Inspection Reports for
Hillcrest Royale

CA, 91360

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Deficiencies (last 6 years)

Deficiencies (over 6 years) 4 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

Same as California average
California average: 4 deficiencies/year

Deficiencies per year

12 9 6 3 0
2021
2022
2023
2024
2025
2026

Census

Latest occupancy rate 63% occupied

Based on a January 2026 inspection.

Occupancy over time

60 90 120 150 Apr 2021 Jun 2022 Aug 2023 Jun 2024 Feb 2025 Jun 2025 Jan 2026

Inspection Report

Complaint Investigation
Census: 91 Capacity: 145 Deficiencies: 0 Date: Jan 29, 2026

Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that staff did not ensure a resident was kept clean, dry, and free of mal odors.

Complaint Details
The complaint alleged that staff did not ensure the resident was kept clean and dry at all times and did not ensure the resident was free of mal odors. The investigation included interviews with staff, residents, family, and the resident's Power of Attorney, as well as record reviews. The allegations were deemed unsubstantiated.
Findings
After interviews, file reviews, and observations, the allegations were found to be unsubstantiated due to insufficient evidence. The resident was considered independent, well-kept, and there were no prior issues or concerns regarding hygiene or mal odors.

Report Facts
Capacity: 145 Census: 91 Number of allegations: 2 Number of interviews: 6 Number of telephonic interviews: 5

Employees mentioned
NameTitleContext
Erica MosleyLicensing Program AnalystConducted the complaint investigation
Michelle GubbayDirector of ServicesMet with Licensing Program Analyst during the investigation
Inga JakobovichAdministratorProvided information regarding the resident and facility care
Kasandra LopezSupervisorSupervisor overseeing the investigation

Inspection Report

Annual Inspection
Census: 87 Capacity: 145 Deficiencies: 0 Date: Jun 26, 2025

Visit Reason
The inspection was an unannounced required annual visit to evaluate the facility's compliance with Title 22 regulations and ensure there are no health and safety hazards.

Findings
The facility was found to be in compliance with all applicable regulations, including fire safety, infection control, emergency disaster planning, medication management, and record keeping. No deficiencies or citations were issued during the inspection.

Report Facts
Residents interviewed: 8 Staff interviewed: 10 Family visitors interviewed: 1 Bedrooms inspected: 10 Personnel files reviewed: 8 Resident files reviewed: 9 Medication review: 6 Fire extinguisher last serviced: Feb 14, 2025 Last fire inspection date: Jun 10, 2025 Last emergency disaster drill: Jun 24, 2025 Hot water temperature range: 114.1-117.7 Perishable food supply: 2 Non-perishable food supply: 7

Employees mentioned
NameTitleContext
Miriam RubinsteinAdministratorMet with Licensing Program Analyst during inspection
Erica MosleyLicensing Program AnalystConducted the inspection and authored the report
Kasandra LopezLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Annual Inspection
Census: 87 Capacity: 145 Deficiencies: 0 Date: Jun 26, 2025

Visit Reason
The inspection was an unannounced required annual visit conducted to ensure the facility's compliance with Title 22 regulations and to check for health and safety hazards.

Findings
The facility was found to be in compliance with Title 22 regulations with no citations issued. The physical plant, infection control, emergency disaster planning, medication storage, resident and personnel records, and other operational areas were all satisfactory at the time of inspection.

Report Facts
Residents interviewed: 8 Staff interviewed: 10 Family visitors interviewed: 1 Bedrooms inspected: 10 Personnel files reviewed: 8 Resident files reviewed: 9 Medications reviewed: 6 Fire extinguisher last serviced: Feb 14, 2025 Last fire inspection date: Jun 10, 2025 Last emergency disaster drill: Jun 24, 2025

Employees mentioned
NameTitleContext
Miriam RubinsteinAdministratorMet with Licensing Program Analyst during inspection
Erica MosleyLicensing Program AnalystConducted the inspection and authored the report
Kasandra LopezLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Monitoring
Census: 82 Capacity: 145 Deficiencies: 0 Date: Feb 14, 2025

Visit Reason
Unannounced case management visit to check the health and safety of residents following a reported smoke/fire incident at the facility on 2025-02-13.

