Inspection Report Summary
Most inspections found no deficiencies, including the most recent report dated October 10, 2025, which was clean and showed the facility had up-to-date staff records and proper safety measures. However, several reports from 2025 revealed issues such as operating beyond licensed capacity, unsecured medications accessible to residents, obstructed passageways, and a resident’s unmanaged health condition, with immediate corrective actions taken. A serious event occurred in June 2025 when a resident overdosed on medication due to staff failing to protect the resident and not promptly calling 9-1-1, which was substantiated and posed immediate health and safety risks. Earlier complaint investigations often found allegations unsubstantiated, though a substantiated sexual abuse case in May 2024 led to staff termination and was a significant concern. Overall, the facility showed improvement by the latest inspection, with no deficiencies cited in October 2025 after addressing prior issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Same as California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
95% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 20
Capacity: 21
Deficiencies: 0
Oct 10, 2025
Visit Reason
The visit was conducted to conclude an annual licensing inspection that commenced on 2025-09-18, as part of the facility's annual licensing requirements.
Findings
The inspection found that all required staff records and certifications were complete and up to date. The facility was properly equipped with safety measures, including a back-up generator and secured hazardous materials. No deficiencies were cited during the visit.
Report Facts
Residents licensed to serve: 21
Residents present: 20
Bedridden residents allowed: 12
Residents allowed to receive Hospice services: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the inspection visit |
| Tess Derafera | Administrator/Director | Facility Administrator |
| Drummond | Administrator | Met with Licensing Program Analyst during inspection |
| Chen | Licensee | Met with Licensing Program Analyst during inspection |
| Madla | Med-Tech | Accompanied Licensing Program Analyst during facility tour |
Inspection Report
Annual Inspection
Census: 22
Capacity: 21
Deficiencies: 3
Sep 24, 2025
Visit Reason
An unannounced case management visit was conducted as a continuation of the Annual Inspection that began on 2025-09-18 to evaluate compliance with licensing requirements.
Findings
The inspection revealed several violations including medications and toxins not centrally stored or locked and accessible to residents, unsupervised medication dispensing, obstructed entry/exits and passageways, a resident with an unmanaged health condition, and improper waste disposal. Immediate corrective actions were agreed upon by the caregiver.
Severity Breakdown
Type A: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Medications and toxins were not centrally stored and/or locked, accessible to residents, violating CCR 87465(h)(2). | Type A |
| Resident's medical needs were not met in accordance with physician's orders, violating CCR 87611(e). | Type A |
| Outdoor and indoor passageways and stairways were obstructed, violating CCR 87307(D)(6). | Type A |
Report Facts
Persons affected by medication storage deficiency: 6
Persons affected by medical care deficiency: 1
Objects obstructing passageways: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the unannounced case management visit and identified deficiencies |
| Galdomer Galvez | Caregiver | Met with Licensing Program Analyst and confirmed immediate corrective actions |
| Robyn Clark | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 21
Capacity: 21
Deficiencies: 1
Sep 19, 2025
Visit Reason
An unannounced case management visit was conducted as a continuation of an Annual Inspection that began on 2025-09-18 to evaluate compliance with licensing requirements.
Findings
The facility was found to have admitted 22 residents despite being licensed for 21, with a shared room converted to accommodate two residents. An application to increase capacity was under review but not yet approved. Deficiencies were cited and further visits are necessary to complete the annual inspection.
Deficiencies (1)
| Description |
|---|
| Admitted more residents than licensed capacity; unauthorized shared room occupancy. |
Report Facts
Residents admitted: 22
Licensed capacity: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gerald Madla | Med-tech | Met with Licensing Program Analyst during inspection and received report. |
| Debbie Correia | Licensing Program Analyst | Conducted the unannounced case management visit and inspection. |
Inspection Report
Annual Inspection
Census: 22
Capacity: 21
Deficiencies: 1
Sep 19, 2025
Visit Reason
The inspection was a Case Management - Annual Continuation visit to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be operating beyond its licensed capacity by admitting a 22nd resident, exceeding the licensed capacity of 21. This posed an immediate health, safety, and personal rights risk to all 22 residents in care.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility admitted a twenty-second (22nd) resident, exceeding the licensed capacity of 21 persons. | Type A |
Report Facts
Licensed capacity: 21
Current census: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tess Derafera | Administrator/Director | Facility administrator named on report |
| Robyn Clark | Licensing Program Manager | Named in report header and signature section |
| Debbie Correia | Licensing Program Analyst | Created report and signed on 09/19/2025 |
| Administrator Drummond | Met with during inspection |
Inspection Report
Complaint Investigation
Census: 21
Capacity: 21
Deficiencies: 2
Sep 18, 2025
Visit Reason
An unannounced case management visit was conducted to deliver findings for an investigation initiated based on a June 2025 incident involving a resident's medication overdose and hospitalization.
