Inspection Report Summary
Most inspections at this facility were clean, with no deficiencies cited in the annual inspections from January 2022 through January 2025, showing a generally well-maintained environment. However, several complaint investigations found deficiencies related primarily to medication management and resident care, including missed or incorrect medication administration and failure to provide prescribed diets or proper supervision. The most serious issues involved a substantiated case in October 2025 where a staff member administered narcotics while impaired and documented medication administration inaccurately, posing immediate health and safety risks; the facility responded by suspending the staff member and notifying law enforcement. Other notable past deficiencies included failure to prevent resident elopement and inadequate administrative oversight, but these were isolated and addressed. The most recent report from October 28, 2025, did have deficiencies, indicating some ongoing challenges with medication safety despite improvements in other areas.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 43
Capacity: 48
Deficiencies: 1
Oct 28, 2025
Visit Reason
An unannounced Case Management deficiencies inspection was conducted to address concerns regarding an incident report dated 10/24/25 related to reported medication violations.
Findings
The inspection found that a staff member (S1) documented administering a narcotic medication to a resident who was not present at the time, and the staff member was under the influence of a narcotic during medication administration. The facility administrator suspended the staff member pending investigation, and law enforcement and the resident's family were notified.
Complaint Details
The visit was complaint-related based on an incident report alleging medication violations involving unaccounted narcotics and staff impairment. The complaint is substantiated by written statements and investigation findings.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Engaged in conduct inimical to the health, morals, welfare, or safety of persons in care by documenting administration of a narcotic to a resident not present and administering medication while under the influence of a narcotic, posing immediate health, safety, and personal rights risks. | Type A |
Report Facts
Facility capacity: 48
Census: 43
Plan of Correction due date: Oct 29, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Andrews | Administrator | Met with Licensing Program Analyst to discuss incident report and suspension of staff member |
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and authored the report |
Inspection Report
Annual Inspection
Census: 35
Capacity: 48
Deficiencies: 0
Jan 29, 2025
Visit Reason
The inspection was conducted as a required 1 year annual inspection of Greenhaven Place Assisted Living to evaluate compliance with health and safety regulations.
Findings
The facility was found to be clean, odor-free, and in good repair with all required furniture and sufficient lighting. Water temperatures were measured and found within acceptable ranges, food supplies were sufficient, and fire safety equipment was current and compliant. No deficiencies were cited during the inspection.
Report Facts
Water temperature measurements: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Andrews | Administrator | Met with Licensing Program Analyst during inspection and participated in facility tour |
| Kevin Gould | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Annual Inspection
Census: 41
Capacity: 48
Deficiencies: 0
Jan 19, 2024
Visit Reason
The inspection was a required 1 year annual unannounced inspection conducted to evaluate the health and safety conditions of the facility.
Findings
The facility was found to be clean, odor-free, and in good repair with all required furniture and sufficient lighting. No deficiencies were cited during the inspection.
Report Facts
Water temperature: 111
Capacity: 48
Census: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and authored the report |
| Morgan Whinery | Administrator met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 48
Deficiencies: 1
Oct 5, 2023
Visit Reason
The visit was conducted as an unannounced investigation of a medication error reported in an Unusual Incident/Injury Report dated 9/15/23 involving resident #1 (R1).
Findings
The investigation confirmed that on 9/12/23, R1 received medication at the wrong time and missed eye drops during the 2pm medication pass due to staff inadvertently switching medications and times. No adverse reactions occurred. Staff member responsible was removed from the Medication Technician position and will be re-trained.
Complaint Details
The complaint investigation was substantiated based on the preponderance of evidence from documents and interviews regarding the medication error involving resident #1.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medication was not administered as prescribed to resident #1, confirmed by documentation and interviews, posing a potential health and safety risk to residents. | Type B |
Report Facts
Census: 36
Total Capacity: 48
Deficiency Count: 1
Medication Error Date: Sep 12, 2023
Incident Report Date: Sep 15, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the investigation and authored the report |
| Stephen Richardson | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the investigation |
| Bailey Leach | Business Office Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 48
Deficiencies: 2
Sep 14, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2023-04-27 regarding resident care, notification failures, staffing, safety, and facility management at Greenhaven Place Independent Living and Assisted Living.
