Inspection Report Summary
This facility’s most recent inspection on October 13, 2025, found no deficiencies, continuing a pattern of clean reports in recent visits. However, earlier reports revealed several serious issues, including a substantiated complaint in November 2024 where inadequate supervision and failure to update care plans contributed to a resident’s death by suicide, resulting in an immediate civil penalty. Other notable deficiencies involved delayed emergency responses, medication errors, insufficient staffing, and violations of residents’ personal rights, particularly from 2022 through mid-2024. Many complaint investigations were unsubstantiated, and some deficiencies were isolated or addressed with corrective actions such as staff termination. The facility’s record shows improvement over time, with recent inspections consistently free of deficiencies after a period of multiple substantiated complaints and enforcement actions.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Census: 157
Capacity: 210
Deficiencies: 0
Oct 13, 2025
Visit Reason
The visit was a Case Management visit conducted in regards to a Change in Management request at the facility.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst requested updated documentation related to the new administrator and other compliance items.
Report Facts
Capacity: 210
Census: 157
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the Case Management visit and requested updated documents |
| Kelly Phillips | Health Services Director | Facility representative who greeted the Licensing Program Analyst and participated in the visit |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 210
Deficiencies: 0
Jul 1, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the licensee was not ensuring that a resident had hot water while in care.
Findings
The Licensing Program Analyst toured the facility, interviewed staff and outside parties, and tested water temperatures in multiple resident bedrooms. The water temperature was found to be within the appropriate range, and contradictory information was provided by the reporting party. The allegation was found to be unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint alleging lack of hot water for a resident was investigated and found to be unsubstantiated due to lack of corroborating evidence.
Report Facts
Complaint Control Number: 14
Complaint Control Number Suffix: 20250602135433
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Fili Igafo | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 153
Capacity: 210
Deficiencies: 0
Mar 26, 2025
Visit Reason
The inspection visit occurred as an unannounced continuation of the Annual Required 1-Year Inspection to evaluate compliance with licensing requirements.
Findings
The Licensing Program Analyst toured the facility and found all exits and doorways free from obstruction, resident bedrooms clean and comfortable, food supplies sufficient and properly stored, and residents engaged in activities. No deficiencies were cited during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Fili Igafo | Executive Director | Met with during the inspection and noted for positive relationship with residents. |
| Dominic Tobola | Licensing Program Analyst | Conducted the inspection visit. |
| Andrea Medlin | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 164
Capacity: 210
Deficiencies: 0
Feb 25, 2025
Visit Reason
An unannounced Annual Required – 1 year inspection was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, safe, and well-maintained with no deficiencies cited. Resident care plans, staff training, and medication records were all in order, and positive staff-resident interactions were observed.
Report Facts
Residents receiving hospice services: 10
Sample file review: 10
Staff files spot check: 10
Administrator Certificate Number: 7003332740
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Program Analyst | Conducted the inspection and file reviews |
| Alan Fox | Regional Operations Specialist | Met with Licensing Program Analyst during inspection |
| Fili Igafo | Executive Director | Administrator Certificate pending renewal |
Inspection Report
Census: 81
Capacity: 210
Deficiencies: 0
Dec 27, 2024
Visit Reason
The unannounced visit was conducted for case management to follow up on several incidents reported by the facility involving resident safety and care concerns.
Findings
The facility responded appropriately to incidents involving residents leaving the premises unsupervised and a resident injury during showering. No deficiencies were cited during the visit.
Report Facts
Incident dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Fili Igafo | Acting Administrator | Met with during inspection and discussed hospice waiver request |
| Dominic Tobola | Licensing Program Analyst | Conducted the unannounced visit and case management follow-up |
| Andrea Medlin | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Capacity: 210
Deficiencies: 4
Nov 7, 2024
Visit Reason
The inspection visit was conducted unannounced on 11/07/2024 to close an investigation regarding a self-reported unusual incident involving a resident found deceased with a plastic bag over their head, related to suicidal ideations and care concerns.
Findings
The investigation found that the facility failed to update the resident's care plan and increase supervision despite awareness of suicidal statements and a hospital visit. The Health Service Director and Executive Director did not ensure one-on-one care or increased checks, contributing to the resident's death. An immediate civil penalty was assessed.
Complaint Details
The visit was complaint-related, closing an investigation into a self-reported incident where resident R1 was found deceased with a plastic bag over their head. The complaint involved failure to provide adequate supervision and care despite known suicidal ideations. The complaint was substantiated with findings of deficient care and oversight.
