resident to get out of bed, diabetic care needs not met, and resident not being rotated and repositioned were unsubstantiated.
Findings
The investigation substantiated that residents R1, R5, and R6 sustained pressure injuries while in care, including a level 3 pressure injury for R1. Other allegations regarding medication administration, forced bed exit, diabetic care, and repositioning were found to be unsubstantiated based on interviews, observations, and medical record reviews.
Deficiencies (1)
Failure to ensure residents did not sustain stage 3 and 4 pressure injuries while in care, posing a health and safety risk.
Report Facts
Capacity: 105
Census: 52
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Ivey-Canady | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation |
| Kayla Davis | Facility representative met during the investigation |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 105
Deficiencies: 0
Date: Nov 7, 2022
Visit Reason
The visit was conducted to investigate an incident of theft involving two residents on 10/20/22, as reported in an Incident Report submitted to Community Care Licensing on 10/25/22.
Complaint Details
The complaint involved alleged theft of money from two residents. The allegation was not substantiated due to lack of evidence and failure to meet the preponderance of evidence standard.
Findings
The investigation found insufficient evidence to substantiate the theft allegations. Interviews with staff and residents' responsible parties revealed no unusual charges or confirmed missing money, and no violations were cited during the visit.
Report Facts
Facility capacity: 105
Resident census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Davis | Administrator | Conducted staff meeting regarding resident missing money and reported incident to LTCO and Law Enforcement |
| Victoria Brown | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
| Stephen Richardson | Licensing Program Manager | Named in report header |
| Bridget Botez | Business Office Manager | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 105
Deficiencies: 0
Date: Nov 4, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-08-17 regarding allegations that staff did not receive training on the memory care (MC) and assisted living (AL) units, and that residents did not receive food.
Complaint Details
The complaint investigation was unsubstantiated as there was no preponderance of evidence to prove the allegations that staff were not trained or residents did not receive food. Staff interviews, resident and family member statements indicated training and meal provision were adequate.
Findings
The investigation found that staff had received training on both the MC and AL units, and residents were provided food as meals were always offered either in the dining hall or in their rooms. Interviews with staff, residents, and a family member supported these findings. The allegations were determined to be unsubstantiated and no deficiencies were cited.
Report Facts
Capacity: 105
Census: 52
Staff interviews: 8
Resident interviews: 4
Family member interviews: 1
Annual training hours requirement: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Stephen Richardson | Licensing Program Manager | Named in report as Licensing Program Manager |
| Kayla Davis | Administrator | Facility administrator met during investigation and exit interview |
| Malissa Acuna | Previous Administrator | Provided information about staff training and facility operations |
Inspection Report
Census: 53
Capacity: 105
Deficiencies: 0
Date: Oct 6, 2022
Visit Reason
The visit was an unannounced Case Management visit focused on legal and non-compliance issues at the facility.
Findings
No deficiencies were observed or cited during the visit. The facility met all regulatory requirements including proper food storage, temperature controls, safety equipment, and medication storage.
Report Facts
Residents receiving hospice care: 9
Caregivers in Assisted Living: 5
Med techs in Assisted Living: 1
LVNs in Assisted Living: 1
Caregivers in Memory Care: 6
Med techs in Memory Care: 1
LVNs in Memory Care: 1
Facility temperature: 72
Hot water temperature: 112.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Malissa Acuna | Administrator | Met with Licensing Program Analyst during the visit |
| Victoria Brown | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 105
Deficiencies: 0
Date: Oct 6, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-09-12 alleging rough handling and yelling at a resident by staff.
Complaint Details
The complaint involved allegations that staff handled a resident in a rough manner and yelled at the resident. The resident initially reported being pushed and yelled at by staff but later recanted. The complaint was found to be unsubstantiated.
Findings
The investigation found no substantiation of the allegations due to lack of evidence and recantation by the resident. No personal rights violations or deficiencies were cited.
Report Facts
Estimated Days of Completion: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Malissa Acuna | Administrator | Facility administrator met during investigation |
| Stephen Richardson | Licensing Program Manager | Named in report header |
Inspection Report
Census: 54
Capacity: 105
Deficiencies: 1
Date: Aug 23, 2022
Visit Reason
The visit was an unannounced health and safety check conducted by the Licensing Program Analyst to evaluate the facility's compliance with cleanliness and safety regulations.
Findings
The inspection found that 4 out of 5 resident rooms were clean and free of debris; however, Resident 1's bathroom had black mold along the floor tiles, which posed a potential health and safety risk. The facility was cited for failing to maintain the bathroom in a clean, sanitary, and odorless condition.
Deficiencies (1)
Resident 1 bathroom was observed to have mold along the floor tiles, which poses a potential health and safety risk to residents in care.