Findings
The investigation substantiated two allegations: the facility did not follow a resident's prescribed diet and failed to notify the resident's power of attorney (POA) of hospitalization. Other allegations related to staffing, call pendant response, resident safety, false statements, rent increase notification, fire drill instructions, physical plant issues, staff training, and incident reporting were found unsubstantiated or unfounded.
Complaint Details
The complaint investigation was substantiated for allegations that the facility did not follow the resident's prescribed diet and failed to notify the resident's POA of hospitalization. Other allegations were unsubstantiated or unfounded. The substantiation was based on interviews, record reviews, and incident reports.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify resident's POA of serious injury within seven days as required by CCR 87211(a)(1)(B). | Type B |
| Failure to provide modified diets prescribed by a resident's physician as a medical necessity per CCR 87555(b)(7). | Type B |
Report Facts
Capacity: 48
Census: 39
Deficiencies cited: 2
Plan of Correction Due Date: Sep 29, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation |
| Bailey Leach | Business Office Director | Met with Licensing Program Analyst during inspection and received exit interview |
| Robert Coe | Administrator | Facility administrator mentioned in report header |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 48
Deficiencies: 0
Sep 14, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-05-12 regarding retaliation against a resident for filing a previous complaint, inappropriate touching by staff, and unclean resident bathroom and kitchen.
Findings
The investigation included interviews, record reviews, and observations. All allegations were found to be unsubstantiated or unfounded based on lack of evidence and observations. No evidence of retaliation or inappropriate touching was found, and the resident's bathroom and kitchen were observed to be clean.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included retaliation against a resident for filing a previous complaint and staff touching a resident inappropriately. After interviews with staff and residents, review of personnel files, and observation, the allegations were not supported by evidence. Additionally, the allegation that the resident's bathroom and kitchen were dirty was found to be unfounded.
Report Facts
Facility capacity: 48
Census: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation |
| Bailey Leach | Business Office Director | Met with Licensing Program Analyst during the investigation and received the report |
| Robert Coe | Administrator | Facility administrator mentioned in the report |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 48
Deficiencies: 1
Aug 30, 2023
Visit Reason
The visit was an unannounced case management inspection to obtain additional information regarding a Special Incident Report about a medication error where resident #1 received resident #2's medication.
Findings
The investigation confirmed the medication error occurred with no adverse reaction. A deficiency was cited for failure to designate an employee responsible for assisting residents with self-administration of medications, posing a potential health and safety risk.
Complaint Details
The visit was triggered by a complaint via a Special Incident Report (SIR-LIC624) received on 08/28/2023 regarding a medication error where resident #1 received resident #2's medication. The preponderance of evidence standard was met confirming the complaint.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Incidental Medical and Dental Care: medication that belonged to resident #2 was administered to resident #1 with no adverse reaction; failure to designate an employee responsible for assisting residents with self-administration of medications. | Type B |
Report Facts
Capacity: 48
Census: 40
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the investigation and authored the report |
| Stephen Richardson | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
| Bailey Leach | Business Office Director | Facility representative met during the inspection |
Inspection Report
Annual Inspection
Census: 33
Capacity: 48
Deficiencies: 0
Jan 13, 2023
Visit Reason
The visit was an unannounced Required - 1 Year inspection conducted to evaluate the facility's compliance with regulations and ensure safety for residents.
Findings
The Licensing Program Analyst toured and inspected the facility, observed residents, and verified safety measures including temperature controls, fire safety equipment, and medication storage. No deficiencies were cited during this inspection.
Report Facts
Residents receiving hospice care: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the inspection and authored the report |
| Robert Coe | Administrator | Facility administrator met with the Licensing Program Analyst during the inspection |
| Stephen Richardson | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 48
Deficiencies: 0
Oct 24, 2022
Visit Reason
The visit was an unannounced Case Management visit triggered by an incident report received on 2022-03-31 regarding a resident's allegation that a caregiver was verbally aggressive while assisting with care needs.
Findings
The investigation found that the caregiver in question resigned after being pulled from the floor and there was insufficient evidence to prove the alleged abuse occurred. No deficiencies were cited during this visit.