Findings
The investigation found that facility staff were aware of the resident's suicidal ideation and medication needs but failed to protect the resident from access to medications, resulting in an overdose and hospitalization. Additionally, staff did not immediately call 9-1-1 during the medical emergency, posing an immediate risk to the resident's health and safety.
Complaint Details
The investigation was initiated following a Special Incident Report regarding a resident's apparent medication overdose on 6/19/2025, hospitalization, and a history of suicidal ideation. The complaint was substantiated based on record reviews and staff interviews.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee did not protect a resident (R1) from access to medications which resulted in overdose and hospitalization, posing an immediate health, safety and personal rights risk. | Type A |
| Facility staff did not immediately telephone 9-1-1 when a resident (R1) was discovered experiencing a medical emergency, posing an immediate health, safety and personal rights risk. | Type A |
Report Facts
Residents in care: 21
Civil penalty amount: 500
Plan of Correction due date: Sep 19, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
| Lynn Drummond | Administrator | Facility administrator involved in interviews and incident response |
Inspection Report
Annual Inspection
Census: 21
Capacity: 21
Deficiencies: 0
Sep 18, 2025
Visit Reason
An unannounced annual required licensing inspection was conducted at the facility.
Findings
No deficiencies were cited during the visit. The inspection included a partial facility tour and records review, with the remaining portion to be completed later due to time constraints.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the unannounced annual licensing inspection. |
| Gerald Madla | Med-tech | Greeted the Licensing Program Analyst during the inspection. |
| Administrator Drummond | Administrator | Met with the Licensing Program Analyst during the inspection and discussed the report. |
Inspection Report
Census: 21
Capacity: 21
Deficiencies: 1
Sep 18, 2025
Visit Reason
An unannounced Case Management Visit was conducted to cite a deficiency identified during a facility file review related to the suspension of the Limited Liability Corporation (LLC) for non-payment.
Findings
One Type B deficiency was cited for failure to exercise general supervision over the affairs of the licensed facility, specifically due to the LLC suspension for non-payment effective May 1, 2025, posing a potential personal rights risk to all 21 residents.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to exercise general supervision over the affairs of the licensed facility; LLC suspended for non-payment effective May 1, 2025. | Type B |
Report Facts
Residents at risk: 21
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the unannounced Case Management Visit and signed the report |
| Lynn Drummond | Administrator | Met with Licensing Program Analyst during the visit |
| Robyn Clark | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Follow-Up
Census: 21
Capacity: 21
Deficiencies: 0
Jun 25, 2025
Visit Reason
The visit was an unannounced case management follow-up regarding a self-reported incident involving Resident #1's misuse of medication.
Findings
During the visit, a health and safety check was conducted, residents were observed, and facility records reviewed. No deficiencies were cited on the date of the visit.
Complaint Details
The visit was triggered by an incident report received on June 24, 2025, describing that on June 19, 2025, Resident #1 consumed three bottles of over-the-counter allergy pills, resulting in lethargy and hospitalization.
Report Facts
Medication quantity consumed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hannah Rodgers | Licensing Program Analyst | Conducted the unannounced case management visit |
| Lynn Drummond | Administrator | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Gerald Madla | Medtech | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 19
Capacity: 21
Deficiencies: 0
Jan 8, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including an unwitnessed resident fall, staff not following feeding/drinking care plans, and untimely diaper changes.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff were observed and interviewed, records reviewed, and it was determined that the resident was not left on the floor for an extended period, feeding plans were followed correctly, and diaper changes were timely.
Complaint Details
The complaint involved three allegations: 1) Resident had an unwitnessed fall and was on the floor for an extended period; 2) Staff were not following the feeding/drinking care plan; 3) Staff were not ensuring timely diaper changes. All allegations were found to be unsubstantiated after investigation.
Report Facts
Capacity: 21
Census: 19
Time of visit: 10.25
Time completed: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gerald Madla | Med Tech | Met with during inspection and involved in exit interview |
| Ryan Fulton | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 20
Capacity: 21
Deficiencies: 0
May 31, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of neglect resulting in pressure injuries and failure to seek timely medical attention for a resident, as well as failure to notify the resident's responsible party of a change in condition.
