Inspection Reports for Ivy Park at Milpitas
80 Cedar Wy, Milpitas, CA 95035, CA, 95035
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with several complaint investigations determined to be unsubstantiated. However, there were some substantiated issues including a medication error in May 2025 where a resident received a higher dose than ordered, and a lack of hot water for several days in late May 2025. The facility also faced repeated concerns about resident supervision, including incidents of residents eloping from the memory care unit, which led to an immediate civil penalty in October 2024 and a prior civil penalty of $500 in February 2024 related to staffing and supervision deficiencies. The most recent report from September 4, 2025, had no deficiencies but noted some administrative updates needed. Overall, the facility shows improvement in recent months, with no new deficiencies cited in the latest inspections following earlier issues.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
81% 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
Complaint Investigation
Census: 183
Capacity: 225
Deficiencies: 0
Date: Sep 4, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to amend a complaint received on 2024-10-17 and to discuss pending complaints from 2024-06-13 and 2025-06-12.
Complaint Details
The visit was complaint-related, investigating allegations from complaints received on 2024-10-17, 2024-06-13, and 2025-06-12. The Licensing Program Analyst determined that the allegations require further investigation and no deficiencies were cited at this time.
Findings
No deficiencies were cited at this time as the allegations require further investigation. The LIC 500 form was noted to need updating along with the current staff list.
Report Facts
Facility Capacity: 225
Census: 183
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Meghian Geul | Executive Director | Met with during the inspection and discussed LIC 500 form and staff list |
| Marcela Yanez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Romeo Manzano | Licensing Program Manager | Conducted the complaint investigation visit and discussed pending complaints |
Inspection Report
Monitoring
Census: 170
Capacity: 225
Deficiencies: 0
Date: Jul 3, 2025
Visit Reason
The visit was an unannounced Case Management to conduct a Non-Compliance Plan Quarterly Visit to ensure the facility is adhering to the Compliance Plan submitted after an informal meeting held on 04/26/2024.
Findings
The Licensing Program Analyst toured the memory care unit, tested delayed egress doors, reviewed resident check-in/out logs, memory care unit exit door logs, and staff training logs. No citations were noted during this visit.
Report Facts
Capacity: 225
Census: 170
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Meghian Geul | Administrator | Met with Licensing Program Analyst during the inspection |
| Steve Chang | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Chihhsien Chang | Licensing Program Analyst | Named as Licensing Program Analyst on the report |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 225
Deficiencies: 0
Date: Jun 12, 2025
Visit Reason
The visit was conducted as a case management-other type to amend a previous complaint investigation report (LIC9099) by adding additional information. The visit was unannounced and aimed to finalize the complaint investigation.
Complaint Details
The complaint was initially received on 2025-03-04. An initial investigation was conducted on 2025-03-12. The department concluded its investigation on 2025-05-23 but the complaint was not closed due to needing additional information. The 2025-06-12 visit was to amend the report, with findings remaining unsubstantiated.
Findings
The findings of the allegations remain unsubstantiated. No deficiencies were cited during this visit.
Report Facts
Capacity: 225
Census: 174
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jmy Ramos | Assisted Living Director | Met during the inspection and reviewed the report findings |
| Marcela Yanez | Licensing Program Analyst | Conducted the inspection visit to amend the complaint investigation report |
| Meghian Geul | Administrator/Director | Named as facility administrator/director |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 225
Deficiencies: 0
Date: Jun 5, 2025
Visit Reason
The inspection was conducted as an unannounced case management visit following an incident report received on 2025-06-04 regarding a memory care resident found outside the facility on 2025-06-02.
Complaint Details
The visit was triggered by a complaint/incident report about a memory care resident found outside the building. The resident was escorted back by another resident and staff, and no injuries were observed.
Findings
The Licensing Program Analyst interviewed the Executive Director, residents, and staff, reviewed the resident's physician report and service plan, and toured the facility. The resident was found without injuries. The case requires further investigation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Meghian Geul | Executive Director | Met with Licensing Program Analyst during the inspection and involved in the incident investigation. |
| Steve Chang | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Chihhsien Chang | Licensing Program Analyst | Named as Licensing Program Analyst on the report. |
Inspection Report
Complaint Investigation
Capacity: 225
Deficiencies: 1
Date: May 30, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff did not ensure the facility had hot water.
Complaint Details
The complaint alleging lack of hot water was substantiated based on interviews with residents, staff, and facility administration, as well as document review. The water heater was out of service from May 16 to May 20, 2025, and no alternative arrangements were made for residents to bathe with hot water.
Findings
The investigation found that the water heater was malfunctioning from May 16 to May 20, 2025, and the facility did not provide any alternative options for residents to have hot water during this period. The allegation was substantiated.
