Inspection Report Summary
Most inspections found no deficiencies, including the most recent report on September 17, 2025, which was clean with no issues cited. Several complaint investigations were substantiated, primarily involving inadequate supervision that led to resident elopements and delayed responses to call buttons, as well as a failure to provide timely personal care. Other substantiated issues included a theft incident involving a staff member, insufficient staffing levels, and failure to provide proper notice of rent increases. The facility has taken corrective actions such as staff training, revising supervision plans, and reversing rent increases, and the most recent reports show improvement with no new deficiencies. Many complaints were unsubstantiated, and no fines, license suspensions, or severe enforcement actions were listed in the available reports.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
92% 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: 126
Capacity: 137
Deficiencies: 0
Sep 17, 2025
Visit Reason
An unannounced Case Management Visit was conducted to deliver an amended complaint report and discuss the purpose of the visit with the Resident Care Coordinator.
Findings
No deficiencies were cited or observed during this visit. An exit interview was conducted and the facility representative was provided with a copy of the report and appeal rights.
Complaint Details
The visit was related to an amended complaint report; the original complaint report findings were delivered on September 11, 2025.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ramon Serrano | Licensing Program Analyst | Conducted the unannounced Case Management Visit and delivered the amended complaint report. |
| Luz Rivera | Resident Care Coordinator | Met with the Licensing Program Analyst to discuss the purpose of the visit and participated in the exit interview. |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 137
Deficiencies: 1
Sep 11, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not prevent a resident from eloping from the facility.
Findings
The investigation substantiated the allegation that staff failed to prevent Resident 1 from eloping on September 2, 2025. Resident 1 was found approximately three blocks from the facility after being outside unsupervised for about two hours. A plan of correction was developed to address the deficiency.
Complaint Details
The complaint alleged that staff did not prevent Resident 1 from eloping from the facility. The allegation was substantiated based on evidence including interviews, records review, and observations. Resident 1 has a diagnosis of Major neurocognitive disorder and requires supervision. The resident eloped on September 2, 2025 and was missing for several hours before being found.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide supervision to Resident 1, who eloped from the facility and was unsupervised for approximately two hours. | Type A |
Report Facts
Census: 126
Total Capacity: 137
Plan of Correction Due Date: Oct 6, 2025
Residents in care: 126
Resident unsupervised duration: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ramon Serrano | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Trobell Orana | Memory Care Director | Facility representative who developed the plan of correction and received the report |
| Calais Anguiano | Administrator | Facility administrator named in the report header |
Inspection Report
Annual Inspection
Census: 121
Capacity: 137
Deficiencies: 0
Aug 25, 2025
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements and assess the facility's condition and operations.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies observed or cited. All required safety equipment, furnishings, and supplies were present and in working order. Staff and resident records were reviewed and found to be complete and properly stored.
Report Facts
Hospice waiver approved residents: 20
Bedridden residents allowed: 44
Hot water temperature: 116
Ambient temperature: 75
Days of perishable food: 2
Days of non-perishable food: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Diana Weinstein | Executive Director | Met with Licensing Program Analyst during inspection and exit interview |
| Ramon Serrano | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Robyn Clark | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 137
Deficiencies: 1
Jun 2, 2025
Visit Reason
An unannounced Case Management Visit was conducted to cite a deficiency identified during a separate complaint investigation.
Findings
One deficiency was cited for failure of the licensee or their designated representative to co-sign the admissions agreement for one resident within seven days after move-in, posing a potential personal rights violation.
Complaint Details
The visit was triggered by a deficiency identified during a separate complaint investigation.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee or their designated representative did not co-sign the admissions agreement for 1 of 113 residents within seven days after admission. | Type B |
Report Facts
Deficiencies cited: 1
Census: 113
Total Capacity: 137
Plan of Correction Due Date: Jun 9, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Calais Anguiano | Executive Director | Met with during inspection and named in findings |
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection |
| Lizzette Tellez | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 137
Deficiencies: 2
May 14, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that staff did not prevent residents from eloping from the facility and did not report incidents to appropriate parties.
