Most inspections found no deficiencies, including the most recent annual inspection on April 11, 2025, which was completely clean. An earlier complaint investigation in August 2022 substantiated a serious issue where staff failed to follow medical orders for a three-person assist during a resident transfer, resulting in injury. The March 22, 2024 inspection cited one deficiency related to medication safety, as over-the-counter medication was accessible in a dementia resident’s bathroom, posing a health risk. Other findings were minor or isolated, and several complaint investigations were unsubstantiated. The facility appears to have improved since the substantiated complaint, with the latest report showing full compliance.
Licensing Program Analyst Claudia Gutierrez made an unannounced visit to conduct a Required/Annual Inspection of the assisted living facility.
Findings
The inspection found the facility to be in compliance with all applicable regulations, with no deficiencies cited. Observations included operational safety features, proper resident accommodations, and secure medication storage.
Report Facts
Water temperature range: 113.1Water temperature range: 119.1Food supply days - perishables: 2Food supply days - non-perishables: 7Inspection start time: 940Inspection end time: 1700Resident files reviewed: 8Staff files reviewed: 5Residents interviewed: 5Staff interviewed: 5
Employees Mentioned
Name
Title
Context
Neha Patel
Health Services Director
Met with Licensing Program Analyst during inspection
Licensing Program Analysts conducted an unannounced visit for the purpose of conducting a Required/Annual Inspection of the assisted living facility.
Findings
One deficiency was cited related to over-the-counter medication being accessible in a dementia resident's bathroom, posing an immediate health and safety risk. The facility otherwise met regulatory requirements including operational safety equipment, adequate food supplies, and proper facility conditions.
Deficiencies (1)
Description
Over-the-counter medication was observed to be accessible in a dementia resident's bathroom, which poses an immediate health and safety risk to persons in care.
Report Facts
Deficiencies cited: 1
Employees Mentioned
Name
Title
Context
Neha Patel
Health Services Director
Met with Licensing Program Analysts during inspection
Rose Calabrese
Executive Director
Arrived during inspection and involved in facility tour
An unannounced complaint investigation was conducted due to allegations that a resident sustained injury while being transferred from a Hoyer Lift to a wheelchair and that staff members did not follow the resident's medical orders.
Findings
The investigation substantiated that staff members did not follow the resident's medical orders dated 7/15/22, which required a three-person assist for transfers, resulting in the resident sustaining an injury on 7/17/22. The facility was found to have endangered the resident's welfare by failing to assume responsibility for their physical health.
Complaint Details
The complaint was substantiated. The resident sustained injury due to staff not following the updated medical order requiring a three-person assist during transfer from Hoyer Lift to wheelchair.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Facility did not assume responsibility for resident’s physical health, endangering resident’s welfare by failing to follow medical orders for a three-person assist during transfer.
Type A
Report Facts
Estimated Days of Completion: 90Capacity: 136Census: 87
Employees Mentioned
Name
Title
Context
Rose Calabrese
Executive Director
Met during investigation and provided statements regarding staff awareness and corrective actions
Claudia Gutierrez
Licensing Program Analyst
Conducted the complaint investigation
Armando J Lucero
Licensing Program Manager
Oversaw the complaint investigation
Grace Cruz
Memory Care Director
Interviewed during investigation regarding staff awareness
Neha Patel
Health Services Director
Interviewed during investigation regarding staff awareness
Inspection Report Original LicensingCensus: 80Capacity: 136Deficiencies: 0Feb 23, 2022
Visit Reason
The visit was a pre-licensing inspection conducted to evaluate the facility for initial licensing and approval of a change of ownership application.
Findings
The facility was toured and inspected for compliance with regulatory requirements including structure, safety, hygiene, emergency preparedness, and resident accommodations. No deficiencies were found and the license will be granted upon final approval.
Report Facts
Capacity: 136Census: 80Fire Clearance Date: Dec 15, 2021Change of Ownership Application Date: Aug 24, 2021
Employees Mentioned
Name
Title
Context
Rose Calabrese
Administrator
Met with Licensing Program Analyst during pre-licensing visit and participated in exit interview
Michelle Reed
Licensing Program Analyst
Conducted the pre-licensing inspection and authored the report
Sheila Santos
Licensing Program Manager
Responsible for final review and approval of licensing
Inspection Report Original LicensingCensus: 84Capacity: 136Deficiencies: 0Dec 27, 2021
Visit Reason
The visit was a pre-licensing inspection conducted via telephone call to complete Component II (COMP II) of the licensing process for the facility.
Findings
The applicant and administrator successfully completed COMP II, demonstrating understanding of Title 22 regulations including facility operation, staff qualifications, training, grievances, complaints, community resources, food service, medication management, and application document review.
Report Facts
Capacity: 136Census: 84
Employees Mentioned
Name
Title
Context
Rose Calabrease
Administrator
Participant in COMP II and applicant/administrator verified during inspection
Shannon Betker
Analyst
CAB analyst conducting COMP II via telephone
Jude De La Concepcion
Licensing Program Manager
Named in report as Licensing Program Manager
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