Complaint Details
The complaint involved an allegation of verbal aggression by a caregiver. The caregiver did not confirm or deny the behavior but admitted to frustration. The caregiver resigned and the facility was found not at fault with no deficiencies cited.
Report Facts
Census: 85
Total Capacity: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Coe | Administrator | Met with Licensing Program Analyst during the visit |
| Victoria Brown | Licensing Program Analyst | Conducted the inspection visit and investigation |
| Stephen Richardson | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 48
Deficiencies: 0
Oct 24, 2022
Visit Reason
The visit was conducted as a Case Management visit following an incident report received on 3/25/2022 alleging physical abuse by a caregiver.
Findings
The investigation found no preponderance of evidence to prove the alleged abuse occurred or that the facility was at fault. No deficiencies were cited during this visit.
Complaint Details
The complaint involved an allegation of physical abuse by a caregiver reported by a resident. The resident refused to be interviewed and stated the incident happened under different management about a year ago. The allegation was not substantiated.
Report Facts
Capacity: 48
Census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the Case Management visit and investigation |
| Robert Coe | Administrator | Facility administrator met with Licensing Program Analyst during the visit |
| Stephen Richardson | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 48
Deficiencies: 1
Sep 23, 2022
Visit Reason
The visit was an unannounced case management incident investigation regarding a car accident involving Resident #1 (R1) that occurred on or about 09/15/2022.
Findings
The investigation revealed that Resident #1 was driving alone and had a car accident with no major injuries. The facility did not ensure supervision as required by the resident's physician report and preplacement appraisal, posing an immediate health and safety risk.
Complaint Details
The visit was triggered by an incident report submitted to Community Care Licensing regarding Resident #1's car accident. The complaint investigation found that the facility failed to provide required supervision to the resident, substantiating the complaint.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to regularly observe residents for changes in physical, mental, emotional, and social functioning, and failure to provide appropriate assistance when such observation reveals unmet needs, as evidenced by Resident #1 having a car accident while driving alone without supervision as required. | Type A |
Report Facts
Capacity: 48
Census: 35
Plan of Correction Due Date: Sep 26, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the investigation and authored the report |
| Stephen Richardson | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the investigation |
| Frances Santillan | Administrator | Facility administrator named in the report |
| Regina Farinias | Marketing Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Census: 35
Capacity: 48
Deficiencies: 2
Sep 23, 2022
Visit Reason
Unannounced case management visit to evaluate deficiencies related to the facility's administration and management, specifically regarding the absence of a qualified and certified administrator and lack of a Designation of Facility Responsibility (LIC308).
Findings
The facility lacked a qualified and currently certified administrator, with no LIC308 designation posted or available, and no administrator hired or present on premises. Staff were unsure about the designation form, posing an immediate health and safety risk to residents.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Administrator - Qualifications and Duties: All facilities shall have a qualified and currently certified administrator with coverage by a designated substitute who has adequate qualifications to be responsible and accountable for management and administration of the facility. | Type A |
| No LIC308 posted or made available and no Administrator either hired or on premises, staff unsure of the designation form for who is in charge at this time. This violation poses an immediate health and safety risk to residents in care. | Type A |
Report Facts
Capacity: 48
Census: 35
Plan of Correction Due Date: 3
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 |
| Regina Farinias | Marketing Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 48
Deficiencies: 0
Mar 10, 2022
Visit Reason
The visit was an unannounced case management incident investigation regarding an incident report submitted about Resident #1 (R1). The Licensing Program Analyst conducted interviews and reviewed documentation related to concerns about R1's safety and financial charges.
Findings
The investigation found that the facility did not violate any Title 22 regulations and is collaborating with Adult Protective Services, the Primary Care Physician, and Law Enforcement to ensure R1's physical and monetary safety. No deficiencies were cited.
Complaint Details
The visit was triggered by a complaint involving concerns about unauthorized charges on Resident #1's bank card and the resident's confusion and safety. The complaint was investigated and found unsubstantiated with no regulatory violations.
