Inspection Reports for Ivy Park at Laguna Creek
6727 Laguna Park Dr., Elk Grove, CA 95758, Elk Grove, CA, 95758
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related primarily to medication management, resident rights, and reporting requirements, with several substantiated complaints involving medication errors and failure to submit timely incident reports. The facility was fined $500 in September 2025 for a serious safety lapse when a resident was missing for over 25 minutes. Other issues included unsecured hazardous materials, improper medication storage, and occasional cleanliness concerns, though many complaint investigations were unsubstantiated. The most recent report from September 30, 2025, had no deficiencies, indicating some improvement in compliance. While problems have occurred intermittently, recent inspections suggest the facility is addressing prior concerns.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
80% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Census: 86
Capacity: 108
Deficiencies: 0
Date: Sep 30, 2025
Visit Reason
The visit was an unannounced case management visit conducted to review an incident involving a resident who fell and was found lying on the floor covered in feces.
Findings
The inspection found no deficiencies. The resident had a fall on 09/21/2025 and was found after about 10 minutes. Staff and the resident reported that the resident sometimes experiences dizziness and does not use the call button for assistance. The resident's care plan did not require additional status checks beyond routine care.
Report Facts
Incident date: Sep 21, 2025
Incident report date: Sep 23, 2025
Visit start time: 900
Visit end time: 1130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Dial | Administrator | Facility administrator met during the visit |
| Vincent Moleski | Licensing Program Analyst | Conducted the case management visit |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 108
Deficiencies: 1
Date: Sep 3, 2025
Visit Reason
The visit was an unannounced case management inspection triggered by an incident report received on 2025-06-24 regarding a resident (R1) who was discovered missing from the facility on 2025-06-23.
Complaint Details
The visit was complaint-related, triggered by an incident report about a resident who wandered away from the facility unassisted. The deficiency was substantiated with evidence from interviews and record reviews.
Findings
The facility was found to have failed to maintain awareness of the resident's general whereabouts for at least 25 minutes, posing an immediate health, safety, and personal rights risk. This resulted in a Type A deficiency and an immediate civil penalty of $500 was assessed.
Deficiencies (1)
Facility staff were unaware of resident R1's general whereabouts for at least 25 minutes, posing an immediate health, safety, and/or personal rights risk.
Report Facts
Civil penalty amount: 500
Time resident missing: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Dial | Facility Administrator | Met with Licensing Program Analyst during inspection and named in exit interview |
| Vincent Moleski | Licensing Program Analyst | Conducted the case management visit and authored the report |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 108
Deficiencies: 1
Date: Sep 3, 2025
Visit Reason
The visit was an unannounced follow-up on a complaint investigation regarding an alleged illegal eviction of a resident. During the investigation, an unrelated deficiency was also discovered.
Complaint Details
Complaint #27-AS-20250617103041 alleged illegal eviction of a resident, which was determined to be unsubstantiated after investigation. The resident moved in on 2025-06-02 and moved out on 2025-06-13. Verbal conversations occurred regarding the move-out, but no formal eviction notice was given.
Findings
The complaint alleging illegal eviction was found unsubstantiated. However, the facility was cited for requiring a resident's attorney-in-fact to acquire and pay for third-party one-on-one caregivers, which violates residents' personal rights and poses an immediate personal rights risk.
Deficiencies (1)
Facility staff 'required' a resident's attorney-in-fact to acquire and pay for third-party one-on-one caregivers, posing an immediate personal rights risk.
Report Facts
Plan of Correction Due Date: Sep 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Dial | Administrator | Met during inspection and involved in interviews regarding the complaint and deficiency |
| Vincent Moleski | Licensing Program Analyst | Conducted the inspection and complaint investigation |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 108
Deficiencies: 0
Date: Sep 3, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of illegal eviction and failure to provide medications as needed for a resident.
Complaint Details
The complaint involved allegations of illegal eviction and medications not being provided to a resident as needed. The investigation found these allegations unsubstantiated, meaning there was not a preponderance of evidence to prove the violations occurred.
Findings
The investigation included interviews and record reviews and found that the allegations of illegal eviction and medications not being provided as needed were unsubstantiated. No deficiencies were cited, and medications were administered as ordered during the resident's stay.
Report Facts
Capacity: 108
Census: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation |
| James Dial | Administrator | Facility administrator involved in interviews and findings |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 81
Capacity: 108
Deficiencies: 4
Date: Aug 14, 2025
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate compliance with licensing requirements at the facility.