Severity Breakdown
Type A: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide care, supervision, and services that meet individual needs, resulting in severe injury/death by suicide. | Type A |
| Failure to observe residents for changes in condition and provide appropriate assistance, leading to severe injury/death. | Type A |
| Failure to update pre-admission appraisal and reappraisals to note significant changes in resident's condition, contributing to severe injury/death. | Type A |
| Administrator failed to have sufficient freedom and presence to adequately manage the facility, resulting in failure to ensure frequent checks and updated care plans. | Type A |
Report Facts
Civil penalty amount: 500
Plan of Correction Due Date: Nov 8, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ella Frick | Administrator/Director | Facility administrator named in relation to oversight responsibilities. |
| Fili Igafo | Executive Director | Interviewed regarding resident care and supervision failures. |
| Dominic Tobola | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Andrea Medlin | Licensing Program Manager | Oversaw licensing program and signed report. |
| S1 | Health Service Director (Licensed Vocational Nurse) | Failed to update care plans and ensure increased supervision for resident R1. |
| S2 | Executive Director | Failed to ensure frequent checks and updated care plans for resident R1. |
Inspection Report
Complaint Investigation
Capacity: 210
Deficiencies: 0
Nov 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff were locking residents in their bedrooms and not conducting planned activities with residents.
Findings
The investigation found that resident bedroom door handles require a key to open from the outside but residents can freely exit from inside, and observed residents participating in planned activities such as group exercise, pet therapy, music, and yoga. Due to lack of corroborating evidence, both allegations were found to be unsubstantiated.
Complaint Details
The complaint alleged that facility staff were locking residents in their bedrooms and not conducting planned activities. The allegations were found to be unsubstantiated due to lack of corroborating evidence.
Report Facts
Facility capacity: 210
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Program Analyst | Conducted the complaint investigation |
| Andrea Medlin | Licensing Program Manager | Named in report signature and oversight |
| Fili Igafo | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 210
Deficiencies: 1
Aug 28, 2024
Visit Reason
The visit was an unannounced case management inspection to follow up on a facility self-reported incident involving a staff member intentionally obstructing a resident's bedroom door.
Findings
The facility failed to ensure that residents' room doors were unobstructed, violating the personal rights of resident R1. Staff member S1 intentionally placed a table in front of R1's door to prevent wandering, which was confirmed by investigation and staff interviews.
Complaint Details
The visit was complaint-related, following up on a self-reported incident where staff (S1) intentionally blocked resident R1's bedroom door. The deficiency was substantiated and corrective action included termination of staff S1.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personal Rights of Residents in All Facilities - failure to ensure residents' room doors were not locked or obstructed, specifically a table was placed in front of resident R1's bedroom door preventing exit. | Type A |
Report Facts
Capacity: 210
Census: 141
Deficiencies cited: 1
Plan of Correction Due Date: Sep 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Program Analyst | Conducted the inspection and documented findings |
| Andrea Medlin | Licensing Program Manager | Supervisor overseeing the inspection |
| Fili Igafo | Executive Director | Facility representative who met with the Licensing Program Analyst and discussed corrective actions |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 210
Deficiencies: 2
Aug 9, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on March 5 and March 12, 2024, regarding inadequate supervision, delayed response to call buttons, and other resident care concerns at Ivy Park at Cathedral Hill.
Findings
The investigation substantiated that staff did not provide adequate supervision resulting in resident falls and failed to respond timely to residents' call buttons, with documented delays up to 289 minutes and 16 residents waiting over 30 minutes for assistance. Other allegations regarding failure to observe changes in resident health and reassess care plans were unsubstantiated due to lack of evidence.
Complaint Details
The complaint investigation substantiated allegations that staff did not provide adequate supervision resulting in resident falls and did not respond to residents' call buttons in a timely manner. The allegation that a resident was left on the floor for an extended period and that staff did not observe changes in health or reassess care plans were unsubstantiated due to lack of evidence.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| 16 out of 137 clients waited in some cases more than 289 minutes for care, which is an immediate health and safety risk to persons in care. | Type A |
| Multiple facility staff are not competent to provide the services necessary to meet resident needs. | Type B |
Report Facts
Residents waiting more than 30 minutes for assistance: 16
Maximum delay in call button response time (minutes): 289
Census: 137
Total Capacity: 210
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Dominic Tobola | Licensing Program Analyst | Assisted in conducting the complaint investigation. |
| Fili Igafo | Executive Director | Facility representative present during the investigation and exit interview. |
| Tam Nguyen | Maintenance Director | Met with investigators during the visit. |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 210
Deficiencies: 0
May 14, 2024
Visit Reason
The visit occurred to deliver an amended complaint investigation report from January 4, 2024, due to new information discovered during the investigation.
