Most inspections found no deficiencies, including the most recent report dated October 22, 2025, which was perfect with no deficiencies noted. A few complaint investigations were substantiated over time, primarily involving resident rights issues such as denying a hospice visit in July 2023 and failing to address a resident disturbing others in the dining room and not reporting incidents in August 2025. Other substantiated deficiencies included fall prevention and nail care failures in 2020 and a personal rights violation related to closing the dining hall for a private event in 2021. Several complaint investigations were unsubstantiated, including allegations about food service, staffing, and medical attention. The facility’s record shows improvement with no deficiencies in recent annual inspections and complaint investigations, although some isolated issues related to resident rights and incident reporting occurred in the past.
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident sustained a fall while in care.
Findings
The investigation included interviews and record reviews and revealed conflicting reports regarding the resident's fall. Due to lack of preponderance of evidence, the allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that a resident sustained a fall while in care. The investigation found conflicting witness statements and record reviews, including a witnessed fall caused by seizure and subsequent hospital transport. The allegation was unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 185Census: 172
Employees Mentioned
Name
Title
Context
Jenifer Tirre
Licensing Program Analyst
Conducted the complaint investigation and made the unannounced visit
Mike Marion
Facility representative met during the investigation and exit interview
The inspection was an unannounced complaint investigation visit triggered by an allegation of unlawful eviction received on 2025-07-22.
Findings
The investigation found that the facility served Resident 1 an eviction notice for violating the Admission Agreement. The eviction notice was lawful and contained all required information. The facility later rescinded the eviction notice and informed Resident 1, who acknowledged the rescission. The allegation of unlawful eviction was deemed unfounded.
Complaint Details
The complaint alleged unlawful eviction. The investigation found the eviction notice lawful but later rescinded by the facility. Resident 1 is no longer required to leave. The allegation was deemed unfounded.
Report Facts
Capacity: 185Census: 170Dates of eviction incidents: Incidents occurred on June 25, 2025 and July 1, 2025
Employees Mentioned
Name
Title
Context
Joseph Alejandre
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Mike Marion
Executive Director
Met with Licensing Program Analyst during the investigation
The inspection was an unannounced case management visit conducted to investigate complaint #22-AS-20250722122317 regarding a resident (R2) coughing and hacking in the dining room disturbing other residents, and incidents involving a resident yelling at another resident and a staff member that were not reported to the Agency.
Findings
The facility failed to address the issue of R2 coughing and hacking in the dining room, violating the personal rights of other residents. Additionally, two incidents of resident yelling were verified but not reported to the Agency, posing potential health, safety, and personal rights risks.
Complaint Details
The complaint investigation substantiated that Resident R2 was coughing and hacking in the dining room since January 2025, disturbing other residents. It was also substantiated that two incidents of resident yelling occurred on June 25 and July 8, 2025, which were not reported to the Agency as required.
Severity Breakdown
Type A: 1Type B: 1
Deficiencies (2)
Description
Severity
Failure to provide safe, healthful and comfortable accommodations, furnishings and equipment as evidenced by the facility not addressing R2 coughing and hacking during mealtimes disturbing other residents since January 2025.
Type A
Failure to report incidents involving resident yelling on June 25, 2025 and July 8, 2025 to the licensing agency, posing a potential health, safety and personal rights risk to residents.
Type B
Report Facts
Residents reporting issue: 8Staff reporting issue: 5Incidents not reported: 2Plan of Correction Due Date: 1Plan of Correction Due Date: 10
Employees Mentioned
Name
Title
Context
Mike Marion
Executive Director
Met with Licensing Program Analyst and verified reports of resident coughing and incidents
Joseph Alejandre
Licensing Program Analyst
Conducted unannounced case management visit and investigation
Sheila Santos
Licensing Program Manager
Named as Licensing Program Manager overseeing the inspection
An unannounced visit was conducted by Licensing Program Analyst Michael Tea to perform a health and safety check and to follow up on a death report for Resident 1 dated August 20, 2025.
Findings
The Licensing Program Analyst toured the facility, conducted a health and safety check on all residents, and observed no health and safety issues. Pertinent resident documentation was reviewed and a questionable death report was completed.