Findings
The inspection identified several deficiencies including admission of a resident with a pressure wound without appropriate skilled medical supervision, unsecured hazardous materials accessible to residents, improper medication storage, and failure to document routine annual medical visits for residents.
Deficiencies (4)
Resident admitted with a pressure wound without home health or skilled medical supervision, resulting in worsening of the wound.
Multiple cleaning solutions and hazardous materials were accessible to residents, including memory care residents.
Medication was stored outside of its originally received container.
Resident did not receive an annual routine visit with a medical practitioner.
Report Facts
Capacity: 108
Census: 81
Deficiencies cited: 4
Plan of Correction Due Date: Aug 15, 2025
Plan of Correction Due Date: Aug 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the inspection and authored the report |
| James Dial | Facility Administrator | Met with Licensing Program Analyst during inspection and named in findings |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 108
Deficiencies: 1
Date: Jul 8, 2025
Visit Reason
The visit was an unannounced case management inspection triggered by a complaint investigation regarding a resident engaged in hazardous wandering and the facility's failure to submit an incident report.
Complaint Details
The complaint investigation revealed that a resident (R1) with dementia engaged in hazardous wandering and left the community on 6/3/25. The facility did not submit an incident report to the licensing agency as required. The incident posed a potential health, safety, and personal rights risk to the resident.
Findings
The facility failed to submit a required incident report to the licensing agency concerning a resident who engaged in hazardous wandering and left the community, posing a potential risk to the resident's health, safety, and personal rights. The facility was cited for this violation.
Deficiencies (1)
Failure to submit a written incident report to the licensing agency within seven days of an incident threatening the welfare, safety, or health of a resident.
Report Facts
Census: 82
Total Capacity: 108
Deficiencies cited: 1
Plan of Correction Due Date: Jul 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Dial | Facility Administrator | Met with Licensing Program Analyst during inspection and acknowledged failure to submit incident report |
| Vincent Moleski | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 108
Deficiencies: 0
Date: Mar 6, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the facility has insufficient staffing to meet resident needs.
Complaint Details
The complaint alleged insufficient staffing to meet resident needs. The investigation included interviews with 15 staff and 7 residents, review of staffing schedules, resident records, and call response logs. Despite some resident concerns about response times, the evidence did not substantiate the allegation.
Findings
Based on interviews, observation, and record review, the allegation of insufficient staffing was found to be unsubstantiated. Staffing schedules and interviews indicated adequate caregiver presence, and no deficiencies were cited. Some residents reported delays in response times, but these were attributed to errors in the call response system.
Report Facts
Residents present: 70
Total capacity: 108
Staff interviewed: 15
Residents interviewed: 7
Call response times (minutes): 128
Call response times (minutes): 181
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation |
| James Dial | Facility Administrator | Met with the Licensing Program Analyst during the investigation and exit interview |
| Michelle Swearingen | Administrator | Named as facility administrator in the report header |
| S2 | Health Services Director | Provided explanation regarding call response log errors |
Inspection Report
Census: 63
Capacity: 108
Deficiencies: 1
Date: Dec 10, 2024
Visit Reason
The visit was an unannounced case management inspection conducted to review deficiencies related to a medication error incident reported on 2024-11-27.
Findings
The facility was cited for failing to assist a resident with self-administered medications as prescribed, resulting in a medication error where a resident received full pills instead of the prescribed half pills on multiple occasions, posing an immediate threat to health and safety.
Deficiencies (1)
The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by a resident not receiving medications as prescribed, posing an immediate threat to health, safety, or personal rights.
Report Facts
Capacity: 108
Census: 63
Plan of Correction Due Date: Dec 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Dial | Director | Met with Licensing Program Analysts during the visit and named in exit interview |
| Vincent Moleski | Licensing Program Analyst | Conducted the inspection and authored the report |
| Holly Williams | Licensing Program Analyst | Assisted in conducting the inspection |
| Michelle Swearingen | Administrator | Facility administrator named in report header |
| Stephen Richardson | Licensing Program Manager | Named as supervisor and licensing program manager |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 108
Deficiencies: 0
Date: Sep 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that a resident fell due to lack of supervision.
Complaint Details
The complaint alleged that a resident fell due to lack of supervision. The investigation included interviews with residents, staff, and review of incident reports and medical records. The resident was diagnosed with a spinal fracture after an injury was discovered. Despite the injury, the evidence did not support the allegation of lack of supervision.
