Most inspections found no deficiencies, including the most recent monitoring visit on April 11, 2025, which had no issues. The facility consistently met licensing requirements for environment, safety, infection control, and resident care throughout annual and licensing inspections. Two complaint investigations in 2023 were unsubstantiated, with no evidence found to support allegations of inadequate supervision or forced hospice changes. No fines, enforcement actions, or severe deficiencies were noted in any report. The facility’s record shows steady compliance and no emerging concerns over time.
The visit was an unannounced one-year inspection to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be in compliance with all applicable regulations. No deficiencies were observed during the inspection. The facility environment, safety equipment, and resident accommodations met required standards.
An unannounced annual required visit was conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be in compliance with all regulations, including proper maintenance of resident rooms, bathrooms, kitchen, medication storage, fire safety equipment, and infection control practices. No deficiencies were observed during the inspection.
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility forced a resident into choosing another hospice agency.
Findings
Based on interviews with staff, witness, and records reviewed, there was insufficient evidence to support the allegation. The complaint was determined to be unsubstantiated with no evidence found to support the claim.
Complaint Details
Allegation: Facility forced resident into choosing another hospice agency. The investigation included interviews with the resident's son, facility staff, and review of records. It was found that the resident's hospice care was switched due to the original hospice not showing up on admission day, but the facility did not force the switch. The allegation was unsubstantiated.
Report Facts
Facility capacity: 6Resident census: 1
Employees Mentioned
Name
Title
Context
Amber Coxsom
Administrator
Met with Licensing Program Analyst during investigation and provided information related to the complaint
Antonine Richard
Licensing Program Analyst
Conducted the complaint investigation visit and interviews
An unannounced complaint investigation visit was conducted in response to allegations that staff were not providing adequate supervision to residents and that staff were intoxicated while caring for residents.
Findings
The investigation found insufficient evidence to substantiate the allegations. Surveillance video and interviews with staff, residents, and witnesses confirmed that residents' needs were met and no staff were intoxicated or failed to provide adequate supervision.
Complaint Details
The complaint alleged inadequate supervision and staff intoxication. The investigation included interviews with the administrator, staff, residents, and witnesses, as well as review of surveillance video. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 6Census: 4
Employees Mentioned
Name
Title
Context
Amber Coxsom
Administrator
Administrator interviewed and involved in complaint investigation
Jose Calderon
Licensing Program Analyst
Conducted the complaint investigation visit
Eva M Alvarez
Licensing Program Manager
Named as Licensing Program Manager on report
Inspection Report Original LicensingCapacity: 6Deficiencies: 0Jan 30, 2023
Visit Reason
The visit was a scheduled pre-licensing inspection conducted to evaluate the facility for licensing as a Residential Care Facility for the Elderly with an approved total capacity of six residents.
Findings
The facility was found to be in good condition with all bedrooms, bathrooms, kitchen, and common areas meeting required standards. Safety features such as smoke detectors, fire extinguishers, sprinklers, and emergency plans were in place and functional. Infection control measures and medication storage protocols were observed and found adequate. No advisory notes were issued.
Met with Licensing Program Analyst during pre-licensing visit
Wendy Gibbs
Licensing Program Analyst
Conducted the pre-licensing inspection visit
Eva M Alvarez
Licensing Program Manager
Named as Licensing Program Manager on report
Inspection Report Original LicensingCapacity: 6Deficiencies: 0Dec 23, 2022
Visit Reason
Initial licensing evaluation conducted via telephone interview to verify applicant/administrator's understanding of community care facility licensing laws and readiness for facility operation.
Findings
Applicant/administrator demonstrated understanding of licensing laws, facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints reporting, and pre-licensing readiness. Signed documentation and photo ID were obtained.
Employees Mentioned
Name
Title
Context
Amber Coxsom
Licensee/Administrator
Applicant/administrator participating in COMP II interview and confirmed understanding of licensing requirements.
Darla Neeley
Licensing Program Manager
Named as Licensing Program Manager on report.
Diamond Law
Licensing Program Analyst
Named as Licensing Program Analyst on report.
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