Findings
The investigation substantiated that two residents eloped from the facility and that staff failed to provide adequate supervision and failed to report one of the elopements to the licensing agency. One staff member was suspended and later terminated due to inaccurate resident counts during an elopement drill.
Complaint Details
The complaint alleged that staff did not prevent Resident 1 and Resident 2 from eloping and did not report these incidents to appropriate parties. The allegations were substantiated based on interviews, records review, and observations. Resident 1 eloped from the memory care unit and was found after approximately 10 minutes. Resident 2 eloped multiple times and one elopement was not reported to the licensing agency.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide adequate care and supervision to residents, resulting in elopements. | Type B |
| Failure to report incidents threatening resident safety, including elopements, to the licensing agency. | Type B |
Report Facts
Census: 113
Total Capacity: 137
Persons in care involved in deficiencies: 2
Plan of Correction Due Date: Jun 9, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Calais Anguiano | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Ramon Serrano | Licensing Program Analyst | Conducted the complaint investigation |
| Robyn Clark | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 137
Deficiencies: 0
Feb 20, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that a resident sustained an injury due to lack of supervision.
Findings
The investigation found that the resident and staff involved in the allegation were not associated with the facility, and the complaint was generated in error. The complaint was determined to be unfounded.
Complaint Details
The complaint alleged that a resident sustained an injury due to lack of supervision, with incidents on October 21st and 22nd resulting in a head injury. The investigation revealed the resident did not reside at the facility and the staff member did not work there. The complaint was found to be unfounded.
Report Facts
Capacity: 137
Census: 113
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Calais Anguiano | Executive Director | Met with Licensing Program Analyst during investigation and provided exit interview |
| Ramon Serrano | Licensing Program Analyst | Conducted the complaint investigation |
| Robyn Clark | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 137
Deficiencies: 0
Sep 25, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 07/29/2024 regarding financial abuse of a resident, improper placement of a resident without dementia in the memory care unit, and staff instructing residents not to use their call pendants.
Findings
The investigation found no evidence to substantiate the allegations. Billing records showed no fraudulent charges for multiple apartments, the resident had a documented dementia diagnosis justifying placement in the memory care unit, and call pendants are not used in the memory care bedrooms, so no instruction to avoid their use was found.
Complaint Details
The complaint included allegations of financial abuse, improper resident placement, and staff instructions regarding call pendants. The investigation was unannounced and included observations, record reviews, and interviews. The allegations were found unsubstantiated based on evidence including billing invoices, physician's reports, and staff and family interviews.
Report Facts
Complaint Control Number: 08-AS-20240729110908
Capacity: 137
Census: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ramon Serrano | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Justin Brown | Maintenance Director | Met with the Licensing Program Analyst during the investigation |
| Calais Anguiano | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 109
Capacity: 137
Deficiencies: 0
Aug 26, 2024
Visit Reason
An unannounced required annual inspection was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies observed or cited. Resident rooms and common areas met all regulatory standards, and required safety equipment and postings were present and functional.
Report Facts
Hospice waiver approved residents: 20
Bedridden residents allowed: 44
Hot water temperature: 117
Ambient temperature: 76
Perishable food supply: 2
Non-perishable food supply: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Calais Anguiano | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Ramon Serrano | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 137
Deficiencies: 1
Jul 29, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations of staff neglect resulting in hospitalization and failure to provide incontinence care at the facility.
Findings
The investigation substantiated that staff neglected a resident resulting in hospitalization due to delayed response to call buttons and insufficient personal assistance. Another allegation regarding failure to provide incontinence care was unsubstantiated based on evidence from facility and outside agency records. Staffing issues and long wait times for care were noted, but improvements were reported by the Executive Director.
