Inspection Report Summary
Most inspections found no deficiencies, with several complaint investigations resulting in unsubstantiated or unfounded allegations. However, some reports cited deficiencies primarily related to medication management, resident supervision, and infection control. The most recent report from August 28, 2025, identified a medication error where drugs were given incorrectly or to the wrong resident, posing a potential health risk. Earlier complaints included a resident injury during transfer and inadequate supervision leading to a resident wandering outside, both substantiated but addressed by the facility. While issues have occurred, the facility has shown some improvement, with no deficiencies noted in its annual inspections and many complaints found unsubstantiated.
Deficiencies per Year
4
3
2
1
0
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 110
Capacity: 140
Deficiencies: 1
Aug 28, 2025
Visit Reason
A case management visit was conducted regarding two separate incident reports received on August 6, 2025 and August 22, 2025 concerning medication errors.
Findings
The visit found that medication was given incorrectly to two residents and medication was given to the wrong resident, posing a potential health and safety risk. A Type B deficiency was cited related to failure to assist residents with self-administered medications as required.
Complaint Details
The visit was complaint-related, triggered by two incident reports regarding medication errors received on August 6 and August 22, 2025.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medication was given incorrectly to two residents and to the wrong resident, posing a potential health and safety risk. | Type B |
Report Facts
Deficiency due date: Sep 11, 2025
Incident report dates: Aug 6, 2025
Incident report dates: Aug 22, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassandra Mikkelson | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Neal Torres | Administrator/Director | Facility administrator named in the report |
| Caroline Frangieh | Executive Director | Met with Licensing Program Analyst during the visit and discussed medication management |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 140
Deficiencies: 1
May 8, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations including staff causing injuries during transfers and failure to meet residents' needs.
Findings
The investigation substantiated one allegation that a resident sustained an injury during transfer. Several other allegations related to timely response, incontinence care, room maintenance, hygiene, medical attention, laundry services, staff training, appointment attendance, and incident reporting were found to be unsubstantiated or unfounded.
Complaint Details
The complaint investigation was substantiated for the allegation that staff caused injuries to a resident during transfers. Other allegations including failure to timely respond to resident alerts, meet incontinence needs, maintain resident rooms, meet hygiene needs, timely seek medical attention, provide appropriate laundry services, staff training, ensuring attendance at scheduled appointments, and proper incident reporting were unsubstantiated or unfounded.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident R1 sustained an injury during transfer. | Type B |
Report Facts
Capacity: 140
Census: 114
Deficiency POC Due Date: May 15, 2025
Average call button response time (minutes): 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Neal Torres | Executive Director | Met during investigation and named in findings |
| Cassandra Mikkelson | Licensed Program Analyst | Conducted investigation and signed report |
| Laura Munoz | Licensing Program Manager | Oversaw investigation and signed report |
Inspection Report
Annual Inspection
Census: 110
Capacity: 140
Deficiencies: 0
Jan 22, 2025
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate the facility's compliance with health and safety regulations.
Findings
The facility was found to be clean, safe, sanitary, and in good condition with no deficiencies observed. Staff training and resident medication orders were reviewed and found compliant.
Report Facts
Residents receiving hospice care: 6
Resident files reviewed: 10
Staff files reviewed: 10
Resident medications reviewed: 2
Resident rooms toured: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danette Fadollone | Business Office Director | Met with Licensing Program Analyst during inspection and toured facility |
| Neal Torres | Executive Director | Current Executive Director since December 2024, met during inspection |
| Chad Rogers | Former Executive Director | No longer the Executive Director as of December 2024 |
| Cheyenne Ratajczak | Licensing Program Analyst | Conducted the annual inspection |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 140
Deficiencies: 0
Sep 26, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was retaining a resident with a higher level of care needed and that staff do not ensure resident's call button is answered in a timely manner.
Findings
The investigation found that although one resident required a 2-person assist and more extensive care, the facility was still able to meet the resident's needs, and the allegation was unfounded. Regarding the call button response times, the average response was approximately 10 minutes, and the allegation was unsubstantiated due to insufficient evidence.
Complaint Details
Two allegations were investigated: 1) Facility retaining a resident with a higher level of care needed, which was found to be unfounded. 2) Staff not ensuring resident's call button is answered timely, which was found to be unsubstantiated.
Report Facts
Average call button response time (minutes): 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Chad Rogers | Administrator | Met with Licensing Program Analyst during inspection |
| Troy Ordonez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 120
Capacity: 140
Deficiencies: 0
Aug 13, 2024
Visit Reason
The inspection was an unannounced case management visit to review two separate incident reports received from the facility.