Report Facts
Deficiency Type Count: 1
Census: 54
Total Capacity: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Malissa Acuna | Administrator / Executive Director | Met with Licensing Program Analyst during inspection and involved in exit interview |
| Christina Valerio | Licensing Program Analyst | Conducted the unannounced health and safety visit and authored the report |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 56
Capacity: 105
Deficiencies: 0
Date: Aug 10, 2022
Visit Reason
The visit was an unannounced Case Management - Legal/Non-compliance inspection conducted to evaluate the facility's compliance with regulations.
Findings
No deficiencies were observed or cited during the inspection. The facility met all regulatory requirements including proper food storage, adequate staffing, environmental conditions, and safety equipment.
Report Facts
Residents receiving hospice care: 7
Caregivers in Assisted Living: 4
Medication technicians in Assisted Living: 1
Caregivers in Memory Care: 6
Medication technicians in Memory Care: 1
Nurses on floor: 1
Facility temperature range (°F): 72
Facility temperature range (°F): 76
Hot water temperature (°F): 108.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Malissa Acuna | Administrator | Met with Licensing Program Analyst during the inspection and mentioned in the report |
| Victoria Brown | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Stephen Richardson | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 105
Deficiencies: 1
Date: Aug 10, 2022
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2022-08-05 regarding multiple allegations about resident supervision, staff treatment, documentation, notification, and confidentiality at Greenhaven Estates.
Complaint Details
The complaint investigation was substantiated for the allegation that a resident was not adequately supervised to prevent entering other residents' rooms. Other allegations were unsubstantiated or unfounded. The substantiated deficiency was cited under CCR 87468.2(a)(1) with a plan of correction due by 2022-09-09.
Findings
The investigation substantiated that a resident was not adequately supervised to prevent entering other residents' rooms, citing a deficiency related to residents' personal rights. Other allegations including staff disrespect, failure to document health changes, failure to notify authorized persons, and disclosure of confidential information were found unsubstantiated or unfounded.
Deficiencies (1)
Resident entering other residents rooms without consent, violating personal rights.
Report Facts
Capacity: 105
Census: 56
Estimated Days of Completion: 30
Plan of Correction Due Date: Sep 9, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation |
| Malissa Acuna | Administrator | Facility administrator met with the Licensing Program Analyst during the investigation |
Inspection Report
Annual Inspection
Census: 52
Capacity: 105
Deficiencies: 1
Date: Jun 17, 2022
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing regulations and facility standards.
Findings
The inspection found unlocked toxins in the memory care common area posing an immediate health and safety risk. Other areas such as physical plant, medication storage, food supplies, fire safety, and staff clearances were found compliant.
Deficiencies (1)
Unlocked toxins observed in the memory care common area accessible to residents, violating care of persons with dementia regulations.
Report Facts
Resident files reviewed: 25
Staff files reviewed: 10
Fire drill date: 5
Plan of Correction due date: Jun 18, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Malissa Acuna | Administrator | Facility administrator met during inspection |
| Stephenie Doub | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 43
Capacity: 105
Deficiencies: 0
Date: Apr 6, 2022
Visit Reason
The visit was an unannounced Case Management visit to ensure there is an Administrator in place as per Title 22 regulations and the Stipulation.
Findings
No deficiencies were cited during this visit. The Licensing Program Analyst was presented with all required documents to change the Administrator in the Community Care Licensing system.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the Case Management visit and stated the purpose of the visit. |
| Christina L. Garcia | Administrator | Met the Licensing Program Analyst upon arrival and was the current Administrator. |
| Malissa Ehrman Acuna | Administrator | Will be the Administrator on file with Community Care Licensing on 4/8/2022. |
| Stephen Richardson | Licensing Program Manager | Named in the report header. |
Inspection Report
Capacity: 105
Deficiencies: 0
Date: Mar 1, 2022
Visit Reason
The visit was an office touch-base conference call requested by the licensee to discuss and review procedures put in place to ensure the facility remains in substantial compliance following a prior Non-Compliance Conference.
Findings
No deficiencies were cited during this visit. The facility discussed updates on administrator change, technical support, medication training/errors, staffing, and reporting requirements. The facility committed to several actions to maintain compliance, and the Department will increase monitoring and re-evaluate compliance before any legal action.
Report Facts
Capacity: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Luna Garcia | Administrator of Record | Named as facility administrator present during the meeting |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager overseeing the visit |
| Jamie Ivey-Canady | Licensing Program Analyst | Named as Licensing Program Analyst involved in the visit |
Inspection Report
Capacity: 105
Deficiencies: 0
Date: Jan 25, 2022
Visit Reason
The visit was an Office type Non-Compliance Conference conducted to discuss the high volume of complaints, deficiencies cited, and inability to remain in substantial compliance with regulations or specific incidents occurring in the last 24 months.
Findings
The facility was cited with 21 Type A citations and 7 Type B citations along with civil penalties from 8/31/2020 to present, involving issues such as Covid-19 response, personnel requirements, personal rights, reporting, and other regulatory areas. No deficiencies were cited during this specific visit.