Findings
The amended complaint investigation report was reviewed with the Executive Director, Fili Igafo, and a copy was left at the facility. No specific findings or deficiencies are detailed in this report.
Complaint Details
This was an amended complaint investigation report from January 4, 2024, updated due to new information discovered during the investigation.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Delivered the amended complaint investigation report and conducted the visit. |
| Fili Igafo | Executive Director | Met with Licensing Program Analyst and reviewed the amended complaint investigation report. |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 210
Deficiencies: 1
May 14, 2024
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following a complaint received on May 9, 2024, regarding staff not ensuring emergency services were contacted in a timely manner.
Findings
The complaint allegation that staff did not contact emergency personnel in a timely manner was substantiated. It was found that staff failed to call 911 immediately for a resident who was found unresponsive, resulting in a delay of approximately two hours before emergency services were alerted.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. Staff failed to contact emergency personnel in a timely manner as alleged.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide assistance in meeting necessary medical and dental needs, specifically staff did not call 911 immediately for a resident found unresponsive, delaying emergency response by approximately two hours. | Type A |
Report Facts
Capacity: 210
Census: 147
Deficiency due date: May 15, 2024
Delay in emergency contact: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Fili Igafo | Executive Director | Facility representative who met with the investigator during the visit |
| Ella Frick | Administrator | Facility administrator named in the report header |
| Andrea Medlin | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 210
Deficiencies: 0
May 14, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to complaints received on 2023-12-26 regarding staff not ensuring records for new residents, pest infestation, resident reassessment, and confidentiality of residents' personal information.
Findings
The investigation found all allegations to be unsubstantiated or unfounded. The facility was determined not to have a pest infestation, had records for new residents, maintained resident confidentiality, and appropriately assessed residents for higher levels of care.
Complaint Details
The complaint investigation addressed multiple allegations including lack of records for new residents, pest infestation, failure to assess residents for higher levels of care, and breaches of resident confidentiality. All allegations were found to be unsubstantiated or unfounded after interviews, record reviews, and observations.
Report Facts
Capacity: 210
Census: 147
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Fili Igafo | Executive Director | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Census: 120
Capacity: 210
Deficiencies: 0
Apr 23, 2024
Visit Reason
The inspection was an unannounced Case Management-Health and Safety check conducted in response to an incident report received regarding the death of a resident.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst reviewed multiple resident-related documents and discussed the findings with the Regional Operations Specialist.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the inspection and requested resident documents. |
| Alan Fox | Regional Operations Specialist | Met with the Licensing Program Analyst and was involved in the inspection. |
Inspection Report
Annual Inspection
Census: 133
Capacity: 210
Deficiencies: 0
Feb 15, 2024
Visit Reason
The inspection visit was conducted to continue the Annual 1-year required inspection as part of routine regulatory oversight.
Findings
No deficiencies were cited during the visit. Resident records were reviewed and found to be complete, and interviews were conducted with residents and staff.
Report Facts
Resident records reviewed: 5
Residents interviewed: 3
Staff interviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the inspection and reviewed records |
| Faimafili Igafo | Executive Director | Met with Licensing Program Analyst during the inspection |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 210
Deficiencies: 0
Jan 4, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted due to multiple allegations including staff not ensuring records for new residents, pest infestation, confidentiality breaches, and failure to assess a resident for a higher level of care.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Resident records were complete and assessments up to date, the facility was clean and orderly, and pest control reports were reviewed. The complaint regarding failure to assess a resident for higher level of care was found to be unfounded.
Complaint Details
The complaint investigation was unsubstantiated for allegations of missing new resident records, pest infestation, and confidentiality breaches. The allegation that staff did not assess a resident for a higher level of care was found to be unfounded.
Report Facts
Capacity: 210
Census: 123
Estimated Days of Completion: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ella Frick | Executive Director | Met with during investigation |
| John Calandra | Licensing Program Analyst | Conducted the complaint investigation |
| Cara Smith | Licensing Program Manager | Conducted the complaint investigation |
| Arturo Balancas | Senior Maintenance Director | Interviewed during investigation with no concerns noted |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 210
Deficiencies: 2
Dec 15, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not administer a resident's medication as prescribed and did not answer residents' call buttons in a timely manner.