Report Facts
Charges on Resident's bank card: 2500
Charges on Resident's bank card: 3620
Facility capacity: 48
Resident census: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Frances Santillan | Administrator | Met with Licensing Program Analyst during investigation |
| Victoria Brown | Licensing Program Analyst | Conducted the investigation and interviews |
| Stephen Richardson | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 30
Capacity: 48
Deficiencies: 0
Jan 20, 2022
Visit Reason
The visit was a required unannounced annual inspection conducted to evaluate the facility's compliance with regulations and ensure safety for residents.
Findings
The inspection found no deficiencies. The facility met all regulatory requirements including safety hazards, temperature controls, medication storage, and emergency supplies.
Report Facts
Residents receiving hospice care: 2
Temperature inside facility: 75
Hot water temperature: 115.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Frances Santillan | Administrator | Met with Licensing Program Analysts during inspection |
| Victoria Brown | Licensing Program Analyst | Conducted the inspection |
| Jamie Ivey Canady | Licensing Program Analyst | Conducted the inspection |
| Stephen Richardson | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 48
Deficiencies: 0
Nov 3, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 09/13/2021 regarding staff intimidation of residents, inadequate food service, and failure to conduct required fire drills.
Findings
The investigation found all allegations to be unfounded after interviews, observations, and document reviews. Staff were not intimidating residents, food service was adequate with balanced menus overseen by a dietician, and required fire drills and trainings were conducted and documented.
Complaint Details
The complaint included allegations of staff intimidating residents, inadequate food service, and failure to conduct fire drills. The investigation concluded these allegations were unfounded based on interviews with residents, staff, and administrators, as well as review of documentation and observations.
Report Facts
Estimated Days of Completion: 30
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 |
| Frances Santillan | Administrator | Facility Administrator interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 48
Deficiencies: 3
Sep 28, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 04/26/2021 regarding staff mishandling medication, failure to prevent a resident from wandering, and failure to properly report an incident involving a resident.
Findings
The investigation substantiated all allegations: staff mishandled medication by failing to administer prescribed medications timely; staff failed to prevent a resident from wandering and eloping from the facility; and staff did not properly report incidents or provide requested documentation to the resident's representative. These deficiencies posed immediate health and safety risks.
Complaint Details
The complaint investigation was substantiated. Allegations included mishandling of medication, failure to prevent resident wandering, and failure to properly report incidents. The resident was diagnosed with Mild Cognitive Impairment and Parkinson's disease, and eloped from the facility on 4/12/21. Documentation and incident reports confirmed the allegations.
Severity Breakdown
Type A: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to timely administer medications and failure to notify family or physician about missed medications. | Type A |
| Failure to regularly observe resident for changes and failure to prevent resident elopement. | Type A |
| Failure to provide requested records to resident's representative. | Type A |
Report Facts
Estimated Days of Completion: 120
Capacity: 48
Census: 29
Plan of Correction Due Date: Sep 29, 2021
Dates of Staff In-Service Training: 4/6/21, 5/28/21, 6/17/21, 6/18/21, 7/28/21, 9/22/21
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 |
| Frances Santillan | Administrator | Facility administrator involved in the investigation and named in findings |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 48
Deficiencies: 1
Jun 22, 2021
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that staff mismanaged a resident's medication.
Findings
The investigation substantiated the allegation that a medication error occurred when a resident missed a dose of insulin due to the staff being unable to locate the medication. The Administrator and Nurse had previously submitted an incident report and conducted in-service training. The deficiency posed an immediate health and safety risk to residents.
Complaint Details
The complaint allegation that staff mismanaged a resident's medication was substantiated based on interviews and documentation review. The preponderance of evidence standard was met.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Incidental Medical and Dental Care: Once ordered by the physician the medication is given according to the physician's directions. LPA observed that resident missed a dose of insulin because the insulin was not located until the next morning, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 48
Census: 38
Estimated Days of Completion: 90
Medication inservice dates: Medication inservices conducted on 5/11/21, 5/13/21, 6/3/21, and 6/17/21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jo Franklin | Administrator | Named in medication error incident report |
| Yvonne Holms | Nurse | Named in medication error incident report |
| Frances Santillan | Met with Licensing Program Analyst during investigation and conducted medication inservices | |
| Angela Maynard | Nurse | Conducted medication inservices |
| Victoria Brown | Licensing Program Analyst | Conducted complaint investigation |
| Stephen Richardson | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Annual Inspection
Census: 38
Capacity: 48
Deficiencies: 0
Jun 22, 2021
Visit Reason
The visit was a required, unannounced annual inspection conducted to evaluate compliance with licensing regulations and ensure resident safety and well-being.