Report Facts
Type A citations: 21
Type B citations: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Luna Garcia | Administrator of Record | Named as facility administrator present during Non-Compliance Conference |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager involved in the report |
| Victoria Brown | Licensing Program Analyst | Named as Licensing Program Analyst involved in the report |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 105
Deficiencies: 1
Date: Jan 12, 2022
Visit Reason
The visit was conducted as a Case Management follow-up to review additional items observed during a complaint investigation on 12/3/2021.
Complaint Details
The visit was triggered by a complaint investigation regarding resident #1 being sent out unsupervised to pick up medication, which was substantiated based on interviews and documentation.
Findings
The investigation found that resident #1 (R1) was sent out to pick up insulin without supervision, which violated regulations as R1 was deemed unable to leave the facility unassisted. The administrator failed to provide adequate supervision, posing an immediate risk to residents.
Deficiencies (1)
Administrator did not provide supervision for resident #1 while being sent to the VA hospital in an Uber, posing an immediate risk to residents in care.
Report Facts
Census: 46
Total Capacity: 105
Deficiency count: 1
Plan of Correction Due Date: Jan 13, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Luna Garcia | Administrator | Named in deficiency for failure to provide supervision for resident #1 |
| Brian Pawloski | Vice President | Met with Licensing Program Analysts during the visit |
| Victoria Brown | Licensing Program Analyst | Conducted the inspection and signed the report |
| Jamie Ivey Canady | Licensing Program Analyst | Conducted the inspection |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 46
Capacity: 105
Deficiencies: 0
Date: Jan 12, 2022
Visit Reason
The visit was an unannounced Case Management visit focused on legal and non-compliance issues conducted by Licensing Program Analysts.
Findings
No deficiencies were cited during this visit. The facility was observed to be in compliance with regulations including physical plant conditions, safety equipment, and resident care activities.
Report Facts
Staff present during visit: 15
Residents receiving hospice care: 2
Room temperature: 75
Water temperature range: 106.9-115.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Luna Garcia | Administrator | Met with Licensing Program Analysts during the visit and mentioned in report |
| Brian Pawloski | Vice President | Met with Licensing Program Analysts during the visit and mentioned in report |
| Victoria Brown | Licensing Program Analyst | Conducted the inspection visit |
| Jamie Ivey Canady | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Census: 50
Capacity: 105
Deficiencies: 0
Date: Dec 28, 2021
Visit Reason
The visit was a Case Management visit conducted due to notice that the Administrator Donna Bautista-Colmenares was no longer working at the facility, and to verify the interim designation of responsibility.
Findings
No deficiencies were cited during this unannounced Case Management visit. The Licensing Program Analysts observed the designation of responsibility posted and reviewed the current Administrator Certificate.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Garcia | Designee | Interim person in charge during the visit |
| Donna Bautista-Colmenares | Administrator | Former Administrator no longer working at the facility |
| Brian Pawloski | LVN Vice President of Operations for Northern California | Reported interim designation of Christina Garcia |
| Victoria Brown | Licensing Program Analyst | Conducted the Case Management visit |
| Jamie Ivey Canady | Licensing Program Analyst | Conducted the Case Management visit |
| Stephen Richardson | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 105
Deficiencies: 2
Date: Dec 3, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including a resident missing medications and illegal eviction due to not providing a 30 day supply of medication prior to admittance.
Complaint Details
The complaint investigation was substantiated based on the preponderance of evidence standard. Allegations included missed medications and illegal eviction due to lack of medication supply. The resident missed a dose of insulin and was evicted without proper notice. The facility was cited for deficiencies related to eviction procedures and medication management.
Findings
The investigation substantiated that a resident missed a dose of insulin due to medication not being timely provided and that the resident was evicted without the required 30 day written notice for not having a 30 day supply of medication upon admittance. The facility failed to provide proper eviction notice and timely refrigerated medication, posing immediate risk to residents.
Deficiencies (2)
The licensee did not provide R1 an eviction notice and evicted R1 for not having a 30 day supply of medication upon admittance, violating CCR 87224(a).
The licensee did not provide R1 with required refrigerated medication timely, resulting in a missed dose of insulin, violating CCR 87465(a)(5).
Report Facts
Capacity: 105
Census: 52
Estimated Days of Completion: 60
Plan of Correction Due Date: Dec 4, 2021
Plan of Correction Submission Due Date: Dec 8, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Donna Bautista-Colmenares | Administrator | Facility administrator involved in findings related to medication and eviction |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 52
Capacity: 105
Deficiencies: 0
Date: Nov 12, 2021
Visit Reason
The visit was an unannounced Case Management visit focused on Legal/Non-compliance issues.
Findings
The Licensing Program Analyst toured the facility including Assisted Living and Memory Care sides, observed compliance with first aid kits, fire extinguishers, alarm systems, and food supplies. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Bautista-Colmenares | Administrator | Met with Licensing Program Analyst during the visit. |
| Victoria Brown | Licensing Program Analyst | Conducted the Case Management visit. |
| Stephen Richardson | Licensing Program Manager | Named in the report header. |
| Christina Garcia | Assisted families during the exit interview. |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 105
Deficiencies: 4
Date: Nov 1, 2021
Visit Reason
The visit was an unannounced subsequent complaint investigation related to alleged deficiencies, including unauthorized release of resident photos and failure to timely report hospitalization and COVID-19 positive cases.