Findings
The fire was electrical in nature with no foul play suspected. Residents were evacuated safely, only one resident was relocated, and no additional residents were affected. The facility was inspected by fire department and fire alarm system representatives with no concerns observed during the visit.

Report Facts
Incident time: 1245 Incident report date: Feb 13, 2025

Employees mentioned
NameTitleContext
Kelly DulekLicensing Program AnalystConducted the unannounced case management visit
Kristin HeffernanLicensing Program ManagerNamed in report header
Michelle GubbayFacility DesigneeMet with Licensing Program Analyst during visit
Marian RubensteinFacility DesigneeArrived during visit related to incident

Inspection Report

Census: 82 Capacity: 145 Deficiencies: 0 Date: Feb 14, 2025

Visit Reason
An unannounced case management visit was conducted to check the health and safety of residents following a reported smoke/fire incident at the facility on 2025-02-13.

Findings
The fire was electrical in nature, activated the sprinkler system, and caused evacuation of residents. One resident was relocated due to the incident. No concerns were observed during the health and safety check, and no citations were issued.

Report Facts
Capacity: 145 Census: 82

Employees mentioned
NameTitleContext
Kelly DulekLicensing Program AnalystConducted the unannounced case management visit
Michelle GubbayFacility DesigneeMet with Licensing Program Analyst and involved in incident response
Marian RubensteinDesigneeArrived during the inspection visit

Inspection Report

Complaint Investigation
Census: 82 Capacity: 145 Deficiencies: 0 Date: Feb 5, 2025

Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation of lack of care and/or supervision resulting in a physical altercation and injury between residents.

Complaint Details
The complaint alleged that due to lack of care and/or supervision, residents engaged in a physical altercation resulting in injury. The investigation included interviews, document reviews, and a facility tour. The allegation was unsubstantiated as evidence was insufficient to confirm the violation.
Findings
The investigation found that a physical altercation occurred between two residents resulting in injury, but both residents were independent and did not require constant supervision. The allegation was deemed unsubstantiated due to insufficient evidence to prove the alleged violation.

Report Facts
Staff response count: 5 Complaint received date: Dec 9, 2024 Incident date: Dec 7, 2024

Employees mentioned
NameTitleContext
Kelly DulekLicensing Program AnalystConducted the complaint investigation and visits
Michael SokolowskiExecutive DirectorMet with Licensing Program Analyst during investigation
Veronica PadillaInvestigations Branch InvestigatorInterviewed residents during investigation
Kristin HeffernanLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Complaint Investigation
Census: 89 Capacity: 145 Deficiencies: 0 Date: Aug 29, 2024

Visit Reason
The visit was conducted as a complaint investigation following an allegation that staff does not provide a comfortable room temperature for residents due to a malfunctioning heater.

Complaint Details
The complaint alleged that staff did not provide a comfortable room temperature for residents because the facility's heater had been in disrepair for months. The allegation was found unsubstantiated based on interviews, records, and observations.
Findings
The investigation found that the facility was undergoing renovations to install a new heating and air conditioning system, residents and family were notified, and portable heaters and air conditioners were provided to affected residents. Interviews with nine residents revealed no concerns about room temperature. The allegation was deemed unsubstantiated.

Report Facts
Capacity: 145 Census: 89 Residents interviewed: 9

Employees mentioned
NameTitleContext
Martha ArroyoLicensing Program AnalystConducted the complaint investigation visit
Michelle GubbayDirector of ServicesMet with the Licensing Program Analyst during the investigation
Desaree PereraLicensing Program ManagerNamed in the report as Licensing Program Manager

Inspection Report

Annual Inspection
Census: 84 Capacity: 145 Deficiencies: 2 Date: Jun 24, 2024

Visit Reason
The inspection was an unannounced required annual visit to ensure the facility's compliance with health and safety regulations and Title 22 requirements.

