Deficiencies (last 5 years)
Deficiencies (over 5 years)
8.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
105% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
85% occupied
Based on a March 2026 inspection.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 158
Capacity: 185
Deficiencies: 0
Date: Mar 5, 2026
Visit Reason
The inspection was an unannounced annual visit conducted using the CARE inspection tool to evaluate compliance with licensing requirements for the facility serving elderly residents aged 60 and above.
Findings
The facility was found to be in good repair with clean and comfortable resident rooms, proper infection control practices, and compliance in staff and resident records. No deficiencies were noted during this visit.
Report Facts
Extinguishers checked: 5
Resident rooms tested for emergency call system: 10
Fire drill frequency: 4
Memory care hospice waivers: 8
Memory care building floors: 2
Assisted living building floors: 2
Days of perishable food observed: 2
Days of nonperishable food observed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Macias-Medina | Administrator | Met with Licensing Program Analyst during inspection and exit interview |
| Bonnie Tao | Licensing Program Analyst | Conducted the inspection and signed the report |
| Fernando Fierros | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 158
Capacity: 185
Deficiencies: 0
Date: Mar 5, 2026
Visit Reason
The inspection was an unannounced annual visit conducted using the CARE inspection tool to evaluate compliance with licensing requirements for the facility serving elderly residents aged 60 and above.
Findings
The facility was found to be in good repair with clean and comfortable resident rooms, proper infection control practices, and compliant staff and resident records. No deficiencies were noted during this visit.
Report Facts
Extinguishers checked: 5
Resident rooms tested for emergency call system: 10
Perishable food days observed: 2
Nonperishable food days observed: 7
Fire drill frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Macias-Medina | Administrator | Met with Licensing Program Analyst during inspection and exit interview. |
| Bonnie Tao | Licensing Program Analyst | Conducted the unannounced annual inspection visit. |
| Fernando Fierros | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 156
Capacity: 185
Deficiencies: 0
Date: Feb 26, 2026
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff were not distributing residents' medication as prescribed.
Complaint Details
The complaint alleged that staff were not distributing residents' medication as prescribed. Interviews with ten residents and ten staff members denied the allegation. Medication procedures were confirmed to be followed, including a two-hour window for administration and documentation of missed medications. The allegation was unsubstantiated.
Findings
The investigation included interviews with residents and staff, document reviews, and observations. All interviewed residents and staff denied the allegation, and no health or safety risks were found in reviewed medication records. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Residents interviewed: 10
Staff interviewed: 10
Residents' prescriptions reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Luis DeLeon | Licensing Program Analyst | Conducted the complaint investigation visit |
| Diana Medina | Administrator | Facility administrator met during investigation and exit interview |
| Fernando Fierros | Supervisor | Supervisor overseeing the investigation |
| Odily Franklin | Assisting Living Coordinator | Assisted during physical plant tour |
| S1 | Staff member who described medication destruction and documentation procedures | |
| W1 | Staff member interviewed regarding response to resident's call for assistance and medication administration |
Inspection Report
Complaint Investigation
Census: 156
Capacity: 185
Deficiencies: 0
Date: Feb 26, 2026
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff were not distributing residents' medication as prescribed.
Complaint Details
The complaint alleged that staff were not distributing residents' medication as prescribed. Interviews with ten residents and ten staff members denied the allegation. Documentation and observations supported that medication distribution procedures were followed properly. The allegation was unsubstantiated.
Findings
The investigation included interviews with residents and staff, document reviews, and observations. All interviewed residents and staff denied the allegation, and no health or safety risks were found in reviewed medication records. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Residents interviewed: 10
Staff interviewed: 10
Prescriptions reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Luis DeLeon | Licensing Program Analyst | Conducted the complaint investigation visit |
| Diana Medina | Administrator | Facility administrator met during investigation and exit interview |
| Fernando Fierros | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 28, 2026
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to clarify and continue the prescribed therapeutic diet for a resident upon admission, resulting in the resident receiving an incorrect diet for several days.
Complaint Details
The complaint investigation found that Resident 1's diet was not properly transferred or reconciled from the previous skilled nursing facility, leading to incorrect diet administration. The deficiency was substantiated with minimal harm or potential for actual harm to a few residents.
