Inspection Report Summary
Most inspections found some deficiencies, though several complaint investigations were unsubstantiated. The most recent report from June 4, 2025, showed no deficiencies and found the facility in compliance with safety and regulatory standards. Earlier reports cited issues such as missing physician orders for bed rails, incomplete staff medication training, incomplete hospice and medical assessments, and a past violation for exceeding licensed capacity that posed an immediate safety risk. Civil penalties were assessed in 2022 for staff working without required criminal record clearances, and minor safety concerns like a missing grab bar in a shower were noted in 2023. The facility’s record shows improvement over time, with the latest inspection clean and no enforcement actions currently active.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 0
Jun 4, 2025
Visit Reason
An unannounced required 1-year comprehensive inspection was conducted to evaluate compliance with licensing requirements for the assisted living facility.
Findings
The facility was found to be in compliance with regulations including safe emergency exits, proper food storage, locked medications, functioning smoke and carbon monoxide detectors, and current resident and staff files. No citations were issued during this inspection.
Report Facts
Residents under hospice care: 2
Fire extinguisher inspection date: May 6, 2025
Water temperature: 107
Disaster drill date: Mar 27, 2025
Staff files reviewed: 4
Resident files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eli Hart Ermitano | Administrator | Met with Licensing Program Analyst during inspection and discussed inspection findings |
| Jaime Vado | Licensing Program Analyst | Conducted the unannounced required 1-year inspection |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 2
Jun 14, 2024
Visit Reason
The inspection was a required unannounced 1-year annual visit to evaluate the Hearts at Millwood Assisted Living Facility for compliance with California Code of Regulations, Title 22.
Findings
The facility was toured and found generally safe with appropriate storage of medications and chemicals, operable safety equipment, and maintained records. However, deficiencies were cited related to missing physician orders for residents using half bed rails and staff not completing required annual medication training.
Deficiencies (2)
| Description |
|---|
| Two residents use half bed rails without physician orders maintained in their records. |
| Two staff members have not received the required annual 8 hours of medication-related in-service training. |
Report Facts
Capacity: 6
Census: 5
Liability insurance coverage: 1000000
Liability insurance coverage: 3000000
Deficiencies cited: 2
Plan of Correction due date: Jun 28, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eli Hart Ermitano | Administrator | Certified RCFE administrator overseeing facility operations |
| Audrey Jeung | Licensing Program Analyst | Conducted facility tour and inspection |
| April Cowan | Licensing Program Manager | Supervisor and licensing program manager overseeing the inspection |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 3
Jun 6, 2023
Visit Reason
To complete the annual inspection of 5/22/23, the Licensing Program Analyst reviewed staff training records, client records, and interviewed staff and clients.
Findings
Deficiencies were cited related to hospice care plans, annual medical assessments for residents with dementia, and medication record-keeping. Some corrective actions such as installation of safety equipment were noted, but proof of liability insurance was still pending.
Deficiencies (3)
| Description |
|---|
| Hospice care plan was not maintained for client #4 who was on hospice from 3/7/23 until 6/5/23. |
| Client #1 with dementia did not have an updated annual medical assessment and reappraisal as required. |
| Medications were not logged on Centrally Stored Medications Records upon receipt, only after started or opened. |
Report Facts
Plan of Correction Due Date: Jun 20, 2023
Number of clients referenced in deficiencies: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elaine B. Ermitano | Administrator | Facility administrator named in report header. |
| Audrey Jeung | Licensing Program Analyst | Conducted review and signed the report. |
| Cara Smith | Licensing Program Manager | Supervisor named in report. |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 1
May 22, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by a complaint received on 2022-08-04 alleging the facility operated over capacity.
Findings
The allegation that the facility operated over capacity was substantiated. The investigation found that there were 7 clients residing in the facility from 1/28/22 through 3/22/22, exceeding the licensed capacity of 6, posing an immediate health, safety, or personal rights risk to clients in care.
Complaint Details
The complaint was substantiated based on information from facility staff and review of resident records. The licensee failed to abide by the licensed capacity limitations, posing an immediate risk to clients.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility operated beyond the licensed capacity of 6 residents, with 7 clients residing for 53 days in 2022, violating CCR 87204(a) regarding limitations on capacity and ambulatory status. | Type A |
Report Facts
Clients residing over capacity: 7
Licensed capacity: 6
Census at time of inspection: 5
Days over capacity: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Cara Smith | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 1
May 22, 2023
Visit Reason
Annual inspection of Hearts at Millwood Assisted Living Facility to evaluate compliance with regulations and facility operations.
Findings
The facility was toured and found generally safe with appropriate storage of medications and chemicals, operable safety equipment, and adequate environmental conditions. However, a deficiency was cited for lack of a grab bar in the shower stall of a full bathroom in room 5, which poses a potential safety risk.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Full bathroom in room 5 does not have grab bar in shower stall, posing a potential health, safety or personal rights risk to persons in care. | Type B |
Report Facts
Capacity: 6
Census: 5
Plan of Correction Due Date: Jun 5, 2023
Liability Insurance Coverage: 1000000
Liability Insurance Aggregate: 3000000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eli Ermitano | Certified RCFE Administrator | Oversees facility operations |
| Audrey Jeung | Licensing Program Analyst | Conducted facility tour and inspection |
| Cara Smith | Licensing Program Manager | Supervisor and report signatory |
Inspection Report
Census: 5
Capacity: 6
Deficiencies: 2
Aug 11, 2022
Visit Reason
The visit was a Case Management - Other type of unannounced inspection to evaluate compliance with criminal record clearance requirements for staff at the assisted living facility.
Findings
The inspection found that two staff members worked at the facility without the required criminal record clearance, posing an immediate health and safety risk to clients. Civil penalties were assessed for these violations.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff #1 worked at the facility for 2 days without criminal record clearance. | Type A |
| Staff #2 worked at the facility from 9/2021 to 6/2022 without criminal record clearance. | Type A |
Report Facts
Civil penalty for Staff #1: 200
Civil penalty for Staff #2: 500
Days Staff #1 worked without clearance: 2
Days Staff #2 worked without clearance (max counted): 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elaine B. Ermitano | Administrator | Verified information about staff working without criminal record clearance |
| Audrey Jeung | Licensing Program Analyst | Conducted inspection and signed report |
| Jackie Jin | Licensing Program Manager | Supervisor of licensing evaluation |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 0
Jul 7, 2021
Visit Reason
An annual unannounced inspection was conducted as a required 1-year visit to evaluate the assisted living facility's compliance with regulations.
Findings
The inspection found no deficiencies. The facility was observed to have proper COVID-19 mitigation measures, adequate supplies of PPE and medications, clear exit routes, and all residents and staff were reported fully vaccinated.
Report Facts
Capacity: 6
Census: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elaine Ermitano | Administrator | Met with Licensing Program Analyst during the inspection |
| Gladys Kuizon | Licensing Program Analyst | Conducted the annual inspection |
| George Nwafor | Licensing Program Manager | Named in report header |
Loading inspection reports...