Employees Mentioned
Name
Title
Context
Michael Tea
Licensing Program Analyst
Conducted the unannounced health and safety visit and follow-up on death report.
Mike Marion
Executive Director
Met with Licensing Program Analyst during the visit and participated in exit interview.
An unannounced annual inspection was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be in compliance with all applicable regulations, with no deficiencies cited. The environment was safe, well-maintained, and residents' files were complete.
Report Facts
Fire extinguishers checked: 11Hot water temperature range: 113.8Hot water temperature range: 115.5Ambulatory residents licensed: 30Non-ambulatory residents licensed: 155Bedridden residents licensed: 15Hospice waiver residents: 30Emergency drill date: Jun 25, 2025
Employees Mentioned
Name
Title
Context
Samer Haddadin
Licensing Program Analyst
Conducted the inspection and authored the report.
Mike Marion
Executive Director
Facility representative who met with the Licensing Program Analyst during the inspection.
The visit was conducted to deliver amended complaint investigation findings related to Complaint Control No 22-AS-20250703124044 for a complaint investigation visit dated July 8, 2025.
Findings
The report documents the delivery of amended complaint investigation findings to the facility's Executive Director. An exit interview was conducted and a copy of the report was provided at the end of the visit.
Complaint Details
The visit was related to complaint investigation findings for Complaint Control No 22-AS-20250703124044. The findings were amended and delivered during this unannounced visit.
Employees Mentioned
Name
Title
Context
Mike Marion
Executive Director
Met with during the visit and involved in the exit interview and delivery of complaint investigation findings.
Eboni Bentley
Licensing Program Analyst
Arrived at the facility to deliver amended complaint investigation findings.
Jessica Cho
Licensing Program Analyst
Arrived at the facility to deliver amended complaint investigation findings.
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not providing adequate food service to residents.
Findings
Based on observations of meal service, interviews with residents and staff, review of menus, and a kitchen tour, the investigation found that residents were provided with adequate, nutritious meals with alternative options available. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff were not providing adequate food service to residents. The investigation found no evidence to substantiate this allegation, and it was deemed unsubstantiated.
Report Facts
Resident count during inspection: 166Facility capacity: 185Number of residents interviewed: 16Number of staff interviewed: 3
Employees Mentioned
Name
Title
Context
Eboni Bentley
Licensing Program Analyst
Conducted the complaint investigation
Jessica Cho
Licensing Program Analyst
Assisted in conducting the complaint investigation
Mike Marion
Executive Director
Met with investigators during the inspection and exit interview
TiMarie Morrissey
Business Office Manager
Met with investigators during the inspection and exit interview
The inspection was an unannounced required annual visit conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements.
Findings
The facility was found to be in compliance with no deficiencies noted. Observations included proper infection control practices, adequate food and emergency supplies, operational safety equipment, and complete resident and staff files.
The visit was an unannounced case management visit to discuss a self-reported incident sent to the Orange County Adult and Senior Care Regional Office on September 30, 2024, and to gather related information and documents.
Findings
No deficiencies were observed during the visit. The Licensing Program Analyst conducted interviews and reviewed records related to the incident involving Resident 1.
Employees Mentioned
Name
Title
Context
Jenifer Tirre
Licensing Program Analyst
Conducted the unannounced case management visit and interviews related to the incident.
Timarie Morrissey
Business Office Manager
Met with Licensing Program Analyst to discuss the incident and provide records.
The inspection was an unannounced complaint investigation visit triggered by allegations including staff speaking inappropriately towards a resident, non-compliance with infection control practices, and staff behavior preventing a resident from sleeping.
Findings
The investigation found no substantiated evidence to support the allegations. Interviews with residents and staff, record reviews, and observations indicated that the allegations could not be proven or refuted, resulting in an unsubstantiated determination.
Complaint Details
The complaint investigation was unsubstantiated as there was insufficient evidence to prove or refute the allegations regarding staff behavior, infection control compliance, and disturbance preventing resident sleep.