Findings
The investigation substantiated that there was a medication administration discrepancy involving Resident 1's Lamotrigine prescription and that staff failed to respond timely to residents' call buttons, with documented delays ranging from 55 to 120 minutes. A civil penalty was assessed for repeat violations.
Complaint Details
The complaint investigation was substantiated based on evidence including interviews, observations, medication review, and call button response records. The complaint control number is 14-AS-20231128101756.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide Resident 1 with prescribed medication as ordered by the physician, including failure to clarify discrepancies between physician's orders and pharmacy prescription. | Type A |
| Failure to respond to residents' call buttons in a timely manner, with documented delays up to 120 minutes. | Type A |
Report Facts
Civil penalty amount: 1000
Call response delay: 67
Call response delay: 55
Call response delay: 120
Call response delay: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ella Frick | Executive Director | Met with Licensing Program Analyst during the complaint investigation and discussed findings. |
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report. |
| Cara Smith | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Annual Inspection
Census: 128
Capacity: 210
Deficiencies: 3
Sep 23, 2023
Visit Reason
The visit was an unannounced annual required inspection to ensure compliance with Title 22 regulations and facility licensing requirements.
Findings
The facility was generally clean and well-maintained with proper emergency supplies and locked medications. However, deficiencies were cited related to expired elevator inspections, missing updated medical assessments (LIC 602) in resident files, and incomplete resident appraisals. Plans of correction were requested with due dates.
Deficiencies (3)
| Description |
|---|
| Elevators were not inspected annually as required, posing a potential health, safety or personal rights risk. |
| 8 out of 10 resident files did not have an updated LIC 602 medical assessment on file. |
| 4 out of 10 resident files did not have a resident appraisal on file. |
Report Facts
Resident files reviewed: 10
Staff files reviewed: 5
Elevators observed: 2
Residents without updated LIC 602: 8
Residents without appraisal: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ella Frick | Administrator | Spoke with Licensing Program Analysts regarding licensing fees and facility operations |
| Michelle Herman | Marketing Director | Met with Licensing Program Analysts and accompanied them during the inspection |
| Christina Valerio | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 210
Deficiencies: 1
Jul 5, 2023
Visit Reason
An unannounced case management visit was conducted to deliver findings related to complaint #14-AS-20230425173240 regarding a resident fall and staff response.
Findings
The investigation found that on 4/20/2023, it took facility staff over 205 minutes to respond to a call cord after a resident fell, resulting in another resident assisting the fallen resident. This failure to provide timely assistance was cited as a deficiency under California Health and Safety Code LIC 809D.
Complaint Details
Complaint #14-AS-20230425173240 was investigated and substantiated based on the delayed staff response and failure to assist a resident after a fall.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide timely assistance to a resident who fell, resulting in another resident assisting the fallen resident off the floor and back to bed, posing an immediate health risk. | Type A |
Report Facts
Response time to call cord: 205
Response time seconds: 46
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
| Cara Smith | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the investigation |
| Jeff Sumabat | Administrator | Facility administrator met during the visit and discussed the report |
| Ella Frick | Administrator | Facility administrator met during the visit |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 210
Deficiencies: 2
Jul 5, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to address allegations including the facility not meeting a resident's dietary needs and not responding to a resident's emergency call cord.
Findings
The investigation substantiated that a resident was served a diet not prescribed by the physician, including raw vegetables despite a mechanical soft diet order, and that staff failed to respond timely to an emergency call cord, resulting in a resident assisting another after a fall. Another allegation regarding laundry services was unsubstantiated.
Complaint Details
The complaint was substantiated. The resident (R1) was served a diet not prescribed by the physician and staff failed to respond to an emergency call cord in a timely manner, resulting in R1 assisting a roommate (R2) who had fallen. The laundry services allegation was unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| It took facility staff 205 minutes and 46 seconds to reset a resident's call cord, posing an immediate health risk. | Type A |
| Resident was served raw vegetables and other foods not prescribed by physician's order for mechanical soft diet, posing a potential health risk. | Type B |
Report Facts
Call cord reset time: 205.77
Call cord reset time: 210.7
Facility capacity: 210
Resident census: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Cara Smith | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Jeff Sumabat | Administrator | Facility administrator involved in the investigation. |
| Ella Frick | Administrator | Met with Licensing Program Analyst during the unannounced visit. |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 210
Deficiencies: 2
May 3, 2023
Visit Reason
The visit was a case management visit conducted to deliver findings related to an abuse allegation reported by the facility involving staff and a resident.