Findings
The facility failed to ensure Resident 1 received the correct therapeutic diet upon admission due to incomplete transfer of diet orders from the previous facility. This resulted in Resident 1 receiving an incorrect pureed diet for three days instead of the prescribed fortified, soft and bite-sized texture diet. The facility's policy on transfer documentation was not fully followed, leading to missing diet orders and lack of reconciliation.
Deficiencies (1)
F 0808: The facility failed to clarify and continue the therapeutic diet for Resident 1 upon admission, resulting in the resident receiving an incorrect pureed diet for three days instead of the prescribed fortified, soft and bite-sized texture diet.
Report Facts
Days resident received incorrect diet: 3
Residents sampled: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding diet order clarification and transfer documentation | |
| Registered Nurse | Interviewed from previous skilled nursing facility regarding resident diet at discharge |
Inspection Report
Routine
Deficiencies: 9
Date: Dec 12, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, medication use, infection control, pressure ulcer prevention, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and hygiene, improper monitoring of psychotropic medication, incomplete care planning, inadequate grooming services, incorrect pressure ulcer mattress settings, failure to measure PICC line catheter length, unsanitary food service items, improper use of personal protective equipment in isolation rooms, and call lights not within residents' reach.
Deficiencies (9)
F 0550: The facility failed to ensure Resident 19 was free from visible food stains on clothing and dry, crusted discharge on the left eye, compromising dignity and psychosocial well-being.
F 0605: The facility failed to monitor Resident 17's hours of sleep to assess the effectiveness of prescribed Trazodone, risking unnecessary psychotropic drug use.
F 0657: The facility failed to revise Resident 17's care plan to include a companion intervention for behavioral problems, risking inadequate care.
F 0677: The facility failed to provide grooming services for Resident 48, resulting in jagged, dirty fingernails that could cause injury or infection.
F 0686: The facility failed to set Low Air Loss mattresses at correct weight settings for Residents 9 and 28, risking pressure ulcer deterioration and development.
F 0694: The facility failed to measure and document the external catheter length of Resident 24's PICC line after dressing changes, risking line dislodgement and complications.
F 0812: The facility failed to maintain food service items in a clean and sanitary condition, including dented saltshaker, dirty pepper shaker, and chipped plate covers and trays, risking foodborne illness.
F 0880: The facility failed to ensure staff donned proper PPE before entering contact isolation rooms for Residents 28 and 45, risking infection spread.
F 0919: The facility failed to ensure call lights were within reach for Residents 65 and 6, risking delayed assistance and potential falls.
Report Facts
Weight: 111.6
Weight: 86.3
Medication dosage: 50
Medication dosage: 25
External catheter length: 39
Number of dented saltshakers: 1
Number of pepper shakers with residue: 1
Number of burgundy plate covers damaged: 3
Number of black food trays damaged: 27
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 2 | Licensed Vocational Nurse | Named in findings related to Resident 19's grooming and Resident 48's fingernail condition |
| ADON | Assistant Director of Nursing | Provided multiple interviews and policy reviews related to deficiencies |
| PC | Pharmacist Consultant | Interviewed regarding psychotropic medication monitoring for Resident 17 |
| RN 1 | Registered Nurse | Documented PICC line dressing change but omitted catheter length measurement |
| CNA 1 | Certified Nurse's Aide | Observed not wearing gown in contact isolation room |
| LVN 1 | Licensed Vocational Nurse | Observed not wearing gown in contact isolation room |
| IP | Infection Preventionist | Interviewed regarding PPE requirements in isolation rooms |
| RD | Registered Dietitian | Interviewed regarding food service sanitation deficiencies |
| DD | Director of Dining | Interviewed regarding food service sanitation deficiencies |
Inspection Report
Complaint Investigation
Census: 164
Capacity: 185
Deficiencies: 0
Date: Nov 24, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not distributing residents' medication as prescribed.
Complaint Details
The complaint alleged that staff were not distributing residents' medication as prescribed. Interviews with ten residents and ten staff members denied the allegation. Documentation and observations supported that medication was distributed properly. The allegation was unsubstantiated.