Complaint Details
The visit was triggered by a complaint investigation (27-AS-20211029101055) concerning unauthorized photo release and reporting failures. The complaint was substantiated by findings of unauthorized photo release, late incident reporting, and false information provided by the administrator.
Findings
The investigation found that the facility did not obtain permission to publish photos of residents R1 and R2, failed to timely submit an incident report for hospitalization of resident R5, and did not include R5 on the required Public Health COVID-19 line list. Additionally, the administrator provided false information regarding the identity of a resident in a Facebook video.
Deficiencies (4)
Failure to submit hospitalization incident report timely for resident R5.
Failure to report COVID-19 positive resident R5 to Public Health within required timeframe.
Unauthorized release of residents R1 and R2's photos on social media without permission.
False claim by administrator regarding identity of resident in Facebook video.
Report Facts
Census: 54
Total Capacity: 105
Deficiencies cited: 4
Incident report delay: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Bautista-Colmenares | Administrator | Named in findings related to unauthorized photo release, false claims, and reporting deficiencies |
| Victoria Brown | Licensing Program Analyst | Conducted investigation and authored report |
| Stephen Richardson | Licensing Program Manager | Conducted investigation and authored report |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 105
Deficiencies: 1
Date: Nov 1, 2021
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that facility staff were not wearing masks.
Complaint Details
The complaint allegation that facility staff were not wearing masks was substantiated based on the preponderance of evidence including interviews, video, and photos.
Findings
The investigation substantiated the allegation that staff were not wearing masks and not social distancing inside the facility, based on interviews, video, and photos. One staff member (S1), identified as an infection control lead, was observed not following infection control practices, posing an immediate health and safety risk to residents.
Deficiencies (1)
S1 was not wearing a mask in the facility while posing for pictures and not social distancing from other staff, violating infection control practices.
Report Facts
Estimated Days of Completion: 30
Capacity: 105
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Stephen Richardson | Licensing Program Manager | Conducted the complaint investigation and cited deficiencies |
| Donna Bautista-Colmenares | Administrator | Facility administrator interviewed during investigation |
| S1 | Staff member found not wearing a mask and not following infection control practices |
Inspection Report
Census: 54
Capacity: 105
Deficiencies: 2
Date: Oct 22, 2021
Visit Reason
The visit was an unannounced Case Management - Health Checks inspection to conduct a health and safety check on the residents and observe procedures put in place following a Health Care Associated Infections (HAI) visit on 10/13/2021.
Findings
The Licensing Program Analyst observed discrepancies in medication management including mismatched room numbers on pill containers, unlabeled medication cups, missing pills from bubble packs, and staff's inability to explain medication systems. Additionally, staff lacked knowledge of the LIC308 Designation of Responsibility form, and required signage and hand sanitizer were not posted in designated areas.
Deficiencies (2)
No LIC 308 designating a substitute administrator was present or known by staff, posing a potential health and safety risk to residents.
Discrepancies in the medication room including mismatched room numbers on pill containers, unlabeled cups, missing lids on medication cups, and staff unable to explain the bubble pack system, posing a potential health and safety risk.
Report Facts
Deficiencies cited: 2
Missing pills: 6
Medication administrations: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Bautista-Colmenares | Administrator | Administrator involved in the inspection and discussions about signage and procedures |
| Victoria Brown | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stephen Richardson | Licensing Program Manager | Supervised the inspection and involved in prior discussions |
Inspection Report
Routine
Capacity: 105
Deficiencies: 0
Date: Oct 19, 2021
Visit Reason
An office meeting was conducted to discuss recommendations from the Health Care Associated Infections (HAI) to ensure the facility remains in substantial compliance with infection control, specifically to mitigate the spread of Covid-19.
Findings
No deficiencies were cited during this visit. The meeting recapped recommendations from CDPH's Covid-19 Outbreak Facility Assessment Tool and reviewed the facility's implementation of these recommendations, including infection control leads and daily reporting commitments.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Bautista-Colmenares | Administrator | Named as facility Administrator and participant in infection control meeting |
| Kandice Alcorn | Vice President of Clinical Services | Participant in infection control meeting |
| Brian Pawloski | Vice President of Operations Northern California | Participant in infection control meeting |
| Eric Guerrero | Environmental Service Director | Infection Control Lead and participant in infection control meeting |
| Brittany Ram | Resident Care Coordinator | Infection Control Lead and participant in infection control meeting |
| Stephen Richardson | Licensing Program Manager | Participant in infection control meeting |
| Victoria Brown | Licensing Program Analyst | Participant in infection control meeting |
| Krystall Moore | Regional Manager | Participant in infection control meeting |
| Kristy Trausche | Infection Preventionist | Health Care Associated Infections representative involved in joint health and safety visit |
Inspection Report
Census: 55
Capacity: 105
Deficiencies: 1
Date: Sep 22, 2021
Visit Reason
This visit was conducted to amend the Case Management visit citation from the previous Case Management visit made on 2021-07-21, related to an incident involving medication administration errors.