Findings
The facility failed to ensure the safety of a resident due to delayed reporting of an abuse incident by staff and failure to ensure required staff training on abuse and neglect. Deficiencies were cited under California Code of Regulations, Title 22.
Complaint Details
The visit was complaint-related due to an abuse allegation involving staff blocking a resident and punching the resident's abdominal area. The complaint was substantiated as the facility failed to ensure timely reporting and required staff training.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff witnessed an abuse allegation but did not report it to the facility director until 8 days later, resulting in the alleged abuser being assigned to care for the resident one more time before administrative leave. | Type A |
| Staff training records did not indicate that the staff received required training on abuse and neglect, posing a potential risk to residents. | Type B |
Report Facts
Capacity: 210
Census: 97
Plan of Correction Due Date: May 4, 2023
Plan of Correction Due Date: May 10, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joy Quilet | Memory Care Director | Met with during the visit and discussed findings |
| Murial Han | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Cara Smith | Licensing Program Manager | Named as Licensing Program Manager overseeing the case |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 210
Deficiencies: 0
Apr 25, 2023
Visit Reason
An unannounced case management visit was conducted to follow up on an incident reported by the facility involving an alleged abuse incident.
Findings
The facility reported an abuse allegation involving staff and a resident. The alleged abuser was placed on administrative leave pending investigation, and no deficiencies were cited as the investigation was not yet complete.
Complaint Details
The visit was complaint-related due to an abuse allegation where staff #1 witnessed staff #2 blocking a resident and punching the resident's abdominal area with small pink dumbbells. The incident occurred on 4/4/2023 but was reported to the facility director on 4/12/2023. The facility took immediate actions including placing the alleged abuser on administrative leave, notifying the responsible party, CCL, and the Ombudsman, and starting daily monitoring and in-services.
Report Facts
Date of incident: Apr 4, 2023
Date incident reported to facility director: Apr 12, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Sumabat | Administrator | Met with Licensing Program Analyst during the visit |
| Joy Quilet | Memory Care Director | Met with Licensing Program Analyst during the visit |
| Murial Han | Licensing Program Analyst | Conducted the unannounced case management visit |
| Cara Smith | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 210
Deficiencies: 0
Apr 24, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 07/01/2022 regarding resident care, staff conduct, medication management, and facility services at Coventry Place.
Findings
After thorough investigation including interviews with staff, responsible parties, and review of documents, all allegations were deemed unsubstantiated due to lack of preponderance of evidence supporting the claims.
Complaint Details
The complaint included allegations such as unexplained resident injuries, failure to follow care plans, inadequate showering and feeding assistance, lack of food menus, inadequate laundry service, delayed response to call buttons, failure to provide timely resident records, inappropriate staff communication, medication mismanagement, insufficient staff training, and failure to safeguard resident personal items. All were investigated and found unsubstantiated.
Report Facts
Facility capacity: 210
Resident census: 67
Complaint receipt date: Jul 1, 2022
Inspection visit time: 12.25
Inspection completion time: 14.08
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Cara Smith | Licensing Program Manager | Reviewed and managed the complaint investigation report |
| Gianni Amari | Business Office Director | Met with Licensing Program Analyst during the inspection visit |
| Jill C. Libhart | Administrator | Facility administrator mentioned in the report |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 210
Deficiencies: 1
Feb 21, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by allegations that staff were mismanaging residents' medications and not properly trained.
Findings
The investigation substantiated that the facility staff failed to properly follow through with medication refills for resident #1, resulting in delayed administration of two prescribed medications. However, the allegation that staff were not properly trained was unsubstantiated as staff were able to articulate proper procedures, though they failed to follow up timely.
Complaint Details
The complaint was substantiated regarding medication mismanagement due to failure to follow up on medication refills from 10/11/2022 to 10/16/2022, causing delayed medication delivery and administration. The allegation that staff were not properly trained was unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff failed to follow through with resident #1's pharmacy and physician on two prescribed medications, resulting in delayed medication administration posing a potential health risk. | Type A |
Report Facts
Capacity: 210
Census: 119
Medication delay days: 8
Medication delay days: 2
In-service training date: Oct 27, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Cara Smith | Licensing Program Manager | Oversaw the complaint investigation |
| Melon Rivera | Administrator | Facility administrator during the investigation |
| Carol Dowell | Administrator | Administrator met with during the inspection visit |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 210
Deficiencies: 3
Nov 2, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of insufficient staffing to meet residents' needs, the facility being unkempt, and failure to provide a safe and comfortable environment for residents.