Findings
Based on interviews, observation, and record review, the allegation was determined to be unsubstantiated. No deficiencies were cited related to the allegation.
Report Facts
Facility capacity: 108
Resident census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Swearingen | Administrator | Met with Licensing Program Analyst and involved in investigation |
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 57
Capacity: 108
Deficiencies: 0
Date: Aug 26, 2024
Visit Reason
Licensing Program Analysts conducted an unannounced annual inspection to evaluate compliance with regulatory requirements.
Findings
No deficiencies were cited during the visit. Technical assistance was provided regarding LIC 602s for dementia residents and staff training. The facility met all environmental and safety standards observed during the inspection.
Report Facts
Resident files reviewed: 10
Staff files reviewed: 10
Staff interviewed: 4
Residents interviewed: 4
Facility temperature: 71
Water temperature: 108
Food supply - perishable: 2
Food supply - nonperishable: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Swearingen | Administrator | Facility administrator met with Licensing Program Analysts during inspection |
| Vincent Moleski | Licensing Program Analyst | Conducted the inspection and met with facility administrator |
| Holly Williams | Licensing Program Analyst | Conducted the inspection |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 108
Deficiencies: 1
Date: May 30, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-02-27 regarding insufficient notice of rate increase and other allegations at Ivy Park at Laguna Creek facility.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not provide sufficient notice of rate increase. Other allegations including staff force feeding a resident, failure to inform resident's authorized person of change in condition, failure to meet resident's needs, failure to refund fees according to admission agreement, and failure to answer the facility telephone were unsubstantiated.
Findings
The investigation substantiated that the facility did not provide sufficient written notice to a resident's responsible party after a rate increase due to a change in level of care. Other allegations including force feeding, failure to inform authorized persons of condition changes, unmet resident needs, refund issues, and telephone answering were unsubstantiated. The facility was cited for failure to provide timely written notice of rate increase.
Deficiencies (1)
No notification was provided to R1’s responsible party after rates were raised due to an increase in level of care, which poses a potential health, safety, and/or personal rights risk.
Report Facts
Refund amount: 2905.45
Capacity: 108
Census: 55
Plan of Correction Due Date: Jun 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Stephen Richardson | Licensing Program Manager | Oversaw complaint investigation |
| Michelle Swearingen | Facility Administrator | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 108
Deficiencies: 1
Date: May 1, 2024
Visit Reason
The visit was an unannounced case management inspection conducted to investigate a complaint regarding a resident's suspected unwitnessed fall and injury that occurred on 2024-03-30.
Complaint Details
A complaint investigation was opened on 2024-04-11 after it was revealed that a resident suffered a suspected unwitnessed fall on 2024-03-30 and was hospitalized. The facility did not notify the licensing agency or other agencies as required.
Findings
The investigation found that the facility failed to submit an incident report to the licensing agency within seven days of the resident's injury and hospital visit, violating reporting requirements.
Deficiencies (1)
Failure to furnish an incident report regarding a resident injury and hospital visit within seven days of the occurrence, posing a potential health, safety, and/or personal rights risk.
Report Facts
Capacity: 108
Census: 56
Plan of Correction Due Date: May 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Michelle Swearingen | Administrator | Facility administrator met during inspection and named in findings |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 108
Deficiencies: 0
Date: May 1, 2024
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2024-04-04 regarding whether staff notified a resident's responsible party of an incident.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violation occurred.
Findings
The allegation that staff did not notify the resident's responsible party of the incident was found to be unsubstantiated based on interviews with staff and the resident's responsible party. No deficiencies were cited related to this allegation.
Report Facts
Capacity: 108
Census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Michelle Swearingen | Administrator | Facility administrator met during investigation and exit interview |
| Stephen Richardson | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 108
Deficiencies: 0
Date: Apr 15, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff did not administer a resident's medication as prescribed and that the facility does not have sufficient staff to meet residents' needs.
Complaint Details
The complaint involved allegations that a former staff member refused to provide PRN medication to a resident and that the facility was understaffed. Interviews with staff, residents, and review of records did not substantiate these allegations. Staffing levels were sometimes perceived as insufficient during busy times, but all care needs were reported as met. Average response times to call pendants were documented for some residents.
Findings
Based on interviews, observation, and record review, the allegations were found to be unsubstantiated. No deficiencies were cited, and residents appeared healthy and clean with care needs being met despite some concerns about staffing levels.