Findings
The investigation included interviews with residents and staff, document reviews, and observations. All interviewed residents and staff denied the allegation, and no health or safety risks were found in reviewed prescriptions. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Residents interviewed: 10
Staff interviewed: 10
Capacity: 185
Census: 164
Medication prescriptions reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Luis DeLeon | Licensing Evaluator | Conducted the complaint investigation visit |
| Ellena Mallett | Licensing Program Analyst | Conducted the complaint investigation visit |
| Morris Shockley | President CEO | Met with LPAs during investigation |
| Erika Castile | Vice President, COO | Participated in exit interview |
| Fernando Fierros | Supervisor | Supervisor overseeing the investigation |
| Odily Franklin | Assisting Living Coordinator | Assisted LPAs during physical plant tour |
Inspection Report
Annual Inspection
Census: 93
Capacity: 185
Deficiencies: 0
Date: Apr 17, 2025
Visit Reason
The inspection was conducted as a subsequent annual inspection visit to complete the annual evaluation of the facility's compliance with licensing requirements.
Findings
The facility was found to be in compliance with licensing requirements with no deficiencies observed. Observations included proper safety measures, medication storage, staff training, infection control practices, and maintenance of resident records.
Report Facts
Personnel records reviewed: 5
Resident records reviewed: 8
Licensed capacity: 185
Current census: 93
Non-ambulatory residents: 20
Non-ambulatory residents: 32
Non-ambulatory residents: 33
Hospice residents limit: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Medina | Administrator | Facility Administrator met during inspection and mentioned in staffing and certification |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the inspection and signed the report |
| Tony Vasallo | Supervisor | Supervisor named in the report |
Inspection Report
Annual Inspection
Census: 93
Capacity: 185
Deficiencies: 2
Date: Mar 25, 2025
Visit Reason
The inspection was an unannounced required annual inspection visit conducted to assess compliance with licensing requirements and regulations.
Findings
Two Type A deficiencies were identified related to water temperature controls exceeding regulatory limits, posing immediate health and safety risks. A $250 civil penalty was issued due to a repeat violation from the previous year's annual inspection.
Deficiencies (2)
Water temperatures in sinks used for grooming were above 120 degrees F, exceeding the maximum allowed temperature.
Water in the laundry room sink was above 125 degrees F without warning signs indicating high temperature.
Report Facts
Civil penalty amount: 250
Residents on hospice: 2
Licensed capacity: 185
Current census: 93
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the annual inspection and identified deficiencies |
| Diana Medina | Administrator | Facility administrator involved in plan of correction agreements |
| Tony Vasallo | Licensing Program Manager | Named as licensing program manager on the report |
Inspection Report
Routine
Deficiencies: 12
Date: Oct 25, 2024
Visit Reason
Routine inspection of Hollenbeck Palms nursing home to assess compliance with regulatory requirements including resident care, medication administration, infection control, food safety, and environmental safety.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity during feeding, lack of advance directives in medical charts, improper use of physical restraints without assessment, inadequate incontinent care, unsafe hot water temperatures, oxygen therapy not administered as ordered, inaccurate nurse staffing postings, medication administration errors including late and out-of-parameter dosing, food safety violations including unlabeled and expired foods, uncovered and overfilled garbage containers, and lapses in infection control practices including failure to use PPE and hand hygiene.
Deficiencies (12)
F 0550: Facility staff failed to maintain resident dignity by standing above Resident 1's eye level while assisting with eating, violating the resident's right to be treated with dignity.
F 0578: Facility failed to ensure advance directives were readily available in medical charts for Residents 6 and 108, risking staff not knowing resident wishes in emergencies.
F 0604: Facility failed to conduct assessment prior to use of geriatric chair as a physical restraint for Resident 19, limiting mobility and dignity.
F 0677: Facility failed to provide timely incontinent care to Resident 108, resulting in resident being left soiled for hours causing discomfort and risk of skin breakdown.
F 0689: Hot water temperatures in residents' bathrooms exceeded 120°F, placing Residents 37, 6, and 10 at risk for scalding and burns.