Findings
The investigation substantiated the allegations that the facility had insufficient staffing, especially in the memory care unit, multiple open shifts, and staff working overtime. The facility was found to be unkempt with dirty resident rooms and unsanitary conditions, and overall failed to provide a safe, clean, and comfortable environment for residents.
Complaint Details
The complaint investigation was substantiated based on evidence including staff interviews, observations of unclean resident rooms, multiple uncovered shifts, and insufficient staffing in the memory care unit. The facility was found to be unkempt and unable to provide a safe and comfortable environment for residents.
Severity Breakdown
Type A: 1
Type B: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| 87411 Personnel Requirements - Facility personnel shall at all times be sufficient in numbers and competent to provide necessary services to meet resident needs. Multiple open shifts and no housekeeping staff assigned in the memory care unit posed an immediate health risk. | Type A |
| 87303 Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. Several rooms in the memory care unit were not cleaned, posing potential health risks. | Type B |
| 87468.1 Personal Rights of Residents - Facility failed to have sufficient personnel at all times to ensure residents are accorded safe, healthful, and comfortable environment, posing potential health risks. | Type B |
Report Facts
Capacity: 210
Census: 144
Deficiencies cited: 3
Plan of Correction Due Dates: Due dates for POCs are 11/04/2022, 11/14/2022, and 11/15/2022
Inspection Report
Complaint Investigation
Census: 144
Capacity: 210
Deficiencies: 1
Nov 2, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not respond in a timely manner to a resident's call for assistance after an injury and that staff did not seek medical attention for the resident in a timely manner.
Findings
The investigation substantiated that staff failed to respond to resident #1's call pendant for assistance for approximately two hours after a fall, posing an immediate health risk. However, the allegation that staff did not seek medical attention in a timely manner was unsubstantiated as the resident declined hospital care.
Complaint Details
The complaint investigation was substantiated regarding delayed staff response to resident's call for assistance after injury. The allegation that staff did not seek medical attention in a timely manner was unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| R1 fell at 1am, R1 pressed the call pendant for assistance and facility staff did not answer R1's call until 3 am which posed an immediately health risk for residents in care. | Type A |
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Nov 4, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Cara Smith | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Jeff Sumabat | Administrator | Facility administrator involved in the investigation |
| Melon Rivera | Administrator | Facility administrator met during the investigation visit |
Inspection Report
Census: 150
Capacity: 210
Deficiencies: 3
Aug 10, 2022
Visit Reason
An unannounced Health and Welfare check was conducted to observe if the facility is following COVID-19 management procedures.
Findings
The inspection found that two residents who tested positive for COVID-19 were participating in activities with non-affected residents without face coverings, and staff were unaware of their positive status. Additionally, the facility failed to report positive COVID-19 cases to the licensing agency within 24 hours as required.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Two residents who tested positive for COVID-19 were observed participating in activities with non-affected residents, posing immediate health and safety risks. | Type A |
| The administrator failed to communicate residents' change of health condition to facility staff, posing immediate health and safety risks. | Type A |
| The facility failed and delayed reporting positive COVID-19 cases to the licensing agency within 24 hours. | Type B |
Report Facts
Capacity: 210
Census: 150
Plan of Correction Due Date: 8
Plan of Correction Due Date: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the unannounced Health and Welfare check and authored the report |
| Jackie Jin | Licensing Program Manager | Supervisor overseeing the inspection |
| Jeff Sumabat | Acting Administrator | Met with Licensing Program Analyst during the inspection and involved in findings related to communication failures |
| Jill C. Libhart | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 210
Deficiencies: 1
Aug 10, 2022
Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to complaints received on 2022-05-20 regarding failure to notify a resident's responsible party in a timely manner and a resident fall resulting in fracture.
Findings
The investigation substantiated that staff failed to notify resident #1's responsible party of a change in condition and hospitalization in a timely manner due to outdated records. Another allegation that a resident suffered a fall resulting in fracture was found unsubstantiated as the facility followed protocols and the fall was accidental.
Complaint Details
The complaint investigation was substantiated for failure to notify the responsible party timely due to outdated face sheet information, but unsubstantiated for the allegation of resident fall resulting in fracture.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify resident #1's responsible party of a change in condition and hospitalization in a timely manner. | Type B |
Report Facts
Capacity: 210
Census: 150
Deficiency Type B: 1
Plan of Correction Due Date: Aug 22, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jackie Jin | Licensing Program Manager | Oversaw the complaint investigation |
| Jeff Sumabat | Acting Administrator | Met with Licensing Program Analyst during investigation and acknowledged findings |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 210
Deficiencies: 1
Aug 10, 2022
Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-04-07 regarding staff not properly reporting an incident involving a resident and staff causing injuries to a resident while in care.
