Most inspections found no deficiencies, including the most recent annual inspection on August 28, 2025, which was completely clean. Earlier reports showed some issues, primarily related to infection control during an active epidemic outbreak in early 2025 and a substantiated complaint in August 2024 about staff not treating residents with respect, which led to the resignation of the involved staff member. Several complaint investigations regarding food service, pest control, and water temperature were unsubstantiated. The facility appears to have addressed the infection control deficiencies, as the latest inspection found no problems in that area. There were no fines, license suspensions, or other enforcement actions listed in the available reports.
An unannounced annual inspection visit was conducted to evaluate compliance with licensing requirements and regulations.
Findings
The inspection found the facility to be in compliance with all applicable regulations, with no deficiencies observed. Safety equipment, resident rooms, food service, activities, emergency preparedness, resident rights, staffing, personnel records, infection control, and resident records were all satisfactory.
Report Facts
Residents on hospice: 12Residents allowed bedridden on 1st floor: 8Maximum hospice residents allowed: 20Personnel records reviewed: 4Temperature range: 105Temperature range: 120Freezer temperature: 0Refrigerator temperature: 40
Employees Mentioned
Name
Title
Context
Daisy Hernandez
Administrator
Facility Administrator met during inspection and named in staffing and certification
An unannounced Case Management - Other visit was conducted regarding the correction of a deficiency issued on 2025-03-11 related to infection control practices.
Findings
One deficiency was cited for failure to ensure infection control practices were maintained during an active epidemic outbreak, posing an immediate risk to the health, safety, or personal rights of persons in care. The previous deficiency from the complaint investigation was dismissed and replaced with this corrected citation.
Complaint Details
This visit was related to a previous complaint investigation (Complaint Control Number: 28-AS-20250304162038) where staff were found not following proper infection control practices. The original deficiency was dismissed after appeal, but a corrected citation was issued during this visit.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Failure to ensure infection control practices were maintained during an active epidemic outbreak, posing an immediate risk to the health, safety, or personal rights of persons in care.
Type A
Report Facts
Deficiencies cited: 1
Employees Mentioned
Name
Title
Context
Kimberly Ramirez
Licensing Program Analyst
Conducted the inspection and authored the report
Lachaun Gill
Business Office Director
Met with the Licensing Program Analyst during the inspection
An unannounced complaint investigation was conducted regarding allegations that facility staff did not provide adequate food service to residents.
Findings
The investigation found that food service met regulatory requirements, including proper food storage, labeling, and staff hygiene. Four out of four staff denied the allegation, while one out of six residents corroborated it. There was insufficient evidence to substantiate the complaint, and no violations were observed.
Complaint Details
The complaint alleged that staff over salted food and did not provide quality food service on 04/19/2025. The allegation was unsubstantiated due to lack of preponderance of evidence.
An unannounced complaint investigation visit was conducted on 04/03/2025 regarding allegations that facility staff were not properly addressing pest infestation, not providing adequate food service, and not ensuring residents were delivered hot water throughout the facility.
Findings
The investigation found no health and safety violations related to the allegations. Staff interviews mostly did not corroborate the complaints, and physical inspections including pest control reports and water temperature tests showed compliance. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included pest infestation, inadequate food service, and lack of hot water delivery. Staff interviews mostly denied the allegations, while one resident corroborated each. Physical inspections and documentation review did not reveal violations. No citations were issued.
Report Facts
Staff interviewed: 4Residents interviewed: 5Pest control service date: Mar 11, 2025Water temperature range: 105Water temperature range: 120
Employees Mentioned
Name
Title
Context
Kimberly Ramirez
Licensing Program Analyst
Conducted the complaint investigation
Daisy Hernandez
Administrator
Facility administrator who assisted with the investigation
Heather Moore
Marketing Director
Greeted the investigator and explained the purpose of the visit
An unannounced complaint investigation visit was conducted regarding allegations that staff were not following proper infection control practices at the facility during an active infectious outbreak.
Findings
The investigation found that staff did not follow infection control practices during a COVID-19 outbreak beginning on 2025-02-23. Despite recommendations to suspend communal dining, it was not suspended and residents were observed dining communally during the outbreak. The allegation was substantiated and one type A violation was cited.
Complaint Details
The complaint was substantiated. It was alleged that facility staff did not follow infection control practices during an active COVID-19 outbreak starting 2025-02-23. Staff failed to suspend communal dining as recommended by CDPH, and multiple staff were observed unmasked indoors. The last positive COVID-19 case was on 2026-02-26, but communal dining was still observed on 2025-03-11.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
The licensee did not ensure infection control practices were maintained during an active epidemic outbreak.
Type A
Report Facts
Residents tested positive for COVID-19: 5Deficiency count: 1Capacity: 81Census: 59
Employees Mentioned
Name
Title
Context
Kimberly Ramirez
Licensing Program Analyst
Conducted the complaint investigation visit and cited deficiencies
Daisy Hernandez
Administrator
Facility administrator met with investigator during the visit
Tony Vasallo
Licensing Program Manager
Named in report as licensing program manager overseeing the investigation
An unannounced complaint investigation visit was conducted on 08/22/2024 regarding an allegation that staff does not treat residents with respect.
Findings
The investigation substantiated the allegation that Staff #10 shouted and did not treat Resident #1 with dignity. Five out of nine staff interviews and three written statements corroborated the allegation. Staff #10 resigned effective 08/22/2024. One resident denied the allegation. Multiple instances of shouting and refusal to assist residents were documented.
Complaint Details
The complaint alleged that Staff #10 did not treat Resident #1 with respect, including shouting and refusing to assist residents. The allegation was substantiated based on staff interviews, written statements, and records. Staff #10 resigned effective 08/22/2024.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Failure to accord residents dignity in their personal relationships with staff, residents, and others as required by CCR 87468.1(a)(1).
Type B
Report Facts
Staff interviews corroborating allegation: 5Written statements corroborating allegation: 3Deficiencies cited: 1Plan of Correction due date: Aug 29, 2024Census: 61Total capacity: 81
Employees Mentioned
Name
Title
Context
Kimberly Ramirez
Licensing Program Analyst
Conducted the complaint investigation
Tony Vasallo
Licensing Program Manager
Named in report as Licensing Program Manager
Daisy Hernandez
Administrator
Facility Administrator named in report
Lachaun Gill
Business Office Director
Met with Licensing Program Analyst during investigation
Inspection Report Original LicensingCensus: 58Capacity: 81Deficiencies: 0Jul 26, 2024
Visit Reason
An announced pre-licensing visit was conducted to evaluate the facility for licensing compliance.
Findings
The facility was found to be in compliance with no deficiencies. Safety measures, infection control, personnel records, and emergency preparedness were all satisfactory.
Report Facts
Personnel records reviewed: 6Facility capacity: 81Census: 58
Employees Mentioned
Name
Title
Context
Daisy Hernandez
Administrator
Facility administrator met during the inspection and involved in review of COMP III.
Kimberly Ramirez
Licensing Program Analyst
Conducted the announced pre-licensing visit and inspection.
Tony Vasallo
Supervisor
Supervisor overseeing the licensing evaluation.
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