Deficiencies (1)
Facility did not ensure safe, healthful and comfortable accommodations by not providing access to hot water during the time the water heater was malfunctioning.
Report Facts
Capacity: 225
Deficiency count: 1
Plan of Correction Due Date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Manuel Monter | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Meghian Geul | Administrator | Facility administrator interviewed regarding the water heater issue |
| Romeo Manzano | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Capacity: 225
Deficiencies: 0
Date: May 23, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2025-03-04 regarding food quality, adherence to a resident's admission agreement, and provision of activities for residents.
Complaint Details
The complaint included allegations of poor food quality, failure to follow a resident's admission agreement related to transportation, and inadequate provision of activities. Interviews with residents and staff, document reviews, and observations were conducted. The facility was found to be actively addressing transportation issues and staff training for activities. The complaint was unsubstantiated.
Findings
The investigation found that although some issues were noted, such as food temperature concerns and lack of experienced staff conducting activities, there was insufficient evidence to substantiate the allegations. No deficiencies were cited, and the allegations were determined to be unsubstantiated.
Report Facts
Capacity: 225
Residents interviewed: 7
Staff interviewed: 5
Residents attending meeting: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Becker | Administrator | Facility administrator named in the report |
| Meghian Geul | Administrator | Met with Licensing Program Analyst during investigation |
| Marcela Yanez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Romeo Manzano | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Follow-Up
Census: 177
Capacity: 225
Deficiencies: 0
Date: May 23, 2025
Visit Reason
The visit was an unannounced case management follow-up to a previous visit on 2025-05-07, triggered by an incident report involving two residents on 2025-04-29.
Complaint Details
The visit was complaint-related, investigating an incident between two residents. Based on interviews and review, no prior altercation was found, and the incident was the first between the residents. Physician reports indicated R2 has verbal aggressive behavior, while R1 has no aggressive behavior. No substantiation status was explicitly stated.
Findings
The investigation found that resident R2 pushed resident R1 without reason, causing R1 to fall. Staff intervened immediately, and care plans for both residents were updated. Staff received training on abuse prevention and managing aggressive behavior. No citations were issued during this visit.
Report Facts
Capacity: 225
Census: 177
Incident date: Apr 29, 2025
Staff training date: May 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Meghian Geul | Executive Director | Met with Licensing Program Analyst during the visit and involved in interviews regarding the incident |
| Steve Chang | Licensing Program Analyst | Conducted the unannounced case management visit |
| Chihhsien Chang | Licensing Program Analyst | Named as Licensing Program Analyst on the report |
Inspection Report
Complaint Investigation
Census: 177
Capacity: 225
Deficiencies: 1
Date: May 21, 2025
Visit Reason
The visit was an unannounced case management follow-up to investigate a medication error reported for Resident R1 that occurred on May 13, 2025.
Complaint Details
The visit was triggered by a complaint/incident report received on May 20, 2025 regarding a medication error involving Resident R1. The complaint was substantiated by the investigation.
Findings
The investigation found that from April 23, 2025 to May 13, 2025, Resident R1 erroneously continued to receive a 50 mg dose of medication M1 despite a physician's order to reduce the dose to 25 mg. This posed an immediate health, safety, and personal rights risk to the resident. A deficiency was issued for this violation.
Deficiencies (1)
Resident R1 erroneously continued to receive the 50 mg dose of medication M1 from 4/23/25 to 5/13/25 despite a physician's order to reduce the dose, posing an immediate health, safety, and personal rights risk.
Report Facts
Deficiency count: 1
Facility capacity: 225
Resident census: 177
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Meghian Geul | Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Manuel Monter | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Marrufo | Interviewed Administrator regarding medication error | |
| Resident Care Coordinator | Interviewed by Licensing Program Analyst regarding medication order and pharmacy update process |
Inspection Report
Complaint Investigation
Census: 179
Capacity: 225
Deficiencies: 0
Date: May 7, 2025
Visit Reason
The inspection was an unannounced case management - incident visit triggered by an incident report received on 2025-04-02 regarding an incident that occurred on 2025-04-29 where one resident pushed another causing a fall and hospitalization.
Complaint Details
The visit was complaint-related due to an incident where resident R2 pushed resident R1 without reason, causing R1 to fall and be sent to the hospital. The case is under further investigation.
Findings
The Licensing Program Analyst conducted interviews with the Executive Director, two residents involved, and two witness staff. Physician reports and service plans were requested for further investigation. The case requires additional investigation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Meghian Geul | Executive Director | Met during the inspection and interviewed regarding the incident. |
Inspection Report
Census: 161
Capacity: 225
Deficiencies: 0
Date: Apr 11, 2025
Visit Reason
The visit was an unannounced Case Management visit to conduct a Non-Compliance Plan Quarterly Visit to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing after an informal meeting held on 2024-04-26.