Report Facts
Capacity: 108
Census: 54
Response time: 14.68
Response time: 9.53
Staff interviewed: 17
Residents interviewed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Morgan Whinery | Administrator | Facility administrator met during the investigation |
| Michelle Swearingen | Facility representative met during the investigation and received report copy |
Inspection Report
Census: 52
Capacity: 108
Deficiencies: 0
Date: Oct 30, 2023
Visit Reason
The visit was an unannounced case management visit conducted by Licensing Program Analyst Vincent Moleski to discuss reporting requirements and provide technical assistance.
Findings
No deficiencies were cited during this visit. An exit interview was held and a copy of the report was left with the resident care coordinator.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daiya Jorlen | Resident Care Coordinator | Met with Licensing Program Analyst during the case management visit. |
| Vincent Moleski | Licensing Program Analyst | Conducted the unannounced case management visit and provided technical assistance. |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 108
Deficiencies: 2
Date: Oct 10, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-12-27 regarding staff not providing resident medication as needed and other care concerns.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not provide resident medication as needed. Other allegations about residents being left in bed or soiled for extended periods, inadequate meal services, and unmet showering needs were unsubstantiated.
Findings
The investigation substantiated the allegation that staff did not provide resident medication as needed, citing missing medication and improper documentation. Other allegations regarding residents being left in bed for extended periods, being left soiled, inadequate meal services, and unmet showering needs were found unsubstantiated.
Deficiencies (2)
Failure to make resident medical records available to licensing agency as required by Title 22 Regulations.
Failure to provide personal assistance and care as needed, including medication administration, dressing, eating, and bathing.
Report Facts
Capacity: 108
Census: 56
Deficiencies cited: 2
POC Due Date: Oct 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Ivey-Canady | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Morgan Greenwood | Executive Director | Facility representative met during investigation and exit interview |
| James Hall | Administrator | Facility administrator present during investigation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 108
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
The visit was an unannounced case management follow-up to an incident report regarding an unwitnessed fall suffered by a resident on September 13.
Complaint Details
The visit was triggered by an incident report of an unwitnessed fall by a resident (R1) on September 13. The resident was hospitalized and returned on hospice, subsequently dying on September 29, 2023.
Findings
No deficiencies were cited during this visit. The incident involved a resident who was hospitalized after the fall and later died on September 29, 2023.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with Licensing Program Analyst during the visit and provided information about the incident and resident. |
| Vincent Moleski | Licensing Program Analyst | Conducted the unannounced case management visit and reviewed the incident report. |
Inspection Report
Follow-Up
Census: 46
Capacity: 108
Deficiencies: 0
Date: Aug 28, 2023
Visit Reason
The visit was an unannounced case management follow-up to verify correction of a deficiency issued during the facility's annual inspection related to a resident's LIC 602 renewal.
Findings
No deficiencies were cited during this visit. The facility has made multiple attempts to renew the resident's LIC 602, including contacting the hospital and planning to use a concierge physician due to lack of hospital response.
Report Facts
Facility capacity: 108
Resident census: 46
Citation date: Jul 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Facility administrator met during the visit and involved in discussion about LIC 602 renewal |
| Vincent Moleski | Licensing Program Analyst | Conducted the follow-up visit and issued the original citation |
Inspection Report
Census: 53
Capacity: 108
Deficiencies: 0
Date: Aug 10, 2023
Visit Reason
The visit was an unannounced case management follow-up to investigate several incidents involving resident aggression and other incidents.
Findings
No deficiencies were cited during this visit. Interviews were conducted with the administrator, staff, and residents involved in the incidents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with Licensing Program Analyst during the visit and interviewed regarding incidents. |
| Vincent Moleski | Licensing Program Analyst | Conducted the unannounced case management visit and interviews. |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 108
Deficiencies: 0
Date: Aug 1, 2023
Visit Reason
The visit was an unannounced case management inspection regarding an incident report of an unwitnessed resident fall.
Complaint Details
The visit was triggered by an incident report describing an unwitnessed resident fall. No deficiencies were found.
Findings
No deficiencies were cited during this visit. The Licensing Program Analyst interviewed the administrator and a staff member, and an exit interview was conducted.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with Licensing Program Analyst during the visit and interviewed regarding the incident. |
| Vincent Moleski | Licensing Program Analyst | Conducted the case management visit and interviews. |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 108
Deficiencies: 1
Date: Aug 1, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2023-05-23 regarding staff speaking inappropriately in the presence of residents and failure to respond timely to residents' calls, as well as allegations of medication mismanagement.