Complaint Details
The complaint investigation was substantiated for staff neglect resulting in hospitalization of Resident 1 due to delayed response to calls. The allegation that staff did not provide incontinence care to Resident 2 was unsubstantiated based on review of records and observations.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure that residents received personal assistance and care as needed on a timely basis to meet the residents’ needs, posing a potential health risk. | Type B |
Report Facts
Capacity: 137
Census: 113
Percentage: 13
Plan of Correction Due Date: Aug 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ramon Serrano | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation |
| Calais Anguiano | Executive Director | Interviewed during investigation and exit interview |
| Rebecca Williams | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 137
Deficiencies: 0
May 21, 2024
Visit Reason
An unannounced complaint investigation visit was conducted following allegations of neglect/lack of supervision resulting in a resident sustaining a head injury and failure of the licensee to address the resident's change in condition.
Findings
The investigation found that Resident #1, a non-ambulatory fall risk, had two unwitnessed falls resulting in injury. Staff conducted increased wellness checks and summoned medical attention promptly. There was insufficient evidence to substantiate neglect or failure to address the resident's change in condition, and the allegations were unsubstantiated.
Complaint Details
The complaint was unsubstantiated. Allegations included neglect/lack of supervision causing a head injury and failure to address a resident's change in condition. Investigations included interviews and record reviews confirming increased monitoring and medical response. No evidence supported the allegations.
Report Facts
Complaint Control Number: 08-AS-20230518133003
Resident Age: 88
Dates of Resident Stay: 4/27/2023 to 5/5/2023
Fall Dates: 5/3/2023 and 5/4/2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Silvia Garcia | Business Office Director | Met with during investigation and exit interview |
| Angela Kaplioff | Administrator | Facility administrator named in report header |
| Lizzette Tellez | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 137
Deficiencies: 0
May 15, 2024
Visit Reason
The visit was initiated due to a self-reported incident involving possible abuse of Resident #1 (R1).
Findings
No immediate health and/or safety concerns were observed during the visit, and no deficiencies were cited.
Complaint Details
The visit was complaint-related due to a self-reported incident involving possible abuse of Resident #1 (R1).
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliana Barfield | Licensing Program Analyst | Conducted the unannounced case-management visit. |
| Silvia Garcia | Business Office Manager | Met with Licensing Program Analyst and provided staff and Resident #1 records. |
| Justin Brown | Maintenance Director | Accompanied Licensing Program Analyst during facility tour. |
Inspection Report
Census: 107
Capacity: 137
Deficiencies: 0
Apr 18, 2024
Visit Reason
The visit was an unannounced Case Management Visit in response to a self-reported incident involving a resident who suffered a fall and hit their head.
Findings
The Licensing Program Analyst interviewed staff and reviewed facility records. The resident remained hospitalized at the time of the visit. No deficiencies were cited or observed during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Silvia Garcia | Business Office Director | Met with Licensing Program Analyst to discuss the purpose of the visit and participated in the exit interview. |
| Ramon Serrano | Licensing Program Analyst | Conducted the unannounced Case Management Visit. |
| Calais Anguiano | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 137
Deficiencies: 1
Feb 14, 2024
Visit Reason
The visit was conducted in response to two SOC341 Reports of Suspected Dependent Adult/Elder Abuse involving theft of cash from Resident #1's wallet, which the licensee self-reported to the Community Care Licensing Division.
Findings
The investigation found that staff member S1 did not ensure protection of Resident #1 from theft, resulting in one deficiency cited for violation of personal rights. A Plan of Correction was developed jointly with the licensee. Additionally, one Technical Violation was issued regarding delayed-egress door signs.
Complaint Details
The visit was complaint-related, triggered by two reports of suspected theft of cash from Resident #1's wallet, with the first incident involving $300 stolen between 11/21/2023 and 12/06/2023, and the second involving $250 stolen between 01/29/2024 and 01/31/2024. Resident #1 was unable to be interviewed due to passing away on 02/09/2024. The first theft was substantiated with evidence implicating staff member S1; the second theft investigation did not reveal any breakthrough.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee’s staff (S1) did not ensure that 1 of 114 residents (R1) was protected from theft or loss, posing an immediate personal rights risk. | Type A |
Report Facts
Residents present: 114
Total licensed capacity: 137
Number of deficiencies cited: 1
Number of Technical Violations issued: 1
Amount stolen in first incident: 300
Amount stolen in second incident: 250
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Blaul | Health Services Director | Met with during inspection and exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lizzette Tellez | Licensing Program Manager | Supervisor and named in report |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 137
Deficiencies: 0
Feb 12, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that a resident sustained injuries due to lack of care from staff.