Findings
The Licensing Program Analyst toured the memory care unit, tested egress doors which had auditory alarms, and reviewed requested documentation for staff in-service training. No deficiencies were cited per California Code of Regulations, Title 22.
Report Facts
Capacity: 225
Census: 161
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marcela Yanez | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Meghian Geul | Administrator | Met with the Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 225
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit following allegations that staff do not provide adequate supervision resulting in residents sustaining falls and that staff do not ensure the facility is cleaned and sanitized.
Complaint Details
The complaint alleged inadequate supervision by staff leading to resident falls and inadequate cleaning and sanitation of the facility. The investigation included interviews with staff and family members, review of resident service plans, physician reports, and incident reports. The findings were unsubstantiated for supervision issues and unfounded for cleaning issues, meaning no evidence supported the allegations.
Findings
The investigation found the allegations to be unsubstantiated and unfounded. The Department reviewed records, interviewed staff and family members, and observed the facility, concluding there was no evidence that staff failed to provide adequate supervision or proper cleaning and sanitation. No citations were issued.
Report Facts
Capacity: 225
Census: 167
Staff interviewed: 3
Resident rooms toured: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steve Chang | Licensing Program Analyst | Conducted the unannounced complaint investigation visit and delivered findings |
| Mimi Co | Business Office Director | Met with Licensing Program Analyst during exit interview |
| Gregory Becker | Administrator | Facility administrator named in the report |
Inspection Report
Census: 83
Capacity: 225
Deficiencies: 0
Date: Dec 28, 2024
Visit Reason
The visit was an unannounced Case Management to conduct a Non-Compliance Plan Quarterly Visit to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing after an informal meeting held on 04/26/2024.
Findings
No deficiencies were cited per California Code of Regulations, Title 22. The licensing analysts toured the memory care unit, tested delayed egress doors, and reviewed staff in-service training summaries.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jmy Ramos | Resident Service Director | Met with during the visit and reviewed the report. |
Inspection Report
Annual Inspection
Census: 83
Capacity: 225
Deficiencies: 0
Date: Dec 28, 2024
Visit Reason
An unannounced Required 1 Year visit was conducted to evaluate the facility's compliance with regulations.
Findings
The Licensing Program Analysts toured the facility, inspected resident rooms, tested water temperatures, checked safety features, and reviewed resident and staff records. No deficiencies were cited during this inspection.
Report Facts
Resident records reviewed: 5
Staff records reviewed: 5
Fire extinguisher last serviced: Apr 22, 2024
Fire and Earthquake drill last conducted: Nov 25, 2024
Sprinkler system last serviced: Dec 6, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jmy Ramos | Resident Service Director | Met with Licensing Program Analysts during inspection |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 225
Deficiencies: 1
Date: Dec 20, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on 2024-05-21 regarding failure to notify a resident's power of attorney about a higher level of care resulting in increased rate, failure to notify family and visitors of a scabies outbreak, denial of resident's use of an electric wheelchair, and understaffing in the memory care unit.
Complaint Details
The complaint investigation was substantiated for failure to notify the resident's power of attorney about the increased level of care and rate increase. Other allegations about scabies outbreak notification, electric wheelchair use denial, and understaffing were unsubstantiated.
Findings
The investigation substantiated the allegation that the facility failed to notify the resident's power of attorney about the increased level of care and resulting rate increase, citing a deficiency. The allegations regarding failure to notify family of a scabies outbreak, denial of electric wheelchair use, and understaffing in the memory care unit were unsubstantiated.
Deficiencies (1)
The licensee did not provide the resident's authorized representative with a written notice regarding the level of care increase prior to charging the new care cost, posing an immediate health, safety and personal rights risk.
Report Facts
Capacity: 225
Census: 29
Care cost increase: 1125
Staff to resident ratio: 1
Staff caregivers: 3
Residents in memory care: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Becker | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation |
| Sarah Yip | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 169
Capacity: 225
Deficiencies: 2
Date: Oct 4, 2024
Visit Reason
The inspection was an unannounced case management visit continuation triggered by an incident report regarding a resident who eloped from the facility.
Complaint Details
The visit was complaint-related due to an incident report of a resident eloping. The complaint was substantiated as staff failed to perform required supervision duties.
Findings
The investigation found that staff failed to conduct required head counts and welfare checks during shift changes, resulting in a resident with neurocognitive disorder eloping from the memory care unit. An immediate civil penalty was issued for the repeat violation of absence of supervision.
Deficiencies (2)
Resident with neurocognitive disorder left the memory care unit unassisted and was found 0.5 miles away, posing immediate health and safety risk.