Findings
The facility was generally found to be in compliance with health and safety standards, including proper food storage, clean and furnished resident rooms, operational safety equipment, and adequate infection control measures. However, deficiencies were cited related to the absence of evacuation chairs in stairwells and lack of valid first aid/CPR certification for most staff files reviewed.

Deficiencies (2)
No evacuation chair at each stairwell as required, posing an immediate health, safety or personal rights risk to persons in care.
Seven out of eight staff files reviewed did not have a valid first aid/CPR certification on file, posing a potential health, safety or personal rights risk to persons in care.
Report Facts
Civil Penalty: 500 Personnel records reviewed: 8 Staff files lacking valid first aid/CPR certification: 7 Resident records reviewed: 8 Bedrooms inspected: 8 Fire extinguishers last serviced: Nov 28, 2023

Employees mentioned
NameTitleContext
Brian BalisiLicensing Program AnalystConducted the inspection and authored the report.
Desaree PereraLicensing Program ManagerSupervisor overseeing the inspection.
Miriam RubinsteinAdministratorFacility administrator met with LPAs during the inspection.

Inspection Report

Annual Inspection
Census: 84 Capacity: 145 Deficiencies: 2 Date: Jun 24, 2024

Visit Reason
The inspection was an unannounced required annual visit to ensure the facility's compliance with Title 22 Regulations and to check for health and safety hazards.

Findings
The facility was generally found to be in compliance with regulations, with clean and properly furnished resident rooms and common areas, adequate infection control measures, and proper medication storage. However, deficiencies were cited related to the absence of evacuation chairs in stairwells and lack of valid first aid/CPR certification for most staff files reviewed.

Deficiencies (2)
No evacuation chair observed at each stairwell, posing an immediate health, safety or personal rights risk to persons in care.
Seven out of eight staff files reviewed did not have a valid first aid/CPR certification on file, posing a potential health, safety or personal rights risk to persons in care.
Report Facts
Civil Penalty Amount: 500 Personnel records reviewed: 8 Staff files lacking valid first aid/CPR certification: 7 Resident records reviewed: 8 Bedrooms inspected: 8 Floors inspected: 3

Employees mentioned
NameTitleContext
Brian BalisiLicensing Program AnalystConducted the inspection and authored the report.
Miriam RubinsteinAdministratorFacility administrator met with LPAs during the inspection.
Desaree PereraSupervisorSupervisor overseeing the inspection.

Inspection Report

Annual Inspection
Census: 87 Capacity: 145 Deficiencies: 2 Date: Aug 2, 2023

Visit Reason
The visit was an unannounced continuation of a required annual inspection that began on 2023-06-19, conducted to review compliance with licensing regulations including personnel records, resident care, medication administration, and infection control.

Findings
The inspection found seven staff members not properly associated with the facility posing an immediate health and safety risk, and one instance of a missed medication administration for a resident. Resident records and infection control measures were found to be in order. Civil penalties were assessed for the deficiencies.

Deficiencies (2)
Seven staff members (S1, S2, S3, S4, S5, S6, S7) were not associated with the facility as required, posing an immediate health and safety risk.
One morning dose of Digoxin for Resident #1 on 08/01/2023 was not administered as prescribed, posing an immediate health and safety risk.
Report Facts
Staff not associated: 7 Resident files audited: 5 Missed medication dose: 1 Facility capacity: 145 Census: 87

Employees mentioned
NameTitleContext
Inga JakobovichAdministratorNamed in relation to staff association deficiencies and facility management.
Elsie CamposLicensing Program AnalystConducted the inspection and authored the report.
Jeralyn Ann PfannenstielLicensing Program ManagerSupervisor overseeing the inspection.