Complaint Details
The complaint investigation was triggered by allegations that staff spoke inappropriately in the presence of residents and did not respond timely to residents' calls, which were found unsubstantiated. Another complaint alleging medication mismanagement was substantiated based on incident reports and interviews.
Findings
The investigation found the allegations of inappropriate staff speech and untimely response to residents' calls to be unsubstantiated based on interviews and record reviews. However, the allegation of medication mismanagement was substantiated due to documented medication errors involving residents R1 and R6, including incorrect dosages and failure to properly transfer medication orders.
Deficiencies (1)
Medications were not administered as required by R1's and R6's doctor's orders, posing an immediate health and safety risk.
Report Facts
Facility capacity: 108
Resident census: 57
Medication errors: 3
Plan of Correction due date: Aug 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation |
| Morgan Whinery | Facility representative and administrator met during investigation and exit interview | |
| James Hall | Administrator | Facility administrator listed in report header |
| S1 | Staff member interviewed regarding medication errors and incidents |
Inspection Report
Annual Inspection
Census: 46
Capacity: 108
Deficiencies: 1
Date: Jul 20, 2023
Visit Reason
The inspection was an unannounced annual inspection conducted by Licensing Program Analyst Vincent Moleski to evaluate compliance with regulatory requirements.
Findings
The facility was found to have sufficient furnishings, appropriate environmental conditions, and proper safety measures in place. However, a deficiency was cited for failing to ensure a resident with dementia had an annual medical assessment as required.
Deficiencies (1)
Failure to ensure a resident with dementia had their annual medical assessment, posing a potential health, safety, or personal rights risk.
Report Facts
Capacity: 108
Census: 46
Plan of Correction Due Date: Aug 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Facility administrator met during inspection and involved in exit interview |
| Vincent Moleski | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 108
Deficiencies: 0
Date: Jul 13, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that staff did not ensure residents' responsible parties were informed of epidemic outbreaks, did not maintain resident records, and did not properly discard soiled gloves.
Complaint Details
Complaint investigation was unsubstantiated. Allegations included failure to inform responsible parties of epidemic outbreaks, failure to maintain resident records, and improper disposal of soiled gloves. Evidence reviewed included illness trackers, posted outbreak letters, interviews, and resident records. No violations were substantiated.
Findings
The investigation included review of facility and resident records, interviews with staff and residents, and review of outbreak communication. The allegations were determined to be unsubstantiated due to insufficient evidence to prove violations occurred. No deficiencies were cited during this visit.
Report Facts
Facility capacity: 108
Census: 54
Complaint received date: Mar 10, 2023
Investigation visit date: Jul 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Morgan Whinery | Facility administrator met during investigation and exit interview | |
| Stephen Richardson | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 108
Deficiencies: 0
Date: Jul 13, 2023
Visit Reason
The visit was an unannounced case management follow-up to review two incident reports involving residents at the facility.
Complaint Details
The visit was triggered by two incident reports: one involving a resident tipping over in a wheelchair in a van without a seatbelt, and another involving a resident walking out into the street. No deficiencies were cited.
Findings
The inspection found no deficiencies. Incident reports described one resident tipping over in a wheelchair in a van without a seatbelt and another resident walking into the street, with staff following until paramedics arrived.
Report Facts
Capacity: 108
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with Licensing Program Analyst during the visit and provided information about incidents |
| Vincent Moleski | Licensing Program Analyst | Conducted the case management visit and reviewed incident reports |
| Stephen Richardson | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 44
Capacity: 108
Deficiencies: 1
Date: Jul 5, 2023
Visit Reason
The visit was an unannounced case management inspection conducted to evaluate the facility's compliance with maintenance and sanitation regulations.
Findings
During the inspection, live and dead cockroaches were observed in room F15, which is used for storage of activity supplies. The facility was cited for failing to maintain a clean and sanitary environment as required by regulation.
Deficiencies (1)
Facility was not clean and sanitary; presence of live and dead cockroaches in room F15.
Report Facts
Deficiency Type B: 1
Plan of Correction Due Date: Jul 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emilee Reyes | Health and Wellness Director | Met with Licensing Program Analyst during inspection and was left with appeal rights and report copy. |
| Vincent Moleski | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report. |
| Stephen Richardson | Licensing Program Manager / Supervisor | Named as supervisor and licensing program manager on the report. |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 108
Deficiencies: 0
Date: Jun 26, 2023
Visit Reason
The visit was an unannounced case management follow-up conducted after an incident report involving a resident calling 911 during mealtime.