F 0695: Resident 51's oxygen tank was empty during observation, failing to provide oxygen therapy as ordered.
F 0732: Facility failed to post nurse staffing information in a prominent location and ensure accuracy of daily nursing staff reports.
F 0755: Resident 35's 8 AM medications were administered late, increasing risk of adverse health effects.
F 0759: Resident 35 received amlodipine, carvedilol, and losartan despite blood pressure and heart rate parameters indicating medications should be held, risking serious medical complications.
F 0812: Facility failed to label numerous food items with open or use-by dates, discarded dented cans and leaking jars, and maintain temperature logs for refrigerators and dry storage areas.
F 0814: Garbage bins and dumpsters were uncovered, overfilled, and trash was found on the ground, risking pest infestation and disease transmission.
F 0880: Facility failed to ensure staff wore PPE when administering medication via gastrostomy tube to Resident 35, did not implement water management program after water main break, and staff failed hand hygiene when assisting multiple residents with feeding.
Report Facts
Medication errors: 9
Hot water temperature: 128.6
Hot water temperature: 127.7
Resident blood pressure: 184
Resident heart rate: 59
Medication administration time: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | LVN | Administered Resident 35's medications late and administered medications outside physician parameters. |
| Certified Nurse Assistant 4 | CNA | Refused to sit while assisting Resident 1 with eating, violating dignity policy. |
| Director of Nursing | DON | Confirmed medication errors and infection control lapses. |
| Assistant Director of Nursing | ADON | Interviewed regarding medication administration and infection control. |
| Food Services Manager | FSM | Interviewed regarding food safety and garbage disposal deficiencies. |
| Engineer Assistant | EA | Interviewed regarding garbage disposal and water supply issues. |
| Restorative Nurse Assistant 1 | RNA | Failed to perform hand hygiene when feeding residents. |
| Minimum Data Set Nurse | MDSN | Failed to perform hand hygiene when feeding residents. |
| Certified Nurse Assistant 5 | CNA | Failed to perform hand hygiene when feeding residents. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 20, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the use of physical restraints, failure to develop and implement a comprehensive fall care plan, failure to prevent multiple falls, and improper use of psychotropic medication for Resident 1 at the facility.
Complaint Details
The complaint investigation focused on Resident 1's use of physical restraints without proper assessment, failure to develop and implement a fall care plan, failure to prevent multiple falls causing injury, and improper use of psychotropic medication without specific behavioral indications. The findings substantiated these issues.
Findings
The facility failed to ensure Resident 1 was free from physical restraints without proper assessment, did not develop or implement a comprehensive fall care plan, failed to prevent multiple falls resulting in serious injury, and administered psychotropic medication without specific target behavior orders. These deficiencies posed risks of physical and psychological harm to Resident 1.
Deficiencies (4)
F0604: The facility failed to conduct a physical restraint assessment before using a seatbelt on Resident 1, limiting her movement and potentially affecting her wellbeing.
F0656: The facility failed to develop and implement a comprehensive fall care plan with measurable interventions for Resident 1, increasing her risk for further falls.
F0689: The facility failed to prevent multiple falls of Resident 1 by not implementing specific care plan interventions, inadequate supervision, and leaving Resident 1 unattended in a wheelchair, resulting in actual harm including hip fracture and dislocation.
F0758: The facility failed to ensure Resident 1's psychotropic medication order included specific target behaviors for Lorazepam use, risking unnecessary medication administration.
Report Facts
Falls: 3
Morse Fall Scale Score: 55
Lorazepam dosage: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding restraint assessment, fall care plan, and medication administration. |
| CNA 1 | Certified Nurse Assistant | Witnessed Resident 1 fall from wheelchair and provided statements about supervision. |
| CNA 2 | Certified Nurse Assistant | Provided statements about leaving Resident 1 unattended in wheelchair. |
| MDSN | Minimum Data Set Nurse | Interviewed regarding assessments, care plans, and medication orders. |
| DON | Director of Nursing | Interviewed about psychotropic medication order requirements. |
Inspection Report
Complaint Investigation
Census: 168
Capacity: 185
Deficiencies: 0
Date: Aug 8, 2024
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff financially abused a resident by withdrawing large amounts of money from the resident's 401k account and giving it to the facility.
