Most inspections found no deficiencies, with the facility generally meeting licensing requirements for physical plant, food service, and care. The most recent report from June 3, 2025, cited one deficiency involving medication documentation where a medication was recorded as given but the bottle was missing, which posed an immediate health and safety risk. An earlier report from April 11, 2024, also noted an immediate risk due to improper storage of used syringes in a non-approved container. Older inspections focused on infection control showed minor technical assistance needs but no citations. Several complaint investigations were not part of these reports, and the overall trend shows isolated issues with medication and safety practices but no enforcement actions or fines.
The visit was an unannounced required comprehensive annual inspection conducted by Licensing Program Analysts Mary Rico and Antoinette Davis to evaluate compliance with licensing requirements.
Findings
The facility was generally compliant with licensing requirements including physical plant, food service, and care and supervision. However, one deficiency was cited related to medication documentation where one resident's medication was documented as given but the medication bottle was missing, posing an immediate health and safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
One out of five resident's medication was documented as given, but the medication bottle was missing, posing an immediate health, safety, or personal rights risk.
The visit was an unannounced required comprehensive annual inspection of the facility.
Findings
The facility was generally found to be in compliance with licensing requirements, including adequate furniture, clean bathrooms, proper postings, and safe storage of medications and dangerous items. However, one deficiency was cited for improper storage of used syringes and needles in a non-approved container, posing an immediate health and safety risk.
Deficiencies (1)
Description
Staff storing used syringes and needles in a plastic container not approved for bloodborne pathogens.
The inspection was an unannounced annual inspection limited to infection control, conducted after a COVID-19 Risk Assessment Screening.
Findings
The facility was found to be successfully incorporating its COVID-19 Mitigation Plan with adequate hand sanitizer and soap supplies, but had a minimal supply of PPE items such as gowns and N95 masks. Technical Assistance notices were issued regarding the need for additional PPE, proper PPE storage for isolation rooms, and staff fit testing for N95 masks.
Report Facts
Capacity: 6Census: 3
Employees Mentioned
Name
Title
Context
Jennifer Semin
Licensing Program Analyst
Conducted the inspection and issued Technical Assistance notices
Noelia Garcia
Administrator/Licensee
Facility administrator met with Licensing Program Analyst during inspection
The inspection was an Annual/Required Visit conducted to evaluate the facility's compliance and readiness to resume care.
Findings
No residents were present as the facility was undergoing updates and had not admitted residents since the pandemic started. The facility had all required COVID signs posted, sufficient PPE supplies, and infection control procedures were reviewed. No technical violations or citations were issued.
Report Facts
Capacity: 6Census: 0
Employees Mentioned
Name
Title
Context
Noelia Garcia
Licensee
Facility representative who accompanied the Licensing Program Analyst during the inspection
Pauline Beschorner
Licensing Program Analyst
Conducted the annual inspection
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