Findings
The investigation found that the resident had an unwitnessed fall and bruising, but hospital records and staff interviews indicated no new injuries or medication issues. The allegation was unsubstantiated as the evidence did not support lack of care by staff.
Complaint Details
The complaint alleged that a resident sustained injuries due to lack of care from staff. The investigation included records review and interviews with staff and the resident's responsible party. The allegation was found unsubstantiated.
Report Facts
Capacity: 137
Census: 109
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Calais Anguiano | Administrator / Executive Director | Facility representative met during the investigation and interviewed regarding resident care |
| Ramon Serrano | Licensing Program Analyst | Conducted the complaint investigation visit |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 137
Deficiencies: 2
Feb 2, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2021-10-11 alleging insufficient staffing to meet residents' needs.
Findings
The investigation substantiated that staffing was insufficient to meet resident needs, with documented delays in responding to call alerts, including some taking over 20 minutes and one incident where a resident waited 45 minutes for assistance, requiring emergency intervention.
Complaint Details
The complaint alleged that staffing was not sufficient to meet residents' needs. The investigation found substantiated evidence that staffing levels were inadequate, resulting in delayed responses to call alerts and potential risk to resident health and safety.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Personnel Requirements - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. | Type B |
| Based on interviews and review of records the licensee did not have personnel sufficient in numbers to provide the services necessary to meet the needs of 104 persons in care which posed a potential risk to the health and safety of persons in care. | Type B |
Report Facts
Call alerts taking 20 minutes or longer to answer: 136
Total call alerts analyzed: 1024
Residents in care: 104
Facility capacity: 137
Call alert response delay: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Becky Kennedy | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Silvia Garcia | Business Office Manager | Met with during the investigation and exit interview; advised of investigation findings. |
| Icela Estrada | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Rebecca Williams | Administrator | Facility administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 137
Deficiencies: 0
Jan 23, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that facility staff were not adequately trained and mismanaged residents' medications.
Findings
The investigation included direct observation, records review, and staff interviews. Training records of three staff members and medication records of three residents were reviewed. Interviews with staff and management indicated improvements and proper training. The allegations were found to be unsubstantiated as the evidence did not support the claims.
Complaint Details
The complaint alleged inadequate staff training and medication mismanagement. The investigation found that staff had completed appropriate medication training and that medication records and refill processes were properly maintained. The Resident Care Coordinator, previously a concern, had been terminated and improvements were noted after hiring the Health Services Director. The complaint was unsubstantiated.
Report Facts
Capacity: 137
Census: 110
Medication training hours: 3
Medication training hours: 8
Medication training hours: 4
Medication training hours: 16
Medication training hours: 12
Medication training hours: 10
Medication refill log entries: 7
Medication order date: Jan 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Calais Anguiano | Executive Director | Met during investigation and provided exit interview |
| Ramon Serrano | Licensing Program Analyst | Conducted the complaint investigation |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 137
Deficiencies: 0
Nov 21, 2023
Visit Reason
The visit was conducted in response to a self-submitted SOC341 Report of Suspected Dependent Adult/Elder Abuse involving a resident and staff member.
Findings
During the unannounced case management incident visit, the Licensing Program Analyst performed a facility tour, welfare check, reviewed records, and interviewed involved parties. No deficiencies were observed or cited.
Complaint Details
The visit was triggered by a report of suspected dependent adult/elder abuse involving Resident #1 and Staff #1. The report was self-submitted by the licensee to the CCLD San Diego Regional Office on 10/26/2023. The complaint was investigated and no deficiencies were found.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Calais Anguiano | Executive Director | Met with Licensing Program Analyst during the visit and involved in the exit interview. |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced case management incident visit. |
| Lizzette Tellez | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 137
Deficiencies: 1
Aug 29, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff did not provide a 60-day notice prior to a rent increase for residents.