Staff failed to conduct head count/welfare checks for all residents in memory care between shift changes at 10pm, failing to meet care and supervision needs.
Report Facts
Civil penalty amount: 1000
Staff interviewed: 13
Staff confirming wandering behaviors: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Becker | Administrator | Met with Licensing Program Analysts during the visit and reviewed the report. |
| Manuel Monter | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Marcella Tarin | Licensing Program Analyst | Conducted the inspection. |
| Romeo Manzano | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Capacity: 225
Deficiencies: 0
Date: Oct 3, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2022-05-17 concerning resident safety, transportation to medical appointments, staff neglect of hygiene, holding a resident against their will, and violation of resident personal rights.
Complaint Details
The complaint investigation was unsubstantiated for allegations that the resident did not feel safe or comfortable, the facility did not provide transportation to medical appointments, and staff neglected the resident's hygiene. The complaint was unfounded for allegations that the facility held the resident against their will and violated the resident's personal rights by denying participation in group outings.
Findings
The investigation found all allegations to be unsubstantiated or unfounded based on interviews, record reviews, and observations. No deficiencies were cited under California Code of Regulations, Title 22. The facility was found to have operable telephones, provide transportation within a 12-15 mile radius with billing for longer distances, and staff did not neglect resident hygiene. The resident was not held against their will and was allowed to participate in group outings.
Report Facts
Facility capacity: 225
Transportation radius: 15
Resident admission date: Apr 18, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Gregory Becker | Executive Director | Met with Licensing Program Analyst during investigation |
| Sheryl Bravo | Administrator | Facility administrator mentioned in report header |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 225
Deficiencies: 0
Date: Sep 17, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit following complaints received on 2023-05-08 alleging staff mishandling resident's medication, a facility outbreak of norovirus, staff refusing to allow a resident to have visitors, and a resident feeling uncomfortable with a male caregiver.
Complaint Details
The complaint investigation addressed multiple allegations: staff mishandling resident medication, a norovirus outbreak, staff refusing visitors, and resident discomfort with male caregivers. The findings were that the medication and norovirus allegations were unfounded, and the visitor refusal and caregiver gender preference allegations were unsubstantiated.
Findings
The investigation found no evidence to support the allegations of medication mishandling or a norovirus outbreak, determining these allegations as unfounded. The complaints regarding refusal of visitors and discomfort with a male caregiver were found to be unsubstantiated, with no preponderance of evidence proving the allegations occurred. No citations were issued.
Report Facts
Facility capacity: 225
Census: 171
Complaint receipt date: May 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Becker | Executive Director | Met with Licensing Program Analyst during investigation and received report |
| Sheryl Bravo | Administrator | Facility administrator named in report header |
| Steve Chang | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Lauren Powell | Previous Executive Director | Interviewed during investigation regarding norovirus outbreak |
| Romeo Manzano | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 225
Deficiencies: 0
Date: Sep 17, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2024-08-13 alleging that facility staff did not properly notify a resident of a rate increase.
Complaint Details
The complaint alleged that facility staff did not properly notify a resident of a rate increase. The investigation included interviews with the Executive Director, Business Office Director, and the resident, as well as review of documents including the resident's account ledger and notices of rate increase. The complaint was found to be unfounded.
Findings
The investigation found that the resident did not receive the original 60-day notice of rate increase issued in October 2023, but the facility subsequently issued a new 60-day notice dated 2024-08-23, which the resident signed. The resident continued to receive services without disruption and agreed to pay the new rate starting 2024-11-01. The allegation was determined to be unfounded.
Report Facts
Capacity: 225
Census: 167
Complaint Control Number: 26-AS-20240813092234
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Becker | Executive Director | Interviewed regarding the rate increase notification and investigation findings |
| Steve Chang | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Chihhsien Chang | Licensing Program Analyst | Conducted the investigation and signed the report |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 225
Deficiencies: 0
Date: Sep 16, 2024
Visit Reason
An unannounced case management visit was conducted in response to an incident report regarding a resident who eloped from the facility.
Complaint Details
The complaint involved a resident (R1) who was found outside the facility after eloping. The incident was reported on August 26, 2024, concerning an event on August 20, 2024. The investigation included interviews with staff and the Memory Care Director.
Findings
The Licensing Program Analyst determined that the incident requires further investigation. No deficiencies were cited at this time according to California Code of Regulations Title 22.
Report Facts
Facility capacity: 225
Resident census: 167
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Becker | Administrator | Met with Licensing Program Analyst during the visit and reviewed the report |
| Manuel Monter | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Capacity: 225
Deficiencies: 0
Date: Sep 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation received on 2023-12-12 that the facility's call system is in disrepair.