Complaint Details
The visit followed up on an incident where a resident called 911 stating they were not feeling well. Staff reported no prior signs or symptoms, and the resident was treated and discharged the same day with no new orders.
Findings
No deficiencies were cited during the visit. The resident did not express any concerns regarding facility staff or staffing levels, and the incident was reviewed with staff and documentation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the case management visit and interviews related to the incident report. |
| Morgan Whinery | Administrator met with the Licensing Program Analyst during the visit. | |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 108
Deficiencies: 1
Date: May 25, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that facility staff mishandled a resident's medication.
Complaint Details
The complaint alleging facility staff mishandling resident’s medication was substantiated based on review of medication administration records and doctor’s orders, and interviews with the administrator.
Findings
The investigation found that a resident's medication dosage was increased without a physician's authorization on file, substantiating the complaint of medication mishandling.
Deficiencies (1)
Dosages of prescribed medication were increased without proper authorization from the resident's physician, violating 22 CCR Section 87465(a)(5)(A).
Report Facts
Capacity: 108
Census: 43
Deficiency Type Count: 1
Plan of Correction Due Date: May 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Morgan Whinery | Administrator interviewed during the investigation and involved in exit interview | |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 108
Deficiencies: 1
Date: Apr 27, 2023
Visit Reason
The visit was an unannounced case management inspection regarding an incident report received by licensing about a resident (R1) not being given medication according to doctor's orders.
Complaint Details
The visit was complaint-related due to an incident report alleging that resident R1 was not given medication in accordance with doctor's orders. The allegation was substantiated by review of medication administration records and doctor's orders.
Findings
The inspection found that R1's medication administration records showed the resident started dementia medication at a higher dose than ordered for the initial two weeks, indicating non-compliance with doctor's orders. The facility was cited for failing to assist residents with self-administered medications as required.
Deficiencies (1)
Incidental Medical and Dental Care - 87465(4): The licensee shall assist residents with self-administered medications as needed. This requirement was not met based on LPA review of R1's medication records. This violation poses a potential risk to health and safety of residents in care.
Report Facts
Capacity: 108
Census: 47
Plan of Correction Due Date: May 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted inspection and cited deficiency |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing inspection |
| Morgan Whinery | Administrator | Facility administrator met during inspection |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 108
Deficiencies: 1
Date: Oct 11, 2022
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that staff were not dispensing medication as prescribed.
Complaint Details
The complaint was substantiated. Staff dispensed medication incorrectly, including giving a higher milligram strength than prescribed, and prescriptions were not refilled timely, affecting residents' medication regimens.
Findings
The investigation found that staff dispensed medication at a greater milligram strength than prescribed, and resident prescriptions were not filled in a timely manner, resulting in inconsistent medication regimens. The allegations were substantiated and cited under California Code of Regulations.
Deficiencies (1)
The licensee did not ensure residents' medication was dispensed as prescribed, posing a potential health and safety risk.
Report Facts
Capacity: 108
Census: 52
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Ivey-Canady | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| James Hall | Administrator | Facility representative met during investigation and exit interview |
| Stephen Richardson | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 108
Deficiencies: 1
Date: Sep 13, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-03-30 regarding staff not answering residents' call buttons timely.
Complaint Details
The complaint was substantiated. The allegation was that staff were not answering residents' call buttons timely, which was confirmed by interviews, witness statements, and record reviews.
Findings
The investigation found that staff did not respond to residents' call buttons in a timely manner, with delays ranging from 20 minutes to 2 hours, including during an emergency medical occurrence. The facility failed to meet the required response times, posing a potential health and safety risk to residents.
Deficiencies (1)
Failure to ensure residents' call buttons were answered in a timely manner, violating personal rights of residents.
Report Facts
Census: 56
Total Capacity: 108
Deficiency Type: 1
Plan of Correction Due Date: Oct 13, 2022
Response Time: 20
Response Time: 120
Staff to Resident Ratio: 2
Staff to Resident Ratio: 1
Call Button Wait Time: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Ivey Canady | Licensing Program Analyst I | Conducted the investigation including interviews and record reviews |
| James Hall | Administrator | Facility administrator present during investigation and exit interview |
| Stephen Richardson | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Annual Inspection
Census: 52
Capacity: 108
Deficiencies: 0
Date: Jul 28, 2022
Visit Reason
An unannounced Required 1 Year Annual Inspection visit was conducted to evaluate compliance with Community Care Licensing regulations.