Findings
The investigation found that the allegations of neglect causing pressure injuries and failure to seek timely medical attention were unsubstantiated, with evidence showing the resident's complex medical condition caused the abscess and that facility staff provided excellent care. The allegation that staff did not notify the resident's responsible party was found unfounded, as the responsible party was present and involved during the change in condition.
Complaint Details
The complaint investigation was unsubstantiated for neglect allegations related to pressure injuries and untimely medical attention, and unfounded for failure to notify the resident's responsible party of a change in condition. The resident had an abscess unrelated to facility neglect, and the responsible party was present during the condition change.
Report Facts
Facility capacity: 21
Census: 20
Complaint control number: 08-AS-20230821153534
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Segura | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tess Derafera | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 20
Capacity: 21
Deficiencies: 1
May 2, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that neglect resulted in sexual abuse of a resident.
Findings
The investigation substantiated that Staff #1 sexually harassed Resident #1 and multiple staff members. Staff #1 was placed on administrative leave and later terminated. The licensee failed to protect one resident from sexual abuse, posing an immediate safety and personal rights risk.
Complaint Details
The complaint alleged neglect resulting in sexual abuse of Resident #1. The investigation found that Resident #1 was sexually assaulted by Staff #1, not by another resident as initially reported. Multiple staff members reported sexual harassment by Staff #1. The allegation was substantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect 1 out of 21 residents in care from sexual abuse, violating Additional Personal Rights of Residents in Privately Operated Facilities. | Type A |
Report Facts
Capacity: 21
Census: 20
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tess Derafera | Administrator | Met during investigation and signed receipt of report and licensing appeal rights |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Annual Inspection
Census: 20
Capacity: 21
Deficiencies: 0
Apr 25, 2024
Visit Reason
An unannounced required annual inspection was conducted to review the facility's compliance with licensing regulations.
Findings
The facility was found to be in full compliance with no deficiencies observed or cited. The environment was safe, clean, and well-equipped, with all required documents and safety equipment in place.
Report Facts
Capacity: 21
Census: 20
Food supply: 2
Food supply: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tess Derafera | Administrator | Facility Administrator present during inspection and exit interview |
| Juliana Barfield | Licensing Program Analyst | Conducted the inspection and authored the report |
| Hydee Jumulon | Caregiver | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 21
Capacity: 21
Deficiencies: 3
Feb 5, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not address a resident's medical condition timely, did not ensure the resident's call pendant was working, did not address a bed bug infestation, and did not meet the resident's incontinence care needs.
Findings
The investigation substantiated that staff failed to timely address a resident's medical condition, did not ensure the call pendant was operable, and did not follow universal precautions regarding bed bugs, posing potential health and safety risks. However, the allegation that staff did not meet the resident's incontinence care needs was unsubstantiated due to inconsistent information and lack of evidence.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not address the resident's medical condition timely, did not ensure the call pendant was working, and did not address bed bug infestation. The allegation that staff did not meet the resident's incontinence care needs was unsubstantiated.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Licensee did not ensure residents are regularly observed for changes in physical condition and report observations. | Type B |
| Licensee did not ensure resident call buttons were operable. | Type B |
| Licensee did not ensure residents were afforded healthful accommodations due to not following universal precautions for bed bug infestation. | Type B |
Report Facts
Capacity: 21
Census: 21
Plan of Correction Due Date: 2024
Number of call buttons given to resident: 3
Resident bowel movements per day: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tess Derafera | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 21
Capacity: 21
Deficiencies: 0
Nov 15, 2022
Visit Reason
The visit was a case management visit initiated by the licensee to review an updated Admissions Agreement.
Findings
The Licensing Program Analyst reviewed the updated Admissions Agreement with the licensee and administrator, identifying sections needing revision including elopement, visitation policy, pet policy, house rules, room changes, and locks for residents. The licensee agreed to rewrite and resubmit the Admissions Agreement for approval.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Esther Miller | Licensing Program Analyst | Conducted the announced case management visit and reviewed the updated Admissions Agreement. |
| Tess Derafera | Administrator | Present during the case management visit. |
| Zayden Chen | Licensee | Requested the case management visit to review the updated Admissions Agreement. |
Inspection Report
Complaint Investigation
Census: 19
Capacity: 21
Deficiencies: 1
Oct 5, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of unlawful eviction of a resident.