Complaint Details
The complaint alleged that the facility call system was in disrepair. The investigation included interviews with residents and staff, review of documents including resident rosters and call system invoices, and observations of the call system functionality. The allegation was found to be unsubstantiated.
Findings
Based on interviews with residents and staff, document reviews, and observations, there was insufficient evidence to substantiate the allegation that the call system was in disrepair. No deficiencies were cited during the visit.
Report Facts
Capacity: 225
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Partoza | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Gregory Becker | Executive Director/Administrator | Met with Licensing Program Analyst and participated in exit interview |
| Romeo Manzano | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Capacity: 225
Deficiencies: 0
Date: Aug 28, 2024
Visit Reason
The inspection was an unannounced case management visit triggered by an incident report stating that a resident had eloped from the facility.
Complaint Details
The complaint involved a resident (R1) who was found outside the facility after staff noted the resident was missing from their bedroom. The incident was reported on August 26, 2024, regarding an event on August 20, 2024. The complaint investigation is ongoing with no substantiation or deficiencies cited yet.
Findings
The Licensing Program Analysts conducted interviews and reviewed documentation related to the incident but did not cite any deficiencies at this time, determining that further investigation is required.
Report Facts
Facility capacity: 225
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Becker | Administrator | Met with Licensing Program Analysts during the visit and reviewed the report |
| Manuel Monter | Licensing Program Analyst | Conducted the case management visit and signed the report |
| Marcela Yanez | Licensing Program Analyst | Conducted the case management visit |
Inspection Report
Capacity: 225
Deficiencies: 0
Date: Jul 30, 2024
Visit Reason
The visit was an unannounced Case Management to conduct a Non-Compliance Plan Quarterly Visit to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing after an informal meeting held on 2024-04-26.
Findings
No deficiencies were cited per California Code of Regulations, Title 22. Staff in-service training summaries on various topics were reviewed and found compliant.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fely Arquero | Resident Service Coordinator | Met with during the inspection and reviewed the report. |
| Gregory Becker | Administrator | Named as facility administrator, not present at time of visit. |
| Simranjit Rai | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Romeo Manzano | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Capacity: 225
Deficiencies: 0
Date: Jun 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to a complaint received on 2024-05-02 alleging that staff physically abused a resident on 2024-04-15.
Complaint Details
The complaint alleged staff physically abused a resident on April 15, 2024. Interviews with staff and residents, law enforcement observations, and review of incident and physician reports indicated the resident was agitated and aggressive, but staff did not abuse the resident. The allegation was determined to be unfounded.
Findings
The investigation found the allegations to be unfounded after interviews with staff, residents, and review of incident and medical reports. No physical abuse was substantiated, and no deficiencies were cited.
Report Facts
Facility capacity: 225
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Becker | Administrator | Met with Licensing Program Analyst during the complaint investigation and participated in exit interview |
| Manuel Monter | Licensing Program Analyst | Conducted the complaint investigation |
| Romeo Manzano | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 170
Capacity: 225
Deficiencies: 0
Date: Jun 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations received on 2023-12-12 regarding facility temperature and ventilation issues.
Complaint Details
The complaint alleged that the facility's temperature was not within the required range and that the ventilation system was not working, causing odor. After investigation, including resident interviews and facility maintenance reviews, the allegations were found unsubstantiated.
Findings
The investigation found the allegations unsubstantiated after interviews, record reviews, and multiple unannounced visits. No foul odors were detected from the ventilation system, and the heating issue in one resident's room was resolved promptly without further deficiencies cited.
Report Facts
Residents interviewed: 9
Residents interviewed: 8
Residents reporting no odor: 7
Residents reporting odor: 2
Residents reporting no temperature issues: 6
Room temperature range: 74
Room temperature range: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Manuel Monter | Licensing Program Analyst | Conducted complaint investigation and interviews |
| Gregory Becker | Administrator | Met with Licensing Program Analyst during investigation |
| Steven Harms | Former Executive Director | Interviewed regarding heating issues in resident's room |
| Romeo Manzano | Licensing Program Manager | Oversaw complaint investigation report |
Inspection Report
Monitoring
Census: 171
Capacity: 225
Deficiencies: 0
Date: Apr 26, 2024
Visit Reason
The visit was a noncompliance meeting conducted to discuss the facility's history of serious violations under Title 22 California Code of Regulations, including Personal Rights, Incidental Medical and Dental Care, Observation of the Resident, Reappraisals, and Reporting Requirements.
Findings
The facility was found to have serious violations and a compliance plan was established. A two-year monitoring plan with more frequent licensing inspections was initiated. The facility may face administrative actions such as Administrator De-Certification, License Revocation, or Employee Exclusion, and additional civil penalties for serious bodily injury are pending review.