Findings
The inspection found no deficiencies cited from California Code of regulations, Title 22. The facility was observed to have proper medication storage, adequate food supplies, functioning safety equipment, and all required resident and personnel records in order.
Report Facts
Residents on Hospice: 5
Residents on Home Health: 6
Number of cottages: 6
Residents in Birch cottage: 13
Residents in Aspen cottage: 14
Residents in Elm cottage: 11
Residents in Fir cottage: 13
Fire extinguisher expiration date: Feb 15, 2023
Last fire drill date: Jun 27, 2022
Hot water temperature: 108.2
Resident records reviewed: 5
Personnel records reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Hall | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Ruth Wallace | Licensing Program Analyst | Conducted the inspection visit |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 54
Capacity: 108
Deficiencies: 1
Date: Jul 14, 2022
Visit Reason
The visit was an unannounced Case Management inspection conducted regarding untimely reporting of resident deaths and incidents to Community Care Licensing (CCL).
Findings
The facility failed to submit required Special Incident Reports (SIRs) and Death Reports to CCL in a timely manner, posing a potential health and safety risk to residents. Two resident deaths were reported late, and a fall incident was not reported as required.
Deficiencies (1)
Failure to submit written reports to the licensing agency within seven days of specified events, including resident deaths and serious injuries.
Report Facts
Days late for Death Report for resident #1: 11
Days late for Death Report for resident #2: 2
Plan of Correction Due Date: Jul 22, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the Case Management visit and authored the report |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection |
| Susie Sarria | Business Office Manager | Facility representative met during the visit |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 108
Deficiencies: 0
Date: Jul 13, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility was not following COVID protocols.
Complaint Details
The complaint was unsubstantiated based on interviews, observations, and lack of evidence. No deficiencies were cited per California Code of Regulations.
Findings
The investigation found that COVID-related cases had mostly cleared except for one resident, sufficient PPE was available, and all staff and visitors were observed using masks with signage posted. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Estimated Days of Completion: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Stephen Richardson | Licensing Program Manager | Named in report header |
| James Hall | Facility Administrator | |
| Susie Sarria | Business Office Manager | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 108
Deficiencies: 0
Date: Sep 16, 2021
Visit Reason
The visit was conducted to investigate a complaint received on 07/30/2021 regarding management not notifying the resident representative about a rent change and not adhering to the admission agreement.
Complaint Details
The complaint was investigated and found to be unfounded based on the preponderance of evidence standard.
Findings
The investigation found that the facility maintained lease agreement guidelines and adhered to the agreement with accurate fees. Staff interviews confirmed that no unauthorized initial fees were charged. The allegations were deemed unfounded due to insufficient evidence.
Report Facts
Estimated Days of Completion: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tirzah Hubbard | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Jerica Howard | Administrator | Facility administrator mentioned in the report |
| Carie Baker | Business Manager | Met with during the investigation |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 108
Deficiencies: 0
Date: Aug 30, 2021
Visit Reason
Unannounced complaint visit to investigate allegations including unexplained bruising, malnutrition, and pressure injuries sustained by residents while in care.
Complaint Details
Complaint investigation was unannounced and conducted due to allegations of unexplained bruising, malnutrition, and pressure injuries. The findings were unsubstantiated based on medical record reviews and interviews.
Findings
The investigation found that although the allegations may have happened, there was not a preponderance of evidence to prove the alleged violations occurred. No deficiencies were observed or cited, and the complaint was determined to be unsubstantiated.
Report Facts
Facility capacity: 108
Resident census: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Stephenie Doub | Licensing Program Manager | Named in the exit interview and report |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 108
Deficiencies: 0
Date: Aug 10, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 07/30/2021 regarding management not notifying the resident representative about a rent change and not adhering to the admission agreement.
Complaint Details
The complaint was investigated and found to be unfounded as the preponderance of evidence standards were not met.
Findings
The investigation found that the facility maintained lease agreement guidelines and adhered to the admission agreement. Fees were accurate and no unauthorized initial fees were charged. The allegations were deemed unfounded due to insufficient evidence.
Report Facts
Estimated Days of Completion: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tirzah Hubbard | Licensing Program Analyst | Conducted the complaint investigation |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager in report |
Inspection Report
Annual Inspection
Census: 47
Capacity: 108
Deficiencies: 3
Date: Jul 28, 2021
Visit Reason
An unannounced annual inspection visit was conducted to evaluate compliance with licensing regulations and assess the facility's operations and conditions.