Inspection Report

Annual Inspection
Census: 87 Capacity: 145 Deficiencies: 2 Date: Aug 2, 2023

Visit Reason
The visit was an unannounced continuation of a required annual inspection that began on 2023-06-19, conducted to review compliance with licensing regulations including personnel and resident records.

Findings
The inspection found that seven staff members were not properly associated with the facility, posing an immediate health and safety risk, and one resident did not receive a prescribed medication dose. All other records and infection control measures were in order.

Deficiencies (2)
Seven staff members (S1, S2, S3, S4, S5, S6, S7) were not associated with the facility as required by criminal record clearance regulations.
One morning dose of Digoxin medication for Resident #1 was not administered as prescribed.
Report Facts
Staff not associated: 7 Resident medication error: 1 Census: 87 Total capacity: 145

Employees mentioned
NameTitleContext
Inga JakobovichAdministratorNamed in relation to staff association deficiencies and facility management.
Elsie CamposLicensing Program AnalystConducted the inspection and authored the report.
Jeralyn Ann PfannenstielSupervisorSupervisor overseeing the inspection.

Inspection Report

Annual Inspection
Census: 87 Capacity: 145 Deficiencies: 0 Date: Aug 1, 2023

Visit Reason
The visit was an unannounced continuation of a required annual inspection that began on 2023-06-19, conducted to review staff records and compliance.

Findings
The Licensing Program Analyst began a records review focusing on staff associations and personnel reports, identifying 7 staff members needing further record review. Due to time constraints, the inspection was not completed and will continue at a later date.

Report Facts
Staff requiring further record review: 7

Employees mentioned
NameTitleContext
Elsie CamposLicensing Program AnalystConducted the inspection and records review
Inga JakobovichAdministratorFacility administrator met with Licensing Program Analyst during inspection
Jeralyn Ann PfannenstielLicensing Program ManagerNamed as Licensing Program Manager on the report

Inspection Report

Annual Inspection
Census: 87 Capacity: 145 Deficiencies: 0 Date: Aug 1, 2023

Visit Reason
The inspection visit was an unannounced continuation of a required annual visit that began on 2023-06-19, conducted to review facility compliance and records.

Findings
The Licensing Program Analyst began a records review focusing on staff associations and personnel reports, identifying 7 staff members needing further record review. Due to time constraints, the inspection was not completed and will be continued at a later date.

Employees mentioned
NameTitleContext
Elsie CamposLicensing Program AnalystConducted the inspection and records review
Inga JakobovichAdministratorFacility administrator met with the Licensing Program Analyst during the visit
Jeralyn Ann PfannenstielSupervisorSupervisor overseeing the inspection

Inspection Report

Annual Inspection
Census: 85 Capacity: 145 Deficiencies: 3 Date: Jun 19, 2023

Visit Reason
The Licensing Program Analyst conducted an unannounced required annual visit to evaluate the facility's compliance with Title 22 Regulations and ensure there are no health and safety hazards.

Findings
The inspection found expired and moldy food items in the kitchen, water damage on the ceiling of bedroom 204, and taps delivering hot water above the regulated temperature, all posing health and safety risks. The facility was otherwise clean, with no obstructions or tripping hazards observed in common areas.

Deficiencies (3)
Ceiling in bedroom 204 observed to have water damage posing an immediate health and safety risk.
Moldy lettuce, moldy tomatoes, and expired prune juice discovered in the kitchen posing an immediate health and safety risk.
Taps throughout the facility delivering hot water up to 125.4 degrees F, exceeding the maximum allowed temperature and posing a potential health and safety risk.
Report Facts
Hot water temperature: 125.4 Deficiency due date: Jun 20, 2023 Deficiency due date: Jun 23, 2023

Employees mentioned
NameTitleContext
Inga JakobovichAdministratorMet with Licensing Program Analyst during inspection and responsible for discarding expired food items
Elsie CamposLicensing Program AnalystConducted the inspection and authored the report
Jeralyn Ann PfannenstielLicensing Program ManagerSupervisor overseeing the inspection

Inspection Report

Annual Inspection
Census: 85 Capacity: 145 Deficiencies: 3 Date: Jun 19, 2023

Visit Reason
The Licensing Program Analyst (LPA) conducted an unannounced required annual visit to evaluate the facility's compliance with Title 22 Regulations and ensure there are no health and safety hazards.