Findings
The report cites a Type B deficiency due to a medication error where Resident #1 received Tramadol twice in one day during medication training, and the narcotics count was off. It was determined that the resident was not in immediate health and safety risk at the time.
Deficiencies (1)
Incidental Medical and Dental Care: Facility staff did not follow the written order from the physician, resulting in a resident receiving the same medication twice during medication training, posing a potential health and safety risk.
Report Facts
Capacity: 105
Census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Bautista-Colmenares | Administrator | Met with Licensing Program Analyst during the visit and involved in the exit interview |
| Victoria Brown | Licensing Program Analyst | Conducted the inspection visit and authored the report |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager and Supervisor |
Inspection Report
Census: 55
Capacity: 105
Deficiencies: 0
Date: Sep 22, 2021
Visit Reason
The visit was an unannounced Case Management visit to review a random amount of resident files, including annual assessments and physician reports.
Findings
No deficiencies were cited during this visit. Six of the seven resident Physician Reports were updated within the year 2021, with one exception for a resident who left prior to the annual due date.
Report Facts
Physician Reports reviewed: 7
Physician Reports updated within year: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the unannounced Case Management visit and reviewed resident files |
| Donna Bautista-Colmenares | Administrator | Met with Licensing Program Analyst during the visit |
| Stephen Richardson | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 105
Deficiencies: 4
Date: Aug 19, 2021
Visit Reason
The visit was an unannounced complaint investigation to cite deficiencies observed during the complaint investigation and file review at Greenhaven Estates.
Complaint Details
The complaint investigation was triggered by concerns including failure to provide admission agreements and unsafe removal of chair wheels for a fall-risk resident. The preponderance of evidence standard was met.
Findings
The investigation found that the facility failed to provide requested admission agreements, removed wheels from a resident's chair without approval or documentation, and did not ensure the resident was checked every 1-2 hours as required by the Interim Service Plan, posing immediate health and safety risks.
Deficiencies (4)
Failure to provide the Admission Agreement despite multiple requests during the investigation.
Removal of wheels from resident's chair without supporting documentation or physician approval, violating resident's rights.
Failure to submit an Exception request to CCL for approval to remove wheels from residents’ chairs.
Failure to ensure the resident was checked every 1-2 hours as stated in the Interim Service Plan.
Report Facts
Census: 53
Total Capacity: 105
Deficiencies cited: 4
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Donna Bautista-Colmenares | Administrator | Facility administrator met during inspection and involved in findings |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection |
| S1 | Med Tech | Interviewed regarding resident fall risk and monitoring |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 105
Deficiencies: 1
Date: Aug 19, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted to deliver findings related to allegations that staff failed to provide timely medical attention after a resident fall and failed to supervise a resident which resulted in death.
Complaint Details
The complaint investigation was substantiated for the allegation that staff failed to provide timely medical attention after a resident fall. The allegation that staff failed to supervise the resident resulting in death was unsubstantiated.
Findings
The investigation substantiated that staff failed to provide medical attention in a timely manner after Resident #1 fell multiple times in 2020 and did not transport the resident to the hospital despite known head trauma. The facility also failed to move the resident to the memory care unit after decline. Another allegation that staff failed to supervise the resident resulting in death was unsubstantiated due to lack of evidence.
Deficiencies (1)
Staff had knowledge of Resident #1's head trauma and failed to transport the resident to the hospital on 7/25/2020, despite history of forgetfulness and confusion prior to the fall. Facility staff did not seek medical attention in a timely manner, posing an immediate health and safety risk.
Report Facts
Estimated Days of Completion: 190
Capacity: 105
Census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Stephen Richardson | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
| Donna Bautista-Colmenares | Administrator | Facility Administrator met during investigation and named in relation to findings |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 105
Deficiencies: 2
Date: Aug 16, 2021
Visit Reason
The visit was conducted as a Case Management investigation following an incident report of a missing narcotic medication from a resident's medication supply.
Complaint Details
The visit was complaint-related due to an incident report of a missing narcotic medication. The preponderance of evidence standard was not met to substantiate staff wrongdoing, but deficiencies were cited related to notification failures and staff termination procedures.
Findings
The investigation found that a narcotic medication was missing from Resident #1's supply, staff involved were drug tested with negative results except one staff member who left early and was scheduled for termination. The facility failed to document notification of the physician and responsible parties, and staff left without proper termination documentation, posing immediate health and safety risks.
Deficiencies (2)
Incident Report does not mention Physician and/or Responsible parties were notified of the missing medication.
Staff left facility during work shift without proper termination documentation.