Report Facts
Monitoring plan duration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Becker | Executive Director/Administrator | Present at noncompliance meeting and discussed in report |
| Steven Harms | Vice President of Operations | Present at noncompliance meeting and discussed in report |
| Angelica Rothhaupt | LVN Regional Resident Services Director | Present at noncompliance meeting and discussed in report |
| Romeo Manzano | Licensing Program Manager | Named in report as Licensing Program Manager |
| Simranjit Rai | Licensing Program Analyst | Named in report as Licensing Program Analyst |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 225
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
The visit was an unannounced Case Management follow-up on an incident report received regarding a medication error at the facility that occurred on 2024-04-09.
Complaint Details
The complaint involved a medication error for resident R1, who took extra medication doses beyond the physician's order. The complaint was investigated and no deficiencies were cited; an Advisory Note was issued.
Findings
The investigation found that a resident (R1) took an additional dosage of medication exceeding the physician's order due to medication brought in by the resident's family and left in the room without staff knowledge. No deficiencies were cited, but an Advisory Note was issued.
Report Facts
Facility capacity: 225
Resident census: 171
Incident date: Apr 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Becker | Administrator | Met during inspection and named in medication error discussion |
| Simranjit Rai | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 225
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2023-06-23 alleging that the facility was not serving food at appropriate temperatures.
Complaint Details
The complaint alleged that the facility was not serving food at appropriate temperatures. Interviews with 13 residents revealed mixed responses, with some residents stating the food was hot and others stating it was not hot enough but staff offered to heat it upon request. The allegation was found unsubstantiated due to lack of preponderance of evidence.
Findings
Based on investigation, records reviewed, and interviews conducted, the Department found the allegation to be unsubstantiated. No deficiencies were cited at this time as per California Code of Regulations Title 22.
Report Facts
Residents interviewed: 13
Facility capacity: 225
Facility census: 171
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Greg Becker | Administrator | Met with Licensing Program Analyst during the investigation and reviewed the report |
| Simranjit Rai | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Romeo Manzano | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 225
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
The inspection visit was conducted to investigate a complaint alleging that facility staff was rough when assisting a resident with postural support and forcefully pushed a resident to a wheelchair.
Complaint Details
The complaint alleged that facility staff forcefully pushed a resident to a wheelchair and was rough when assisting with postural support. Interviews with the resident, staff, and review of progress notes and training records were conducted. The resident reported being pushed but did not experience increased pain or bruising. Staff interviews did not corroborate aggressive behavior. The allegation was found unsubstantiated.
Findings
After interviews, record reviews, and investigation, the Department found the allegations unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited, and the resident was observed to have no bruises or marks.
Report Facts
Facility capacity: 225
Census: 171
Complaint received date: Mar 22, 2024
Training duration: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Becker | Administrator | Met with Licensing Program Analyst during investigation |
| Simranjit Rai | Licensing Program Analyst | Conducted the complaint investigation visit |
| Manuel Monter | Licensing Program Analyst | Interviewed resident and participated in investigation |
| Romeo Manzano | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 225
Deficiencies: 1
Date: Apr 25, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that residents were not provided transportation services and that staff suggested residents cancel or reschedule appointments due to lack of transportation.
Complaint Details
The complaint investigation was substantiated regarding transportation services; residents were asked to cancel or reschedule medical appointments due to lack of transportation. The complaint about inadequate meals and food supply was unsubstantiated.
Findings
The investigation substantiated that the facility failed to provide or arrange transportation for medical appointments when no driver was available, causing residents to cancel or reschedule appointments. The facility has since hired a driver. Another complaint regarding inadequate meals and food supply was unsubstantiated.
Deficiencies (1)
Facility did not provide transportation or make arrangements when no driver was available, causing residents to cancel or reschedule medical appointments, posing potential health, safety, or personal rights risks.
Report Facts
Capacity: 225
Census: 171
Deficiency count: 1
Plan of Correction Due Date: May 2, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Greg Becker | Administrator | Met with Licensing Program Analyst during investigation and discussed findings |
| Steven Harms | Administrator | Interviewed during initial investigation regarding transportation services |
| Simranjit Rai | Licensing Program Analyst | Conducted the complaint investigation visit |
| Romeo Manzano | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 179
Capacity: 225
Deficiencies: 5
Date: Feb 23, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-08-21 regarding staff neglect resulting in multiple fractures, inadequate staffing, and failure to submit incident reports.
Complaint Details
The complaint investigation was substantiated. Allegations included staff neglect causing multiple fractures to a resident, inadequate staffing to meet residents' needs, and failure to submit incident reports. The resident sustained injuries from falls and altercations with other residents. The facility failed to report incidents timely and did not reappraise the resident after injuries. A civil penalty of $500 was assessed with additional penalties pending.