Report Facts
Residents tested positive for COVID-19: 15Total census: 166Total capacity: 185Percentage threshold for outbreak: 20
Employees Mentioned
Name
Title
Context
Ruth Martinez
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Armando J Lucero
Licensing Program Manager
Oversaw the complaint investigation
Gregory Case
Administrator
Facility administrator named in the report
Timarie Morrissey
Business Office Manager
Met with Licensing Program Analyst during investigation
Morgan Ware
Executive Director Specialist
Met with Licensing Program Analyst during investigation
Unannounced visit to investigate a complaint alleging that staff does not ensure reporting requirements are met for residents in care.
Findings
The investigation included record reviews and staff interviews, revealing that the facility uses multiple methods to communicate changes in residents' conditions and incidents, including a messaging program and end-of-day reports. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
Complaint was unsubstantiated; investigation found no sufficient evidence to prove the alleged violations occurred.
Report Facts
Capacity: 185Census: 154
Employees Mentioned
Name
Title
Context
Jenifer Tirre
Licensing Program Analyst
Conducted the complaint investigation and unannounced visit
Zehra Syed
Executive Director
Met with Licensing Program Analyst during investigation
Gregory Case
Administrator
Named as facility administrator
Luz Adams
Licensing Program Manager
Oversaw licensing program related to the investigation
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2020-12-16 regarding staff failing to meet residents' needs, untimely response to resident calls, insufficient staffing, improper medication dispensing, and personal rights violations.
Findings
The investigation included interviews with residents and staff and review of documentation. Conflicting reports were found, and although some allegations may have occurred, there was no preponderance of evidence to substantiate the claims. Therefore, all allegations were deemed unsubstantiated.
Complaint Details
The complaint involved multiple allegations including failure to meet resident needs, delayed response to calls, insufficient staffing, medication dispensing issues, and personal rights violations. Interviews with residents and staff revealed mixed perceptions, and documentation review showed no conclusive evidence to support the allegations. The complaint was ultimately unsubstantiated.
Report Facts
Resident daily status checks: 12Facility capacity: 185Resident census: 146Staff response time: 10Staff response time range: 15
Employees Mentioned
Name
Title
Context
Jenifer Tirre
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Zehra Syed
Administrator
Met with Licensing Program Analyst to discuss findings
Linda Hiles
Administrator
Named as facility administrator in report header
Luz Adams
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not seek medical attention for a resident in a timely manner and did not ensure the resident's dietary needs were met.
Findings
The investigation found that although the resident was hospitalized with a stroke and dehydration and required special dietary needs, staff were communicating with the resident's approved doctor and following physician orders. It was unclear if timely services were sought, and the resident's refusal to eat complicated assessment of dietary needs. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to seek timely medical attention and failure to meet dietary needs for Resident 1 (R1). The investigation included interviews with staff, residents, witnesses, and review of documentation. Despite some concerns, evidence did not prove violations occurred.
Report Facts
Facility capacity: 185
Employees Mentioned
Name
Title
Context
Jenifer Tirre
Licensing Program Analyst
Conducted the complaint investigation and inspection
Zehra Syed
Administrator
Met with Licensing Program Analyst during the investigation
The inspection was an unannounced complaint investigation visit conducted due to an allegation that staff denied a hospice visit for a resident.
Findings
The investigation found that on 3/5/22, a hospice nurse's attempted visit was initially denied due to verification of visitation rights amid a pending lawsuit. However, records show the hospice nurse and resident's doctor did visit on that day, and the hospice made an initial visit three days later. The allegation was substantiated as the facility failed to honor the resident's choice of hospice agency, posing an immediate health and safety risk.
Complaint Details
The complaint was substantiated. The allegation was that staff denied hospice visit for a resident. The investigation confirmed the denial occurred initially but was later resolved after intervention by the resident's doctor.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Facility failed resident's choice of hospice company was denied access, violating residents' rights to select their own healthcare providers.