Report Facts
Capacity: 105
Census: 53
Plan of Correction Due Date: Aug 17, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Bautista-Colmenares | Administrator | Met with Licensing Program Analyst during visit and provided information about the incident and staff |
| Victoria Brown | Licensing Program Analyst | Conducted the unannounced Case Management visit and authored the report |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 105
Deficiencies: 2
Date: Aug 16, 2021
Visit Reason
The visit was an unannounced Case Management inspection triggered by an incident report regarding missing and tampered medications involving Hydrocodone at the facility.
Complaint Details
The visit was complaint-related due to an incident report of medication tampering involving missing Hydrocodone tablets replaced with unknown pills. Drug testing of staff was negative except one staff member who failed to appear for work and was being terminated. The preponderance of evidence standard was not met.
Findings
The investigation found that prescribed medications were missing and replaced with unknown pills, posing an immediate health and safety risk. Drug tests on staff were negative, and corrective actions including staff removal from medication duties and hiring a replacement were underway. The preponderance of evidence standard was not met to substantiate exploitation.
Deficiencies (2)
Staff found that resident(s) medication(s) were missing, indicating failure to prevent exploitation by removing prescribed medication from the medication room.
Staff replaced prescribed medication with unknown medication, indicating failure to ensure prescribed medications were centrally stored safely.
Report Facts
Missing Hydrocodone tablets: 4
Half tablets of Hydrocodone replaced: 1
Plan of Correction Due Date: Aug 17, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Bautista-Colmenares | Administrator | Met with Licensing Program Analyst during the visit and involved in medication count review. |
| Victoria Brown | Licensing Program Analyst | Conducted the unannounced Case Management visit and authored the report. |
| Stephen Richardson | Licensing Program Manager / Supervisor | Named as Licensing Program Manager and Supervisor overseeing the evaluation. |
Inspection Report
Census: 52
Capacity: 105
Deficiencies: 0
Date: Jul 29, 2021
Visit Reason
The visit was a Case Management - Other type of unannounced inspection to evaluate the facility.
Findings
This report amends a previous case management report dated 7/21/21, correcting the visit date. No other findings or deficiencies are detailed in this report.
Inspection Report
Census: 52
Capacity: 105
Deficiencies: 0
Date: Jul 29, 2021
Visit Reason
The visit was a Case Management - Other type of unannounced visit to the facility.
Findings
This report amends a previous case management report dated 7/21/21 due to an incorrect visit date being input. The licensing program analyst will assess civil penalties for the repeat violation.
Inspection Report
Complaint Investigation
Census: 53
Capacity: 105
Deficiencies: 1
Date: Jul 21, 2021
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that a resident was admitted to the hospital with an opiate overdose.
Complaint Details
Complaint was substantiated. The allegation involved a resident admitted to the hospital with an opiate overdose. The investigation found multiple medication errors and failure to follow safety protocols. The preponderance of evidence standard was met.
Findings
The allegation was substantiated based on documentation and interviews revealing multiple incidents of medication errors and drug delivery to a resident despite a plan to prevent it. The facility failed to effectively follow protocols to ensure resident safety, with a history of overdosing residents from 2020 to date.
Deficiencies (1)
Failure to develop and effectively implement a plan for incidental medical and dental care, including medication procedures, resulting in drugs being delivered to a resident despite a plan and multiple medication errors.
Report Facts
Census: 53
Total Capacity: 105
Incident Reports: 3
Estimated Days of Completion: 30
Plan of Correction Due Date: Aug 21, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Donna Bautista-Colmenares | Executive Director/Administrator | Facility administrator involved in interviews and acknowledged findings |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 105
Deficiencies: 1
Date: Jul 21, 2021
Visit Reason
The visit was an unannounced Case Management inspection conducted due to an incident report indicating that a resident took medication twice in one day.
Complaint Details
The visit was triggered by a complaint/incident report regarding Resident #1 taking medication twice in one day. The deficiency was substantiated as the facility did not provide assistance as required.
Findings
The facility failed to assist a resident with medication administration as required by the physician's report, resulting in the resident taking medication twice in one day. This posed an immediate health and safety risk to residents in care.
Deficiencies (1)
Resident was not assisted with medications as stated on the physician report, resulting in medication being taken twice in one day.
Report Facts
Census: 53
Total Capacity: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection |
| Luna Garcia | Business Office Manager | Facility staff met during the inspection |
| Donna Bautista-Colmenares | Administrator | Facility administrator named in the report |
Inspection Report
Census: 53
Capacity: 105
Deficiencies: 1
Date: Jul 21, 2021
Visit Reason
The visit was an unannounced Case Management inspection conducted to investigate an incident report regarding a medication error involving Resident #1 receiving Tramadol twice in one day and discrepancies in the narcotics count.
Findings
The inspection found a medication error during medication training where a resident received the same medication twice, and the facility failed to ensure proper medication procedures were followed, posing an immediate health and safety risk to residents.