Findings
The investigation substantiated that a resident (R1) with motor impairment and neurocognitive disorder sustained multiple injuries including fractures and bruises due to falls and altercations with other residents. The facility failed to submit required incident reports and did not reappraise the resident after injuries. Staffing and supervision were inadequate to meet the resident's needs. Deficiencies were cited and a civil penalty was assessed.
Deficiencies (5)
Failure to submit a written report to the licensing agency for R1's injury in June 2023, posing a potential health and safety risk.
Failure to conduct reappraisals after multiple physical altercations in June and August 2023, posing a potential health and safety risk.
Failure to regularly observe residents for changes in physical, mental, emotional, and social functioning and provide appropriate assistance when unmet needs are revealed.
Failure to arrange or assist in arranging medical care appropriate to the conditions and needs of residents, evidenced by delayed medical follow-up for R1's injuries.
Failure to provide care, supervision, and services sufficient in numbers, qualifications, and competency to meet residents' individual needs.
Report Facts
Capacity: 225
Census: 179
Civil penalty amount: 500
Incident dates: 3
Caregiver staffing: 4
Caregiver staffing: 3
Caregiver staffing: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Greg Becker | Executive Director | Met with Licensing Program Analyst during investigation and reviewed report |
| Simranjit Rai | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Romeo Manzano | Licensing Program Manager | Oversaw complaint investigation and signed report |
Inspection Report
Complaint Investigation
Census: 160
Capacity: 225
Deficiencies: 0
Date: Oct 18, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-05-14 alleging that the facility does not maintain adequate staffing to meet residents' needs and does not have planned activities for the residents.
Complaint Details
The complaint contained two allegations: inadequate staffing to meet residents' needs and lack of planned activities. Interviews with the Executive Director, staff, and residents, as well as document reviews, showed sufficient staffing and planned activities. The complaint was found unsubstantiated.
Findings
The investigation found that the facility generally maintained adequate staffing levels with some periods of one care staff covering both memory care and assisted living units, and that residents' needs were met. The facility also had a full-time Activities Director and offered a variety of planned activities, although not all residents were interested in participating. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 225
Census: 160
Care staff count: 5
Care staff count: 4
Residents in memory care unit: 3
Residents in assisted living unit: 1
Residents in independent living unit: 8
Residents interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Baddas | Current Executive Director | Met with during the investigation and exit interview |
| Dimple Kamdar | Executive Director | Interviewed regarding staffing and resident needs |
| Steve Chang | Licensing Program Analyst | Conducted the complaint investigation visit |
| Regina Brigham | Activities Director | Interviewed regarding planned activities |
| Chihhsien Chang | Licensing Program Analyst | Conducted investigation and signed report |
| Romeo Manzano | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 225
Deficiencies: 1
Date: Aug 22, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-10-14 regarding a resident wandering away from the facility due to lack of supervision.
Complaint Details
The complaint was substantiated. The resident wandered away from the facility due to lack of supervision. The resident has a dementia diagnosis and requires 24-hour supervision. The resident left the facility unassisted at 11:30 pm, outside the caregiver's shift, and was found by law enforcement.
Findings
The investigation found that on 2021-10-08, a resident with dementia left the facility unassisted at 11:30 pm, outside the 1:1 caregiver's shift hours, and was found by law enforcement. The allegation was substantiated based on interviews, records, and review of the resident's condition indicating a need for supervision.
Deficiencies (1)
Personal Rights: (a)(2) Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by a demented resident leaving the facility unassisted and being found unattended by law enforcement, posing an immediate health and safety risk.
Report Facts
Capacity: 225
Census: 144
Deficiencies cited: 1
Plan of Correction Due Date: Aug 23, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Powell | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Simranjit Rai | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Steve Chang | Licensing Program Analyst | Conducted initial complaint investigation visit and interviews |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 225
Deficiencies: 0
Date: Mar 13, 2023
Visit Reason
The visit was an unannounced case management inspection regarding multiple reported incidents of theft involving residents at the facility.
Complaint Details
The complaint involved four reported theft incidents affecting residents R1 through R4. The residents and responsible parties were aware, and the facility took steps including police notification and resident meetings. The complaint was investigated with no deficiencies found.
Findings
Four incidents of theft involving residents were reported between 02/28/2023 and 03/13/2023. The facility reported the incidents to police and Ombudsman, held a town hall meeting to address the issue, recommended securing valuables, and provided lockboxes to some residents. No deficiencies were cited per California Code of Regulations, Title 22.
Report Facts
Number of theft incidents reported: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Powell | Executive Director | Met with Licensing Program Analyst during the visit and discussed action plan |
| Christine Dolores | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Annual Inspection
Census: 100
Capacity: 225
Deficiencies: 0
Date: Dec 29, 2022
Visit Reason
An unannounced annual inspection visit was conducted to evaluate the facility's compliance with regulatory requirements.