Complaint Details
The complaint alleged staff financially abused a resident. The investigation was unannounced and conducted by Licensing Program Analyst Kimberly Ramirez. The complaint was found to be unfounded, meaning the allegation was false or without reasonable basis.
Findings
The investigation found that the resident resides in an independent living accommodation and does not receive care or supervision from the facility. Based on records and interviews, the complaint was found to be unfounded and was dismissed.
Report Facts
Facility capacity: 185
Census: 168
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Diana Medina | Administrator | Met with investigator during the visit |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 162
Capacity: 185
Deficiencies: 1
Date: Apr 16, 2024
Visit Reason
The inspection was an unannounced annual visit conducted using the full Care Compliance and Regulatory Enforcement (CARE) Tools to complete the required yearly inspection of the facility.
Findings
The facility was generally found to be in good repair with adequate staffing, training, and care plans. However, a deficiency was noted where hot water temperatures in 4 out of 28 resident rooms were below the required minimum of 105 degrees Fahrenheit, posing a potential health and safety risk.
Deficiencies (1)
Hot water temperature in 4 resident rooms was below the required minimum of 105 degrees Fahrenheit.
Report Facts
Residents present: 162
Total licensed capacity: 185
Resident rooms with low hot water temperature: 4
Resident rooms reviewed for water temperature: 28
Full-time staff: 167
Staff files reviewed: 8
Resident files reviewed: 8
Hospice waiver capacity: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Medina | Administrator | Facility administrator met during inspection and responsible for compliance |
| Erik Zaragoza | Licensing Evaluator | Conducted the inspection and authored the report |
| David Sicairos | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Annual Inspection
Census: 162
Capacity: 185
Deficiencies: 0
Date: Apr 4, 2024
Visit Reason
The inspection was an unannounced required 1-year visit to evaluate compliance with care and regulatory standards at the facility.
Findings
The inspection covered 12 CARE tool domains including infection control, physical plant safety, staffing, and resident rights. The facility was found to have adequate staffing, proper fire clearance, and clean food service areas. Due to time constraints, the annual inspection was not completed and will be continued at a later date.
Report Facts
Staff members: 167
Staff files reviewed: 8
Resident files reviewed: 8
Resident files reviewed: 8
Food supply duration: 2
Food supply duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Medina | Administrator | Facility administrator present during inspection |
| Morris Shockley | President and CEO | Facility licensee who granted entrance to inspectors |
| Erik Zaragoza | Licensing Evaluator | Conducted the inspection |
| David Sicairos | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 19, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to report and investigate an injury of unknown origin that may be a result of abuse or neglect for one resident.
Complaint Details
The complaint investigation found that the facility staff failed to report and investigate an injury of unknown origin for Resident 16, which may have been due to abuse or neglect. The deficiency was substantiated based on interviews and record reviews.
Findings
The facility staff failed to implement their Abuse Prevention, Management, and Reporting Policies by not reporting and investigating an injury of unknown origin for Resident 16, resulting in a delay of care for a fracture of the left shoulder. Interviews and record reviews confirmed staff did not report skin discoloration and redness in a timely manner, contrary to facility policies.
Deficiencies (1)
F 0607: The facility failed to develop and implement policies and procedures to prevent abuse, neglect, and theft. Staff did not report or investigate an injury of unknown origin for one resident, resulting in delayed care for a left shoulder fracture.
Report Facts
Residents affected: 1
Inspection Report
Routine
Deficiencies: 9
Date: Nov 19, 2023
Visit Reason
Routine state inspection survey conducted to assess compliance with regulatory requirements in a nursing home facility.
Findings
The facility was found deficient in multiple areas including failure to ensure proper documentation and physician signature on POLST forms, failure to notify physicians of changes in resident conditions, failure to report and investigate potential abuse, inadequate personal care and grooming, improper pressure ulcer prevention, unsafe medication cart security, improper food storage and labeling, lack of coordinated hospice care, and lapses in infection prevention and control practices.