Findings
The inspection found deficiencies including medication administration logging errors, facility cleanliness issues such as cobwebs, bugs, and stained carpets, and a smoke detector in disrepair. Some areas were in compliance, such as the memory care cottage and first aid kit contents.
Deficiencies (3)
Cobwebs and bugs located in the corners of each cottage posing potential health, safety, or personal rights risks.
Flooring of each cottage containing dirt and stains with need for replacement, posing potential health, safety, or personal rights risks.
Night shift caregiver did not log medication administered at 6:30am for dates 7-27-21 and 7-28-21, posing immediate health, safety, or personal rights risk.
Report Facts
Staff Census: 10
Number of cottages: 6
Hot water temperature (°F): 116
Medication administration errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jerica Howard | Administrator | Named as facility administrator responsible for corrective actions. |
| Susie Sarria | Business Officer Manager | Met with Licensing Program Analysts during inspection. |
| Mary Ann | Health and Wellness Coordinator | Met with Licensing Program Analysts during inspection. |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection and cited deficiencies. |
| Tirzah Hubbard | Licensing Program Analyst | Conducted inspection and authored report. |
| Charlie Yang | Licensing Program Analyst | Conducted inspection. |
| S1 | Unspecified Staff | Discussed medication log and schedule with LPAs. |
| S2 | Medication Aide | Discussed medication guidelines for logging into MARS. |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 108
Deficiencies: 3
Date: Jul 21, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2020-12-03 regarding cleanliness of a resident's room and mattress, and staff not meeting resident hygiene needs.
Complaint Details
The complaint investigation was substantiated for failure to maintain clean and safe accommodations and protect resident property. Some allegations related to hygiene needs were unsubstantiated. The investigation included interviews, record reviews, and observations.
Findings
The investigation found that the facility failed to ensure the resident's room was properly cleaned and fixtures replaced before moving the resident in. The resident's mattress was damaged from urine, and the room had water damage and a broken towel rack. Some allegations were substantiated, including failure to maintain safe and clean accommodations, while others related to hygiene needs were unsubstantiated.
Deficiencies (3)
Facility failed to ensure resident's room was clean and fixtures replaced before moving resident in, including water damage to wall and damaged towel rack.
Bed had stains from urine from resident, posing a potential health, safety or personal rights risk.
Facility was not clean, safe, sanitary and in good repair; room had damage to wall and towel rack.
Report Facts
Capacity: 108
Census: 47
Estimated Days of Completion: 90
Deficiency count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephenie Doub | Licensing Program Manager | Oversaw the complaint investigation |
| Carrie Baker | Executive Director | Met with investigator during inspection and participated in exit interview |
| Jerica Howard | Administrator | Facility administrator named in report header |
| James Hall | Executive Director | Mentioned in findings regarding room repairs |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 108
Deficiencies: 2
Date: Jul 3, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that facility staff did not assist in transferring a resident as needed and that the facility did not ensure the resident's room was clean.
Complaint Details
The complaint investigation was substantiated based on evidence that the facility staff did not assist resident R1 with transfers as needed and did not maintain cleanliness of the resident's room. The preponderance of evidence standard was met and the allegations were substantiated.
Findings
The investigation substantiated that resident R1 was not assisted with transfers as required by her service plan, resulting in confinement to bed except for showering. Additionally, the resident's room was found to be unclean with stained carpets and debris, and the facility lacked maintenance records for cleaning services.
Deficiencies (2)
Failure to provide assistance with activities of daily living, including transferring resident as required, posing immediate health and safety risk.
Failure to maintain facility grounds and cleanliness, including dirty carpets and debris in resident's room, posing potential safety risk.
Report Facts
Capacity: 108
Census: 45
Plan of Correction Due Date: 7
Plan of Correction Due Date: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Amanda Stewart | Facility representative met during exit interview |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 108
Deficiencies: 0
Date: Jun 29, 2021
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations that the facility did not administer medications as prescribed, did not notify responsible party of medication refusals, and staff were not following training to provide effective services to a resident with dementia.
Complaint Details
Complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or were without reasonable basis.
Findings
The investigation found that when the resident refused medications, the facility notified the resident's medical power of attorney and attempted various techniques to administer medications, including redirection and calling the resident's daughter. The complaint was determined to be unfounded as the allegations were false or without reasonable basis.
Report Facts
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation |
| James Hall | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager on report |
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