Findings
The inspection found water damage on the ceiling in bedroom 204, expired and moldy food items in the kitchen, and taps delivering hot water above the regulated temperature, posing immediate or potential health and safety risks. The facility was otherwise clean, with no obstructions or tripping hazards observed.

Deficiencies (3)
Ceiling in bedroom 204 had water damage posing an immediate health and safety risk.
Moldy lettuce, moldy tomatoes, and expired prune juice found in the kitchen posing an immediate health and safety risk.
Taps throughout the facility were delivering hot water up to 125.4 degrees F, exceeding the maximum allowed temperature and posing a potential health and safety risk.
Report Facts
Water temperature: 125.4 Deficiency due date: Jun 20, 2023 Deficiency due date: Jun 23, 2023

Employees mentioned
NameTitleContext
Inga JakobovichAdministratorMet with Licensing Program Analyst during inspection and responsible for discarding expired food items
Elsie CamposLicensing Program AnalystConducted the inspection and authored the report
Jeralyn Ann PfannenstielSupervisorSupervisor overseeing the inspection

Inspection Report

Annual Inspection
Census: 94 Capacity: 145 Deficiencies: 3 Date: Jun 18, 2022

Visit Reason
The visit was an unannounced required annual inspection with a specific emphasis on infection control practices and procedures.

Findings
The inspection found deficiencies related to hot water temperature in resident faucets, staff not wearing masks in common areas, and the medication room door lock being non-functional, posing immediate health and safety risks. The facility was otherwise compliant with infection control signage, PPE supply, and visitation requirements.

Deficiencies (3)
Level 2 resident's restroom faucets deliver hot water measured at 100 and 104 degrees Fahrenheit, below the required minimum of 105 degrees Fahrenheit.
Four staff were observed not wearing masks/face coverings in common areas.
The medication room door lock did not lock, making medication accessible to residents.
Report Facts
Census: 94 Total Capacity: 145 Hot water temperature: 100 Hot water temperature: 104 Hot water temperature: 116.6 Hot water temperature: 105.8 Fire extinguisher last serviced: Nov 21, 2021 Plan of Correction Due Date: Jun 24, 2022

Employees mentioned
NameTitleContext
Inga JakobovichAdministratorNamed in relation to findings and corrective actions
Martha ArroyoLicensing Program AnalystConducted the inspection and authored the report
Desaree PereraLicensing Program ManagerSupervisor overseeing the inspection

Inspection Report

Annual Inspection
Census: 94 Capacity: 145 Deficiencies: 3 Date: Jun 18, 2022

Visit Reason
The Licensing Program Analyst conducted an unannounced required annual inspection with a specific emphasis on infection control practices and procedures.

Findings
The facility was found to have deficiencies including staff not wearing masks, hot water temperatures below required levels in resident restrooms, and the medication room door not locking. The Administrator took immediate corrective actions during the visit.

Deficiencies (3)
Level 2 resident restroom faucets deliver hot water measured at 100 and 104 degrees Fahrenheit, below the required minimum of 105 degrees Fahrenheit.
Four staff were observed not wearing masks/face coverings in common areas, posing a health and safety risk.
Medication room door did not lock, making medications accessible to residents.
Report Facts
Hot water temperature: 100 Hot water temperature: 104 Hot water temperature: 116.6 Hot water temperature: 105.8 Staff not wearing masks: 4 Resident bedrooms observed: 4 Capacity: 145 Census: 94

Employees mentioned
NameTitleContext
Inga JakobovichAdministratorFacility Administrator present during inspection and involved in corrective actions
Martha ArroyoLicensing Program AnalystConducted the inspection
Desaree PereraSupervisorSupervisor overseeing the inspection

Inspection Report

Complaint Investigation
Census: 72 Capacity: 145 Deficiencies: 2 Date: Apr 23, 2021

Visit Reason
The visit was a Case Management-Incident investigation initiated to conclude a previous investigation regarding a resident with a pressure injury and related incident reports.