Findings
The facility was toured inside and out, with observations including COVID-19 precautions, locked medication and cleaning supply rooms, sufficient food and PPE supplies, and proper fire safety equipment. No citations were noted during the inspection.
Report Facts
Room temperature: 72
Hot water temperature: 110
Fire extinguisher service date: Aug 23, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Powell | Administrator | Met with Licensing Program Analyst during inspection |
| Steve Chang | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 225
Deficiencies: 0
Date: Dec 12, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation received on 07/15/2022 that a resident was physically abused while in care.
Complaint Details
The complaint alleged that a resident was physically abused while in care. The investigation included interviews with the Executive Director, Memory Care Director, the resident, and the resident's family member. The resident confirmed being threatened but not physically harmed. The family member could not confirm the incident due to the resident's history of similar allegations at another facility. The allegation was found unsubstantiated.
Findings
The investigation found insufficient evidence to substantiate the allegation of physical abuse. Interviews and assessments revealed no bruising or signs of injury, and the resident had a history of similar allegations at a previous facility. The allegation was determined to be unsubstantiated.
Report Facts
Complaint Control Number: 26
Complaint Control Number suffix: 20220715145551
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chihhsien Chang | Evaluator / Licensing Program Analyst | Conducted the complaint investigation visit |
| Lauren Powell | Executive Director | Interviewed during the investigation and exit interview |
| Natalie Jones | Memory Care Director | Interviewed during the investigation |
| Romeo Manzano | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Annual Inspection
Census: 48
Capacity: 225
Deficiencies: 0
Date: Dec 20, 2021
Visit Reason
An unannounced annual required inspection was conducted to focus on infection control at the facility.
Findings
The facility was found to have adequate infection control measures including screening, PPE supplies, hand sanitizer stations, and signage. No deficiencies were cited during the visit per California Code of Regulations, Title 22.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Lydia Hertzler | Regional Director | Met with the Licensing Program Analyst during the inspection and reviewed the report. |
| Cristina Pedaghat | Business Office Director | Met with the Licensing Program Analyst during the inspection. |
| Conrado Duarte | Community Relations Director | Met with the Licensing Program Analyst during the inspection. |
Inspection Report
Census: 6
Capacity: 225
Deficiencies: 0
Date: Mar 11, 2021
Visit Reason
The visit was a Case Management - COVID-19 unannounced technical assistance visit conducted via FaceTime to provide technical assistance for Infection Prevention and Control guidelines for Adult and Senior Care facilities.
Findings
The Licensing Program Analyst conducted a virtual tour and provided recommendations including posting mask signage at the entrance, posting hand washing signage near sinks, and utilizing foot operated trash cans in various areas of the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marybeth Donovan | Licensing Program Analyst | Conducted the Technical Assistance visit and provided recommendations. |
| Emina Okanovic | LVN | Met with Licensing Program Analyst during the visit. |
| Marylene Majeska | CDPH Health Facilities Evaluator Nurse | Participated in the Technical Assistance visit. |
Inspection Report
Original Licensing
Capacity: 225
Deficiencies: 0
Date: Dec 21, 2020
Visit Reason
The inspection was a pre-licensing tele-inspection conducted due to COVID-19 restrictions suspending in-person visits.
Findings
The facility was observed to be in good repair with all required furnishings and safety features. No deficiencies were noted during the inspection, and the physical plant is recommended for licensure pending completion of application documents.
Report Facts
Facility capacity: 225
Census: 0
Memory Care Unit capacity: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Bravo | Administrator | Met with Licensing Program Analyst during pre-licensing inspection |
| Gladys Kuizon | Licensing Program Analyst | Conducted the pre-licensing tele-inspection |
| Sarah Yip | Licensing Program Manager | Named in report header and signature section |
| Lydia Hertzler | Regional Director for Operations | Met with Licensing Program Analyst during pre-licensing inspection |
Inspection Report
Original Licensing
Capacity: 225
Deficiencies: 0
Date: Nov 24, 2020
Visit Reason
Initial licensing evaluation of the facility to verify applicant and administrator qualifications and understanding of Title 22 regulations.
Findings
The applicant and administrator successfully completed Component II of the licensing process, confirming understanding of facility operation, staff qualifications, program policies, and application document requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Torrie Tortorelli | Administrator | Named as facility administrator during initial licensing evaluation. |
| Sheryl Bravo | Met with during the office visit. | |
| Jude De La Concepcion | Licensing Program Manager | Named as Licensing Program Manager. |
| Bethany Hunter | Licensing Program Analyst | Named as Licensing Program Analyst conducting the evaluation. |
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