Findings
The investigation substantiated the allegation that staff did not properly report a resident's change of health condition to the responsible party, posing a potential health risk. The facility conducted an in-service on Incident Reporting Protocols as part of the plan of correction. The allegation that staff caused injuries to a resident during transfer was unsubstantiated based on interviews and observations.
Complaint Details
The complaint investigation was substantiated for failure to properly report a resident's change of health condition to the responsible party. The allegation that staff caused injuries to a resident during transfer was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform resident's responsible party of change in health condition, posing a potential health risk. | Type B |
Report Facts
Capacity: 210
Census: 150
Deficiency count: 1
Plan of Correction Due Date: Aug 22, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jackie Jin | Licensing Program Manager | Oversaw the complaint investigation |
| Mark Nitsche | Administrator | Facility administrator named in relation to findings |
| Jeff Sumabat | Acting Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 210
Deficiencies: 1
Aug 10, 2022
Visit Reason
An unannounced case management visit was conducted to deliver findings related to complaint #14-AS-20220520135606 concerning staff failure to notify a resident's responsible party in a timely manner.
Findings
The investigation found that the facility did not maintain the current record for resident #1, resulting in the responsible party not being informed of the resident's change of condition. This was due to the updated responsible party information not being printed in the resident's paper chart.
Complaint Details
Complaint #14-AS-20220520135606 was investigated and substantiated as the facility failed to ensure resident #1's current record was maintained, leading to failure to notify the responsible party of a change in condition.
Deficiencies (1)
| Description |
|---|
| Facility failed to update resident #1's responsible party information in the paper chart, resulting in staff contacting the old responsible party, posing a potential health and safety risk. |
Report Facts
Capacity: 210
Census: 150
Plan of Correction Due Date: Aug 22, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the investigation and authored the report |
| Jackie Jin | Licensing Program Manager | Supervisor and Licensing Program Manager named in the report |
| Jeff Sumabat | Acting Administrator | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 210
Deficiencies: 1
Apr 12, 2022
Visit Reason
An unannounced case management visit was conducted to deliver findings related to complaint #14-AS-20211214115249 regarding the facility's failure to provide alternate accommodations for residents to take hot showers during a repair.
Findings
The facility failed to ensure residents were provided with comfortable and healthful accommodations during the repair of the hot water pump, as 7 out of 7 residents reported not being offered an alternate location for hot showers.
Complaint Details
The visit was complaint-related, investigating complaint #14-AS-20211214115249. The complaint was substantiated as the facility failed to provide alternate accommodations during hot water pump repair.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to provide an alternate accommodation(s) for the residents to take a hot shower while the circulator pump was in repair which posed potential health and safety risks to residents in care. | Type B |
Report Facts
Residents interviewed: 7
Deficiency count: 1
Plan of Correction Due Date: Due date is 04/26/2022 as stated in the report
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nitsche | Administrator | Met with Licensing Program Analysts during the visit |
| Murial Han | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Julio Montes | Licensing Program Manager | Supervisor and Licensing Program Manager named in the report |
Inspection Report
Complaint Investigation
Capacity: 210
Deficiencies: 1
Apr 12, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that the facility was in disrepair, specifically that there was no hot water from 12/2/21 to 12/14/21, failure to provide an alternate location for hot showers, and lack of proper communication to residents during the repair.
Findings
The investigation found that the facility did experience a hot water outage due to a malfunctioning circulator hot water pump, and the repair was delayed due to a part shipment from another state. Residents were offered hot showers in unaffected apartments and received updates via a broadcast system. However, residents were not offered an alternate location for hot showers during the repair. The allegation was ultimately unsubstantiated due to insufficient evidence of violations.
Complaint Details
The complaint was unsubstantiated. The facility did not have hot water for several days due to a malfunctioning circulator hot water pump. The facility acted promptly to address the issue, but the repair was delayed due to a part shipment. Residents received updates but were not offered alternate shower locations.