Complaint Details
The investigation was complaint-related, initiated due to an Unusual Incident Report about a resident's pressure injury worsening and failure to report an urgent care visit. The complaint was substantiated based on evidence of prohibited health condition retention and reporting failures.
Findings
The facility retained a resident with a prohibited health condition (Stage 3 or higher pressure injury) and failed to submit an incident report for an urgent care visit, posing health and safety risks to residents.

Deficiencies (2)
Retained Resident #1 with a prohibited health condition, a Stage 3 or 4 pressure injury.
Failed to submit an incident report when Resident #1 went to the emergency room on 3/16/2021.
Report Facts
Facility capacity: 145 Resident census: 72 Plan of Correction due date: Apr 26, 2021 Plan of Correction due date: Apr 28, 2021

Employees mentioned
NameTitleContext
Ashley SmithLicensing Program AnalystConducted the Case Management-Incident visit and investigation
Inga JakobovichAdministratorInterviewed during the investigation and discussed findings
Marian RubensteinAdministratorInterviewed telephonically during the complaint investigation

Inspection Report

Complaint Investigation
Census: 72 Capacity: 145 Deficiencies: 2 Date: Apr 23, 2021

Visit Reason
The visit was a Case Management-Incident investigation initiated to conclude a complaint investigation started on 2021-04-01 regarding a resident's pressure injury and related incident reports.

Complaint Details
The complaint investigation was substantiated based on evidence that the facility retained a resident with a Stage 3 pressure injury and failed to report an incident related to the resident's urgent care visit on 2021-03-16.
Findings
The facility retained a resident with a prohibited health condition (Stage 3 pressure injury that became unstageable) and failed to submit an incident report for the resident's urgent care visit on 2021-03-16. Deficiencies were cited for these violations.

Deficiencies (2)
Retained resident with a prohibited health condition: Stage 3 or 4 pressure injuries.
Failure to submit required incident report for resident's ER visit on 2021-03-16.
Report Facts
Deficiencies cited: 2 Plan of Correction Due Dates: POC due dates were 2021-04-26 for Type A deficiency and 2021-04-28 for Type B deficiency.

Employees mentioned
NameTitleContext
Ashley SmithLicensing Program AnalystInitiated and conducted the Case Management-Incident visit and investigation.
Inga JakobovichAdministratorFacility administrator interviewed during investigation and discussed findings.
Marian RubensteinAdministratorAdministrator interviewed telephonically during complaint investigation.

Inspection Report

Complaint Investigation
Census: 87 Capacity: 145 Deficiencies: 0 Date: Apr 1, 2021

Visit Reason
The inspection was conducted as a Case Management-Incident visit triggered by a complaint investigation related to an unusual incident report about a resident's pressure injury.

Complaint Details
The complaint investigation was initiated due to an Unusual Incident Report submitted on 04/01/2021 regarding Resident #1 who developed a Stage 4 pressure injury after initial redness was observed on 03/16/2021. The resident was taken to urgent care and later hospitalized. The Administrator reported leaving a message for the On-Duty Worker about the incident on approximately 03/19/2021.
Findings
The facility reported a resident with a Stage 4 pressure injury that was initially observed as redness and progressed despite care. No immediate health and safety concerns were observed during the virtual physical plant tour. Further investigation is required prior to issuing findings.

Report Facts
Facility capacity: 145 Resident census: 87

Employees mentioned
NameTitleContext
Ashley SmithLicensing Program AnalystInitiated the Case Management-Incident visit and conducted the virtual inspection
Inga JakobovichAdministratorFacility Administrator involved in the incident and virtual inspection

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