Findings
The investigation substantiated the allegation that the facility failed to provide a 60-day prior written notice to Resident 1 before a rent increase for July and August 2023. The facility reversed the rent increase for the affected resident and is issuing rent credits and conducting staff training.
Complaint Details
The complaint was substantiated. It was found that Resident 1 received a rent increase without the required 60-day prior notice. The facility acknowledged a personnel transition caused the issue and has reversed the rent increase and notified affected residents and their representatives.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide residents or their representatives with no less than 60 days' prior written notice of rent increase as required by CCR 1569.655(a). | Type B |
Report Facts
Census: 92
Total Capacity: 137
Deficiencies cited: 1
Persons in care affected: 1
Plan of Correction Due Date: Due date is 09/11/2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Calais Anguiano | Executive Director | Named in relation to findings and corrective actions regarding rent increase notice |
| Ramon Serrano | Licensing Program Analyst | Conducted the complaint investigation |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 137
Deficiencies: 2
Aug 28, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2023-07-27 alleging that staff spoke inappropriately to residents and did not attend to residents' call buttons in a timely manner.
Findings
The investigation substantiated that staff spoke inappropriately to residents and that response times to residents' call buttons were excessively long, sometimes up to 1-2 hours, exceeding the facility standard of 15 minutes. Facility management took corrective actions including staff training and reassessment of staffing levels.
Complaint Details
The complaint was substantiated based on evidence including interviews, observations, and records review. Allegations included inappropriate staff communication with residents and delayed response to call buttons. Facility management acknowledged issues and implemented corrective actions.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff spoke inappropriately to residents, violating residents' personal rights. | Type B |
| Residents did not receive personal assistance and care as needed on a timely basis, posing a potential health risk. | Type B |
Report Facts
Census: 92
Total Capacity: 137
Call Button Excessive Response Report June 2023: 867
Call Button Excessive Response Report July 2023: 1207
Response time range: 1
Response time range: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marisela Garcia-Centeno | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Denise Powell | Licensing Program Manager | Oversaw the complaint investigation |
| Calais Angiano | Executive Director | Facility representative met during the investigation |
| Angela Kaplioff | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 137
Deficiencies: 0
Aug 28, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2022-01-25 alleging that facility staff did not meet a resident's hygiene and incontinence care needs.
Findings
The investigation included observations, interviews, and record reviews. The evidence was insufficient to substantiate the allegations, and the complaint was deemed unsubstantiated.
Complaint Details
The complaint alleged that staff did not meet resident R1's hygiene needs and incontinence care needs. The investigation found that R1 was observed clean and groomed during visits, and staff accommodated R1's shower schedule and incontinence care needs with flexibility. Staff documented refusals and followed up accordingly. Outside sources indicated no concerns. Therefore, the allegations were unsubstantiated.
Report Facts
Complaint received date: Jan 25, 2022
Capacity: 137
Census: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marisela Garcia-Centeno | Licensing Program Analyst | Conducted the complaint investigation visit |
| Calais Angiano | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 137
Deficiencies: 0
Jul 27, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that the licensee did not protect residents in care and that staff did not treat residents with dignity.
Findings
The investigation included interviews, records review, and facility tour. The allegations were found to be unsubstantiated based on the preponderance of evidence, including physician reports and staff interviews. Residents R1 and R2 had behavioral challenges but no evidence supported the allegations.
Complaint Details
The complaint alleged that staff did not treat residents with dignity and that the licensee did not protect residents in care. The investigation found no substantiation for these allegations after interviews and records review.
Report Facts
Capacity: 137
Census: 91
Estimated Days of Completion: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Calais Anguiano | Executive Director | Met with the Licensing Program Analyst during the investigation |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 83
Capacity: 137
Deficiencies: 0
Mar 1, 2023
Visit Reason
The visit was an unannounced Case Management - Other visit to deliver an amended LIC9099-D report.