Deficiencies (1)
During medication training, Resident #1 received the same medication twice, and the facility did not ensure medication procedures were followed, posing an immediate health and safety risk.
Report Facts
Census: 53
Total Capacity: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the inspection and signed the report |
| Stephen Richardson | Licensing Program Manager | Supervisor and Licensing Program Manager named in the report |
| Luna Garcia | Business Office Manager | Met with the Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 105
Deficiencies: 1
Date: Jul 21, 2021
Visit Reason
The visit was an unannounced Case Management inspection conducted due to an incident report received regarding a medication error involving Resident #1 on 05/26/2021.
Complaint Details
The visit was triggered by a complaint/incident report indicating that Resident #1 received incorrect medication on 05/26/2021, which resulted in decreased pulse and activation of 911. The incident report was incomplete and lacked medication details.
Findings
The facility was found to have a deficiency for administering incorrect medication to a resident, posing an immediate health and safety risk. The incident report was incomplete and the facility self-reported the incident, leading to citation of the deficiency.
Deficiencies (1)
Resident received incorrect medication; facility did not ensure resident was administered the correct medication as prescribed, posing an immediate health and safety risk.
Report Facts
Census: 53
Total Capacity: 105
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection |
| Luna Garcia | Business Office Manager | Facility staff met during the inspection |
| Donna Bautista-Colmenares | Administrator | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 105
Deficiencies: 0
Date: Jul 14, 2021
Visit Reason
The visit was an unannounced Case Management - Incident investigation conducted to follow up on medication error incident reports received for several dates in 2020 and 2021.
Complaint Details
The visit was triggered by incident reports indicating medication errors on 7/14/2020, 8/25/2020, 9/25/2020, 9/26/2020, and 5/26/2021. Further investigation is needed.
Findings
The Licensing Program Analyst attempted to conduct interviews and requested additional documentation related to medication errors occurring on multiple dates. The occurrences require further investigation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Bautista-Colmenares | Executive Director/Administrator | Met with Licensing Program Analyst during the visit and was requested to provide documentation related to medication errors. |
| Victoria Brown | Licensing Program Analyst | Conducted the unannounced Case Management visit and attempted interviews regarding medication errors. |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 48
Capacity: 105
Deficiencies: 0
Date: Jun 14, 2021
Visit Reason
The Licensing Program Analyst conducted an unannounced Required - Annual visit to evaluate the facility's compliance with regulations and ensure safety and proper care.
Findings
No deficiencies were observed or cited during the inspection. The facility met all regulatory requirements including safety systems, medication storage, and environmental conditions.
Report Facts
Temperature inside facility: 77
Hot water temperature: 106.5
Capacity: 105
Census: 48
Perishables observed: 2
Non-perishables observed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Bautista-Colmenares | Administrator | Facility Administrator who assisted with the inspection visit |
| Victoria Brown | Licensing Program Analyst | Conducted the inspection visit |
| Stephen Richardson | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 105
Deficiencies: 0
Date: Jun 14, 2021
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff were overmedicating a resident in care.
Complaint Details
The complaint alleged that staff were overmedicating a resident. The investigation was unsubstantiated based on lack of evidence and documentation review.
Findings
The investigation found no evidence of medication errors or overmedication. Medication logs and administration records were reviewed, and no incidents or reports of medication errors were documented. The complaint was unsubstantiated.
Report Facts
Estimated Days of Completion: 90
Residents receiving anti-anxiety medication (PRN): 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Donna Bautista-Colmenares | Administrator | Facility administrator met during investigation |
| Stephen Richardson | Licensing Program Manager | Named in report as Licensing Program Manager |
| Christina Luna Garcia | Business Office Manager | Met during investigation and assisted with medication record review |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 105
Deficiencies: 0
Date: Jun 3, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not administer residents' medication in a timely manner and did not answer residents' call buttons promptly.
Complaint Details
The complaint was unsubstantiated due to lack of sufficient evidence to prove the alleged violations occurred. The investigation included interviews with administrators and staff, review of medical and facility records, and attempted resident interviews which were unsuccessful.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Medication Administration Records and call button response times were reviewed and showed no evidence of negligence or unreported issues. Staffing coverage was adequate, and no deficiencies were cited.
Report Facts
Capacity: 105
Census: 46
Call response time: 10
Number of allegations: 2
Number of staff interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dale Masters | Administrator | Administrator at the start of the investigation, terminated in October 2020 |
| Donna Bautista-Colmenares | Administrator | Administrator at time of inspection and exit interview |
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 105
Deficiencies: 0
Date: May 27, 2021
Visit Reason
Unannounced complaint investigation visit conducted to investigate multiple allegations including inappropriate restraint use, inadequate food service, medication administration delays, unclean facility conditions, bad odor from dog feces, and failure to provide resident activities.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included inappropriate restraint use, inadequate food service, medication administration delays, unclean facility, bad odor from dog feces, and failure to provide activities. Interviews with staff and review of evidence did not support the allegations.