Deficiencies (1)
| Description |
|---|
| Residents were not offered an alternate location for hot showers during the repair. |
Report Facts
Facility capacity: 210
Number of residents interviewed: 7
Dates without hot water: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nitsche | Administrator | Met with Licensing Program Analyst during investigation and provided statements |
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation visit |
| Julio Montes | Licensing Program Manager | Reviewed and signed the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 210
Deficiencies: 2
Apr 14, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including failure to provide medical care, failure to notify authorized representatives of incidents, facility disrepair, inadequate staff training, and failure to assist residents with hygiene needs.
Findings
The investigation found some allegations to be unfounded or unsubstantiated, such as failure to provide medical care and timely notification, facility disrepair, and cleanliness issues. However, two allegations were substantiated: a resident sustained an unexplained injury while in care, and staff failed to adequately assist a resident with eating, posing a potential health and safety risk.
Complaint Details
The complaint investigation was initiated based on allegations received on 01/16/2020. The investigation included interviews and record reviews. Some allegations were found to be unfounded or unsubstantiated, while others were substantiated. The substantiated allegations involved unexplained injury to a resident and failure to assist with eating. Deficiencies were cited accordingly.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Former client sustained a lump and hematoma on upper chest from unexplained blunt force trauma observed on 12/29/19, indicating failure to ensure client's right to safety. | Type B |
| Staff failed to adequately assist client with eating, as food remained in her mouth after meals, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 210
Census: 127
Deficiencies cited: 2
Plan of Correction Due Date: Apr 28, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nitsche | Administrator | Met with during investigation and named in report |
| Audrey Jeung | Licensing Program Analyst | Investigator who conducted the complaint investigation |
| Julio Montes | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 160
Capacity: 210
Deficiencies: 0
Mar 26, 2021
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations received on 2021-02-17 regarding psychiatric care, medication training and errors, and facility disrepair.
Findings
All allegations were investigated through interviews and record reviews, and found to be unsubstantiated due to lack of evidence or confirmation from involved parties.
Complaint Details
The complaint included allegations that facility staff did not seek psychiatric help for a resident, medical technicians were not properly trained to assist residents with medication, medication errors were not reported to licensing, and the facility was in disrepair. After investigation, all allegations were found unsubstantiated.
Report Facts
Facility capacity: 210
Census: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nitsche | Facility Director | Interviewed regarding complaint allegations and findings |
| Mohamed Filouane | Licensing Program Analyst | Conducted complaint investigation and interviews |
| Murial Han | Licensing Program Analyst | Assisted in complaint investigation |
| Julio Montes | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 160
Capacity: 210
Deficiencies: 0
Mar 22, 2021
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that staff refused to allow a resident to have visitors and receive phone calls.
Findings
The investigation found that visitor limitations were due to COVID-19 policies and a prior physical altercation between visitors, and that the resident had access to phone calls with staff assistance. Both allegations were deemed unsubstantiated due to lack of evidence.
Complaint Details
The complaint involved allegations that staff refused to allow a resident to have visitors and receive phone calls. The allegations were unsubstantiated after investigation, with explanations including COVID-19 visitation policies and confirmed phone access for the resident.
Report Facts
Facility capacity: 210
Census: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nitsche | Administrator | Met with during investigation and discussed report findings |
| Bertha Raygoza | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 160
Capacity: 210
Deficiencies: 0
Mar 22, 2021
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations received on 2020-06-22 regarding staffing adequacy, staff training, first aid kit supplies, access to drinking water, and access to telephone for residents.
Findings
All allegations were investigated and found to be unsubstantiated based on staff interviews, training logs, virtual observations, and submitted evidence. The facility was found to have adequate staffing, properly trained staff, a fully supplied first aid kit, access to drinking water, and working telephones accessible to residents.
Complaint Details
The complaint included allegations that the facility did not have adequate staff to meet residents' hygiene needs, staff were not properly trained, the first aid kit was not fully supplied, residents did not have access to drinking water, and residents did not have access to a telephone. All allegations were deemed unsubstantiated after investigation.
Report Facts
Capacity: 210
Census: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nitsche | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Bertha Raygoza | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Capacity: 210
Deficiencies: 0
Nov 19, 2020
Visit Reason
The inspection was conducted as a Case Management inspection in response to an Unusual Incident reported by the facility.
Findings
The Licensing Program Analysts interviewed a resident and the Executive Director, and requested multiple documents related to the incident including medical records, staff training records, investigation summary, staffing schedules, and contact information. The Executive Director agreed to submit the requested documents within 24 hours.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nitsche | Executive Director | Met with during inspection and named in relation to the incident investigation. |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Murial Han | Licensing Program Analyst | Conducted the inspection and named as Licensing Program Analyst. |
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