Deficiencies (9)
F 0578: Facility failed to ensure POLST forms coincided with advance directives and were signed by the attending physician, risking conflict in resident care wishes.
F 0580: Licensed nursing staff failed to notify the physician of a resident's change in skin condition, risking delayed care.
F 0607: Facility staff failed to report and investigate an injury of unknown origin that may be abuse or neglect, delaying care for a resident with a fractured shoulder.
F 0677: Facility failed to provide adequate grooming and personal hygiene care to a resident, negatively impacting quality of life.
F 0686: Facility failed to set low air loss mattresses according to resident weight, placing residents at risk for pressure ulcers.
F 0761: Medication cart was left unlocked during medication administration, risking unauthorized access and potential harm.
F 0812: Facility failed to label, date, and discard expired food items properly and maintain infection control in food storage areas, risking resident foodborne illness.
F 0849: Facility failed to ensure coordinated hospice care documentation for residents under hospice services, risking inadequate care.
F 0880: Facility failed to follow infection prevention and control practices including timely PICC dressing changes, hand hygiene during medication administration, and proper disposal of soiled diapers, risking resident infections.
Report Facts
Residents affected: 1
Residents affected: 15
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 6
Weight: 82
Weight: 137
LAL mattress setting: 440
LAL mattress setting: 350
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 3 | LVN | Failed to practice hand hygiene during medication administration and left medication cart unlocked |
| Certified Nursing Assistant 2 | CNA | Reported skin condition change late for Resident 17 |
| Licensed Vocational Nurse 3 | LVN | Failed to notify physician of Resident 17's skin condition |
| Director of Nursing | DON | Acknowledged oversight in POLST signature and medication cart safety |
| Assistant Director of Nursing | ADON | Provided statements on mattress settings and grooming care |
| Registered Nurse Supervisor 2 | RNS | Provided statements on reporting skin changes and abuse |
| Certified Nursing Assistant 1 | CNA | Observed but did not report redness on Resident 16's arm |
| Licensed Vocational Nurse 6 | LVN | Unaware of skin discoloration report on Resident 16 |
| Licensed Vocational Nurse 7 | LVN | Failed to perform hand hygiene during medication administration |
| Medical Record Assistant | MRA | Reported lack of hospice documentation |
| Medical Record Supervisor | MRS | Discussed hospice care coordination |
| Director of Staff Development | DSD | Verified PICC dressing deficiency and infection control issues |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 2
Date: Jul 16, 2023
Visit Reason
The inspection was conducted due to a complaint or concern regarding food safety and pest control in the facility's kitchen, including an active cockroach infestation and suspension of the facility's Public Health Permit by the County of Los Angeles Department of Public Health.
Complaint Details
The visit was complaint-related due to reports of cockroach infestation and unsafe food preparation conditions. The complaint was substantiated by observations of live cockroaches, fecal spotting, damaged kitchen infrastructure, and serving food during permit suspension.
Findings
The facility failed to maintain a safe and sanitary environment in the kitchen, resulting in an active cockroach infestation, damaged wall and floor tiles, and food being served despite suspension of the Public Health Permit. The pest control program was ineffective, leading to closure of the kitchen and potential health risks for all 49 residents.
Deficiencies (2)
F 0812: The facility had an active cockroach infestation in the kitchen, damaged wall and floor tiles, and served food after the Public Health Permit was suspended. These conditions risk food contamination and health hazards for residents.
F 0925: The facility failed to maintain an effective pest control program, resulting in an active cockroach infestation and suspension of the kitchen's Public Health Permit from 7/5/23 to 7/19/23, affecting all 49 residents.
Report Facts
Residents affected: 49
Cockroach sightings: 7
Dates of pest inspections: Pest control inspections were conducted on 1/10/23, 2/17/23, 3/20/23, 4/5/23, 5/6/23, and 6/20/23 with no cockroach activity reported.