Type A
Report Facts
Census: 146Total Capacity: 185Plan of Correction Due Date: Jul 12, 2023Hospice Nurse Visit Duration (minutes): 95Doctor Visit Duration (hours): 2
Employees Mentioned
Name
Title
Context
Jenifer Tirre
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Luz Adams
Licensing Program Manager
Oversaw the complaint investigation and signed the report
Gregory Case
Administrator
Former Administrator interviewed regarding the incident
An unannounced complaint investigation was conducted in response to an allegation that the facility failed to provide records to an attorney.
Findings
The investigation found that the facility did receive the records request and sent the requested documents to the law firm, which confirmed receipt. Therefore, the allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged the facility failed to provide records to a family attorney. The investigation revealed the facility did submit the requested documents, and the allegation was unsubstantiated.
Report Facts
Capacity: 185Census: 146
Employees Mentioned
Name
Title
Context
Jenifer Tirre
Licensing Program Analyst
Conducted the complaint investigation
Luz Adams
Licensing Program Manager
Oversaw the complaint investigation
Gregory Case
Administrator
Confirmed facility sent records during investigation
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2021-06-02 alleging that residents were forced to eat in their rooms.
Findings
The investigation substantiated the allegation that on May 27, 2021, residents were instructed to eat in their rooms due to the dining room being reserved for a public Commence Mixer event. This was found to violate residents' personal rights under California Code of Regulations.
Complaint Details
The complaint alleging residents were forced to eat in their rooms was substantiated based on the preponderance of evidence. The investigation found that on May 27, 2021, residents were instructed to eat in their rooms due to the dining room being reserved for a public event.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Facility closed dining hall to residents for marketing function, posing a potential personal rights risk to persons in care.
Type B
Report Facts
Capacity: 185Census: 137Deficiency count: 1Plan of Correction Due Date: Apr 6, 2022
Employees Mentioned
Name
Title
Context
Jenifer Tirre
Licensing Program Analyst
Conducted the unannounced complaint investigation visit
Gregory Case
Administrator
Facility administrator involved in investigation and exit interview
Norman Woodridge
Licensing Program Analyst
Conducted an earlier unannounced visit related to the complaint
The visit was an unannounced complaint investigation regarding an allegation that the facility was not following the admission agreement, specifically concerning transportation for group outings and recreational outings.
Findings
The investigation reviewed admissions agreements, resident handbook, employment ads, and transportation logs. It was found that transportation was provided as indicated in the logs, though group outings may have been put on hold due to COVID-related staffing issues. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that the facility was not following the admission agreement related to transportation for group and recreational outings. The allegation was found unsubstantiated after investigation.
Report Facts
Capacity: 185Census: 139
Employees Mentioned
Name
Title
Context
Ruth Martinez
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Gregory Case
Administrator
Met with Licensing Program Analyst during the investigation
Licensing Program Analyst Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual visit.
Findings
The facility was found to be in compliance with no deficiencies noted. Observations included proper COVID signage, adequate supplies, current resident files, and functional safety equipment.
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-06-22 regarding multiple allegations including lack of fall prevention, inadequate nail care, unkempt clothing, and unexplained bruising of a resident.
Findings
The investigation substantiated that the facility failed to implement a fall prevention plan and did not provide adequate nail care for a resident, partly due to COVID-19 disruptions. The allegation of unkempt clothing was unsubstantiated, and the allegation of unexplained bruising was unfounded, with bruising explained by a fall and an incident involving another resident.
Complaint Details
The complaint investigation was substantiated for allegations related to fall prevention and nail care. The allegation regarding unkempt clothing was unsubstantiated, and the allegation of unexplained bruising was unfounded.
Severity Breakdown
Type A: 1Type B: 1
Deficiencies (2)
Description
Severity
Failure to ensure an annual medical assessment and reappraisal for dementia care needs, resulting in no fall prevention plan for resident R1 despite frequent falls.
Type A
Failure to develop and implement a plan for incidental medical and dental care, specifically failure to assist resident R1 with nail hygiene.
Type B
Report Facts
Number of falls: 9Facility capacity: 185Census: 155
Employees Mentioned
Name
Title
Context
Michelle Reed
Licensing Program Analyst
Conducted the complaint investigation visit.
Linda Hiles
Administrator
Facility administrator involved in interviews and exit interview.
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