Findings
Based on interviews with staff and lack of evidence, all allegations were found to be unsubstantiated. The facility was reported to be clean, residents received timely medication and adequate food, and activities were provided. No deficiencies were cited during this visit.
Report Facts
Estimated Days of Completion: 190
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Donna Bautista-Colmenares | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 46
Capacity: 105
Deficiencies: 0
Date: Apr 6, 2021
Visit Reason
The visit was an unannounced tele-visit conducted due to COVID-19 and precautionary measures to ensure the care home is meeting the terms and conditions of its probationary license effective from 6/18/2020 to 6/18/2023.
Findings
No deficiencies were observed or cited during the visit. The facility was found to be in compliance with regulations including safety, medication storage, first aid kit contents, and resident and staff file requirements.
Report Facts
Hot water temperature: 116.2
Hot water temperature: 115.8
Temperature inside facility: 72
Capacity: 105
Census: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Bautista-Colmenares | Administrator | Met during visit and participated in inspection |
| Eric Guererro | Environmental Service Director | Participated in physical plant inspection |
| Victoria Brown | Licensing Program Analyst | Conducted the inspection |
| Tirzah Hubbard | Licensing Program Analyst | Conducted the inspection |
| Stephen Richardson | Licensing Program Manager | Oversaw the inspection |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 105
Deficiencies: 1
Date: Mar 27, 2021
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation received on 06/15/2020 that staff handled a resident in a rough manner causing bruises.
Complaint Details
The complaint was substantiated based on interviews and evidence. Staff member S13 confirmed yelling and grabbing R1's wrists. The preponderance of evidence standard was met and the allegation was substantiated.
Findings
The investigation substantiated the allegation that staff member S13 grabbed Resident #1's wrists causing bruises. The licensee failed to ensure the resident was kept free from abuse, posing an immediate health and safety risk. Employment of S13 was suspended and terminated, and the plan of correction was cleared prior to the visit.
Deficiencies (1)
Personal Rights of Residents in All Facilities - To be free from abuse or other actions of a punitive nature. R1 had bruises on the wrist. Licensee did not ensure S13 kept resident free from abuse.
Report Facts
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Dale Masters | Administrator | Facility Administrator named in the report |
| Donna Bautista-Colmenares | Facility representative met with during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 105
Deficiencies: 1
Date: Mar 27, 2021
Visit Reason
This Case Management visit was conducted as a result of a deficiency noted during a complaint investigation, specifically related to COVID-19 precautionary measures and resident care.
Complaint Details
Visit was complaint-related; deficiency noted during complaint investigation. Substantiation status not explicitly stated.
Findings
The licensing analyst confirmed through interviews that a staff member was eating food off residents' plates during meal times, resulting in residents not receiving the quantity of food necessary to meet their nutritional needs, posing a potential health and safety risk.
Deficiencies (1)
Residents having food eaten off the meal plate by staff, resulting in failure to ensure residents received the quantity of food necessary to meet their nutritional needs daily.
Report Facts
Deficiency Plan of Correction Due Date: Apr 26, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Bautista-Colmenares | Administrator | Met with Licensing Program Analyst during visit and involved in exit interview |
| Victoria Brown | Licensing Program Analyst | Conducted the unannounced tele-visit and evaluation |
| Stephen Richardson | Licensing Program Manager | Supervisor named in report |
Inspection Report
Census: 44
Capacity: 105
Deficiencies: 0
Date: Feb 24, 2021
Visit Reason
The visit was an unannounced tele-visit conducted due to COVID-19 precautionary measures to ensure the care home is meeting the terms and conditions of its probationary license effective from 6/18/2020 to 6/18/2023.
Findings
No deficiencies were observed or cited during the visit. The facility was found to be in compliance with regulations including medication security, first aid kit contents, safety hazards, and environmental conditions.
Report Facts
Temperature inside facility: 72
Hot water temperature room 119: 114.2
Hot water temperature room 126: 116.2
Non-perishable food supply: 7
Perishable food supply: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Bautista-Colmenares | Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Victoria Brown | Licensing Program Analyst | Conducted the inspection visit and authored the report |
| Eric Guererro | Maintenance staff | Participated in physical plant inspection |
Inspection Report
Census: 44
Capacity: 105
Deficiencies: 0
Date: Feb 24, 2021
Visit Reason
The visit was a case management visit conducted to deliver an Order To Individual of Immediate Exclusion from all facilities and the Order to Licensee/Facility of Immediate Exclusion From Facility.
Findings
The Licensing Program Analysts delivered exclusion orders to the facility administrator and staff, requiring the excluded staff member to leave the facility immediately. The exclusion was not related to this facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Bautista-Colmenares | Administrator | Met with Licensing Program Analysts during the case management visit and received the exclusion order. |
| Bruce Jacobs | Licensing Program Analyst | Conducted the case management visit and delivered the exclusion orders. |
| Anthony Tuck | Licensing Program Analyst | Conducted the case management visit and delivered the exclusion orders. |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager on the report. |
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