Kitchen closure period: 14
Residents served cake: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| District Manager | Interviewed and confirmed live cockroach sightings in the kitchen. | |
| Food Services Manager | Interviewed regarding pest risks, kitchen conditions, and food service during permit suspension. | |
| Environmental Health Specialist | From Los Angeles County Department of Public Health, confirmed suspension of Public Health Permit. | |
| Food Service Staff | Observed serving cake to residents during permit suspension. |
Inspection Report
Annual Inspection
Census: 144
Capacity: 185
Deficiencies: 0
Date: Jun 12, 2023
Visit Reason
The inspection was an unannounced required annual visit conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements for the facility.
Findings
The facility was observed to be in good repair, properly furnished, and compliant with safety and infection control standards. Resident and staff files were complete and in order. No deficiencies were found during this inspection visit.
Report Facts
Residents in hospice care: 0
Resident rooms inspected: 10
Staff files reviewed: 8
Resident files reviewed: 10
Hospice waiver beds: 8
Facility buildings: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Medina | Administrator | Met with Licensing Program Analyst during the inspection and participated in exit interview |
| Alma Gonzalez | Licensing Program Analyst | Conducted the inspection visit |
| Wei Siew Ho | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Capacity: 185
Deficiencies: 0
Date: Nov 29, 2022
Visit Reason
The visit was an unannounced case management inspection triggered by an incident reported on 2022-11-02 involving a resident who fell from an exterior staircase.
Complaint Details
The complaint involved Resident #1 who lost balance and fell from an exterior staircase. The resident was independent and fully ambulatory with no cognitive impairments. The investigation concluded no neglect or supervision issues.
Findings
The investigation found no signs of neglect or lack of supervision related to the incident. No deficiencies were issued following the review of relevant medical and facility records.
Report Facts
Facility capacity: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Medina | Administrator | Met with Licensing Program Analyst during the visit and provided information about the incident. |
| Ashley Calderon | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report. |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 185
Deficiencies: 0
Date: Nov 10, 2022
Visit Reason
The visit was an unannounced case management inspection triggered by an incident reported to Licensing on 2022-11-03 involving a resident fall.
Complaint Details
The complaint involved a fall incident of Resident #1 on 2022-11-01 resulting in injury. The complaint was not substantiated as no neglect or lack of supervision was found.
Findings
The investigation found that Resident #1, an independent resident, fell due to missing a step and sustained a Le Fort 1 level fracture. No neglect or lack of supervision was found, and no deficiencies were issued. Preventative measures such as yellow strips on steps were implemented.
Report Facts
Facility capacity: 185
Resident census: 134
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Medina | Administrator | Met with Licensing Program Analyst during the visit and provided information about the incident |
| Cynthia Chan | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Annual Inspection
Census: 131
Capacity: 171
Deficiencies: 0
Date: Apr 13, 2022
Visit Reason
An unannounced Annual Required / Infection Control visit was conducted to evaluate compliance with health and safety regulations.
Findings
The facility was found to be in good repair with no observed deficiencies. Infection control practices were properly implemented, including COVID-19 protocols, PPE availability, and resident/staff health screenings.
Report Facts
PPE supply duration: 30
Facility capacity: 171
Resident census: 131
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Medina | Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Alma Gonzalez | Licensing Program Analyst | Conducted the inspection visit |
| Stefanie Coronel | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Census: 131
Capacity: 171
Deficiencies: 0
Date: Apr 13, 2022
Visit Reason
The visit was conducted as a Case Management visit to evaluate the facility and discuss a requested increase in capacity from 171 to 185 residents.
Findings
The facility was toured including the memory care unit, bedrooms, bathrooms, and common areas. All areas met Title 22 regulations, emergency systems were tested and working, and no deficiencies were cited during the visit.
Report Facts
Capacity increase request: 185
Current capacity: 171
Current census: 131
Fire safety inspection date: Mar 20, 2022
Non-ambulatory residents clearance: 85
Memory care units: 21
Delayed egress doors: 5
Water temperature: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Medina | Administrator | Met with Licensing Program Analyst and toured facility |
| Patricia Murphy | Vice President | Toured the memory care unit with Licensing Program Analyst and Administrator |
| Alma Gonzalez | Licensing Program Analyst | Conducted the announced visit and inspection |
| Stefanie Coronel | Supervisor | Supervising Licensing Evaluator |
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