Findings
The investigation found that the facility unlawfully evicted a resident by not providing the required 30-day written eviction notice and not allowing the resident to return after hospitalization. The allegation was substantiated based on observations, interviews, and record reviews.
Complaint Details
The complaint alleged unlawful eviction of a resident. The investigation substantiated the allegation, finding that the facility failed to provide the required 30-day written eviction notice and did not allow the resident to return after hospitalization.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee did not give thirty (30) days written notice to evict in one of nineteen residents, posing a potential personal rights risk. | Type B |
Report Facts
Capacity: 21
Census: 19
Deficiencies cited: 1
Plan of Correction Due Date: Oct 28, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Esther Miller | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Denise Powell | Licensing Program Manager | Oversaw the complaint investigation |
| Tess Derafera | Administrator | Facility administrator involved in the investigation and findings |
| Zayden Chen | Licensee | Admitted that the resident was not allowed to return to the facility after hospitalization |
Inspection Report
Census: 19
Capacity: 21
Deficiencies: 1
Oct 5, 2022
Visit Reason
Licensing Program Analyst Esther Miller conducted a case management visit to address a technical violation identified during a prior visit.
Findings
Two staff members were observed providing care without masks. Both staff complied and put on masks when requested. A technical violation was cited per Title 22, Division 6 of the California Code of Regulations.
Deficiencies (1)
| Description |
|---|
| Staff members providing care without a mask |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tess Derafera | Administrator | Administrator involved in the exit interview and notified of the technical violation. |
| Esther Miller | Licensing Program Analyst | Conducted the case management visit and observed the violation. |
Inspection Report
Annual Inspection
Census: 20
Capacity: 21
Deficiencies: 0
Mar 10, 2022
Visit Reason
An unannounced annual required inspection was conducted to verify compliance with statutes, regulations, and other requirements relevant to protecting the health of residents and staff, including infection control practices.
Findings
The inspection found that the facility had implemented COVID-19 mitigation measures including symptom screening, visitor sign-in policy, posted signage for hygiene and distancing, face coverings worn by most staff, hand hygiene stations, designated visitation area, emergency contact information, and adequate PPE supply. However, the visitor sign-in policy was not being enforced by staff.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Manuel Delacruz | Caregiver | Met with Licensing Program Analyst during inspection and discussed COVID-19 mitigation plan. |
Inspection Report
Complaint Investigation
Census: 14
Capacity: 21
Deficiencies: 2
Aug 25, 2021
Visit Reason
An unannounced complaint investigation was conducted based on allegations received on 08/16/2021 regarding hazardous items accessible to residents and failure to follow universal precautions.
Findings
The investigation substantiated that toxic chemicals and hazardous items were accessible to residents with dementia, posing a safety risk, and that universal COVID-19 screening precautions were not properly followed during the visit. Other allegations such as lack of auditory devices and debris hazards were unsubstantiated.
Complaint Details
The complaint investigation was substantiated for hazardous items accessible to residents and failure to follow universal precautions. Other allegations including lack of auditory devices monitoring exits and property debris hazards were unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Toxic substances and hazardous items were accessible to residents with dementia, posing a safety risk to 3 of 14 residents. | Type B |
| Failure to follow universal COVID-19 screening protocols, posing a potential health risk to all 14 residents. | Type B |
Report Facts
Residents in care with dementia at safety risk: 3
Total residents in care: 14
Total licensed capacity: 21
Plan of Correction due date: Sep 3, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tess Derafera | Administrator | Met during investigation and named in findings |
| Dawn Segura | Licensing Program Analyst | Conducted the complaint investigation |
| Rebecca Hedgecock | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Original Licensing
Census: 17
Capacity: 21
Deficiencies: 0
May 19, 2021
Visit Reason
The visit was a pre-licensing virtual inspection conducted to evaluate the facility's compliance with regulations prior to licensing approval.
Findings
The facility was found to be in compliance with Title 22, Division 6, Chapter 8, of California Code of Regulations. Observations included adequate resident accommodations, safety measures, and proper storage of medications and toxic substances.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tiffany Holmes | Licensing Program Analyst | Conducted the pre-licensing virtual visit and inspection. |
| Zayden Chen | Owner | Met with Licensing Program Analyst during the visit. |
| Ma Teresa Derafera | Administrator | Administrator certification expiration date noted. |
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