Findings
No deficiencies were observed during the visit. An exit interview was conducted and licensee rights were provided to the facility representative.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Justin Brown | Maintenance | Met during the visit and received the amended report and licensee rights. |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 137
Deficiencies: 1
Feb 24, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-11-15 alleging that staff did not distribute residents' medications as prescribed and did not properly supervise a resident.
Findings
The investigation substantiated that staff did not distribute medications in accordance with physician directions for one resident, including distribution of discontinued medication to another resident. Another allegation regarding improper supervision of a resident was unsubstantiated. Deficiencies were cited related to medication administration.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not distribute residents' medications as prescribed, including distribution of discontinued medication to Resident 3 on November 2, 2022. The allegation that staff did not properly supervise Resident 4 was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Incidental Medical and Dental Care Services. Once ordered by the physician, medications shall be given in accordance with the physician’s directions. This requirement was not met as evidenced by staff not giving medications in accordance with physician's directions for 1 of 85 persons in care (R1), posing a potential health risk. | Type B |
Report Facts
Capacity: 137
Census: 85
Deficiencies cited: 1
Plan of Correction Due Date: Mar 6, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ramon Serrano | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Angela Scott Kaplioff | Executive Director | Met with Licensing Program Analyst and involved in investigation interviews |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 85
Capacity: 137
Deficiencies: 0
Aug 19, 2022
Visit Reason
An unannounced Required 1-Year Visit was conducted to evaluate the facility's compliance with licensing requirements and infection control protocols.
Findings
No deficiencies were cited or observed during the inspection. The Licensing Program Analyst provided technical assistance and evaluated the facility's infection control mitigation plan including disinfection, testing surveillance, screening protocols, and PPE use.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Kaplioff | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview. |
| Ramon Serrano | Licensing Program Analyst | Conducted the unannounced Required 1-Year Visit and inspection. |
| Denise Powell | Licensing Program Manager | Named in report header as Licensing Program Manager. |
Inspection Report
Census: 78
Capacity: 137
Deficiencies: 0
May 12, 2022
Visit Reason
Licensing Program Analyst Carmen Lopez conducted an unannounced collateral visit to the facility to conduct interviews with residents and staff and to obtain relevant documents.
Findings
No deficiencies were observed during the visit. An exit interview was conducted and a copy of the report along with Licensee/Appeal Rights was provided to the Executive Director and Evergreen Director.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Scott-Kapiloff | Executive Director | Met with during the visit and received report and appeal rights. |
| Jael Wisdom Sanbrano | Evergreen Director | Met with during the visit and received report and appeal rights. |
| Carmen Lopez | Licensing Program Analyst | Conducted the unannounced collateral visit and interviews. |
| Rebecca Hedgecock | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 79
Capacity: 137
Deficiencies: 0
Apr 11, 2022
Visit Reason
An unannounced collateral visit was conducted to interview Resident #1 (R1) and discuss the reason for the visit with the Administrator.
Findings
No deficiencies were observed during the visit. An exit interview was conducted with the Administrator, and relevant documents were provided and acknowledged via email.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Scott-Kapiloff | Administrator | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
| Marisela Garcia-Centeno | Licensing Program Analyst | Conducted the unannounced collateral visit and interview with Resident #1. |
| John Rante | Licensing Program Manager | Named in the report header. |
Inspection Report
Original Licensing
Census: 68
Capacity: 137
Deficiencies: 0
Aug 12, 2021
Visit Reason
Licensing Program Analysts conducted a Prelicensing/Component III Visit to observe the physical plant for compliance and assess readiness for licensing.
Findings
The facility was found to be in compliance with regulations regarding resident accommodations, safety features, food service, medication storage, and physical plant requirements. No deficiencies or violations were noted during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Brennan | Executive Director | Met with during the inspection and discussed continuing operation requirements, record keeping, and physical plant compliance. |
Loading inspection reports...