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
Residents receiving hospice services: 2
Temperature inside facility: 77
Hot water temperature: 114.4
Perishables observed: 2
Non-perishables observed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Frances Santillan | Administrator | Met during inspection and named in report |
| Angela Maynard | Health and Wellness Director | Met during inspection and named in report |
| Victoria Brown | Licensing Program Analyst | Conducted the inspection |
| Stephen Richardson | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 48
Deficiencies: 0
Jun 18, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 01/11/2021 regarding facility cleanliness, maintenance, resident activities, transportation, and visitation policies.
Findings
All allegations were investigated and deemed unsubstantiated. Observations confirmed that trash was properly managed despite staff shortages, the handicap button was functional though some repairs were pending, activities were provided according to schedule, transportation was limited due to COVID-19 guidelines, and visitation restrictions had been lifted with appropriate communication.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to keep the facility free of trash, disrepair of the handicap button, lack of resident activities, failure to provide transportation as agreed, and prohibition of resident visits. All were found unsubstantiated after inspection and review of documentation.
Report Facts
Capacity: 48
Census: 36
Estimated Days of Completion: 90
Complaint Control Number: 27
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 |
| Frances Santillan | Facility representative met during the investigation | |
| Jo Franklin | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 48
Deficiencies: 4
Jun 14, 2021
Visit Reason
The inspection visit was conducted to investigate a complaint alleging that staff failed to safeguard a resident's financial property resulting in grand theft.
Findings
The complaint was substantiated based on interviews and a police report indicating that Staff #1 misappropriated over $14,000 from Resident #1's finances. The Administrator allowed Staff #1 access to the resident's personal finances, posing an immediate health and safety risk.
Complaint Details
The complaint was substantiated. Staff failed to safeguard a resident's financial property resulting in grand theft. Evidence included interviews and a Sacramento Police Report confirming misappropriation of over $14,000 by Staff #1.
Severity Breakdown
Type A: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Administrator allowed Staff #1 to gain access to Resident #1's personal finances, violating administrative responsibilities. | Type A |
| Staff #1 used Resident #1's funds for personal use, violating residents' personal rights. | Type A |
| Licensee failed to remove Staff #1 from the premises prior to the visit. | Type A |
| Licensee failed to remove Staff #1 from the facility staff roster prior to the visit. | Type A |
Report Facts
Amount misappropriated: 14000
Estimated days of completion: 90
Capacity: 48
Census: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation. |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation. |
| Jo Franklin | Administrator | Administrator who allowed Staff #1 access to resident finances. |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 48
Deficiencies: 0
May 6, 2021
Visit Reason
An unannounced complaint investigation visit was conducted due to allegations received on 2021-01-07 concerning resident neglect, unmet needs, lack of family contact assistance, unclean resident room, and missing belongings.
Findings
The investigation found no substantiated evidence to support the allegations. Interviews and observations indicated that resident needs were met, rooms were cleaned regularly, and missing items were either recovered or unconfirmed. The complaint was determined to be unsubstantiated with no deficiencies cited.
Complaint Details
The complaint investigation was unsubstantiated based on interviews, observations, and review of evidence. Allegations included resident decline due to neglect, unmet needs, lack of assistance with family contact, unclean room, and missing belongings. No deficiencies were cited.
Report Facts
Estimated Days of Completion: 190
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 on the report |
| Jo Franklin | Administrator | Facility administrator named in the report |
| Frances Santillan | Facility representative met during the investigation |
Inspection Report
Census: 35
Capacity: 48
Deficiencies: 0
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 staff requiring immediate removal from the facility. One staff member was excluded as a result, but this exclusion was not related to the facility itself.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jo Franklin | Executive Director | Met with Licensing Program Analysts during the visit. |
| Bruce Jacobs | Licensing Program Analyst | Conducted the case management visit and delivered exclusion orders. |
| Anthony Tuck | Licensing Program Analyst | Conducted the case management visit and delivered exclusion orders. |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager on the report. |
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