Findings
The Licensing Program Analyst interviewed the administrator and reviewed documentation, finding that the facility followed proper protocol and regulation on each incident. No deficiencies were cited during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chad Rogers | Administrator | Met with during inspection and interviewed concerning incident reports. |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the inspection and interviewed the administrator. |
| Graham Gunby | Licensing Program Analyst | Arrived unannounced to conduct the case management inspection. |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 140
Deficiencies: 2
May 1, 2024
Visit Reason
Unannounced complaint investigation visit triggered by allegations that staff did not provide adequate supervision resulting in a resident wandering away from the facility unsupervised, and that the facility front door alarm was not working.
Findings
The investigation substantiated both allegations: staff failed to adequately supervise a resident who wandered outside the facility, and the wanderguard alarm system was not properly functioning due to sensor settings and placement issues. The facility has since updated the wanderguard system and implemented weekly checks.
Complaint Details
The complaint was substantiated. Allegations included inadequate supervision leading to a resident wandering unsupervised outside the facility and failure to ensure the front door alarm was working. Investigation included interviews and record reviews confirming these issues.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision resulting in resident wandering away from the facility. | Type B |
| Failure to ensure the wanderguard alarm system was working correctly. | Type B |
Report Facts
Capacity: 140
Census: 119
Plan of Correction Due Date: May 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Troy Ordonez | Licensing Program Manager | Oversaw the licensing program and signed the report |
| Danette Fadollone | Business Office Director | Met with Licensing Program Analyst during the investigation |
| Chad Rogers | Administrator | Facility administrator involved in the investigation and corrective actions |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 140
Deficiencies: 2
Mar 6, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-01-02 regarding inadequate monitoring of residents for early signs of illness and failure to follow infection control requirements.
Findings
The investigation substantiated that staff did not ensure residents were monitored for early signs of illness and failed to follow infection control requirements, including a staff member entering a resident's room without proper PPE. Another allegation regarding insufficient care and supervision was found to be unfounded.
Complaint Details
The complaint investigation was substantiated based on evidence that staff did not monitor residents for early signs of illness and did not follow infection control requirements, including PPE usage. One allegation regarding insufficient care was found to be unfounded.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow facility plan for incidental medical and dental care, posing a potential health and safety risk to residents. | Type B |
| Failure to follow infection control plan, posing a potential health and safety risk to residents. | Type B |
Report Facts
Capacity: 140
Census: 120
Deficiencies cited: 2
Plan of Correction Due Date: Mar 25, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Chad Rogers | Administrator | Met with Licensing Program Analyst during inspection and provided information |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 140
Deficiencies: 0
Feb 21, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was not abiding by the admissions agreement and that staff were not allowing residents to have visitors.
Findings
The investigation found both allegations to be unfounded. The facility's admission agreement allows for fees related to room service and guest meals, and visitors are allowed during business hours with restrictions on overnight stays requiring prior approval.
Complaint Details
The complaint investigation addressed two allegations: 1) Facility not abiding by the admissions agreement regarding charges for meals delivered to resident rooms, and 2) Facility staff not allowing residents to have visitors. Both allegations were found to be unfounded after review of documents and interviews.
Report Facts
Capacity: 140
Census: 116
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Chad Rogers | Administrator | Met with Licensing Program Analyst during inspection and provided information regarding facility policies |
Inspection Report
Annual Inspection
Census: 119
Capacity: 140
Deficiencies: 0
Jan 10, 2024
Visit Reason
The inspection was an unannounced annual inspection conducted to ensure the health and safety of residents in care at the facility.
Findings
No deficiencies were observed during the inspection. The facility was found to have adequate food supply, proper medication storage, complete first aid kit, and staff records indicating required clearances and training.
Report Facts
Residents receiving hospice care: 7
Resident files reviewed: 10
Staff files reviewed: 10
Resident medications reviewed: 3
Hot water temperature: 119
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chad Rogers | Administrator | Met with Licensing Program Analyst during inspection |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the annual inspection |
| Troy Ordonez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 140
Deficiencies: 1
Jan 10, 2024
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations received on 2023-11-08 regarding facility hazards, medication administration, mold presence, meal replacement requests, facility repairs, disrepair, and dietary plan adherence.
Findings
Most allegations were found to be unsubstantiated or unfounded after interviews, file reviews, and facility tours, except for the allegation that facility staff did not follow a resident's dietary plan, which was substantiated due to serving melon to an allergic resident and lack of allergy documentation in the kitchen.
Complaint Details
Complaint investigation involved multiple allegations including hazardous conditions leading to resident fall, medication administration errors, mold presence, meal replacement refusals, untimely facility repairs, facility disrepair, and failure to follow resident dietary plan. All allegations except the dietary plan violation were found unsubstantiated or unfounded. The dietary plan allegation was substantiated due to serving allergenic food and lack of proper allergy documentation.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances. All food shall be selected, stored, prepared and served in a safe and healthful manner. Licensee did not ensure resident was served safe food posing potential health and safety risk. | Type B |
Report Facts
Capacity: 140
Census: 119
Deficiency count: 1
Plan of Correction due date: Jan 31, 2024
Work orders completed: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Troy Ordonez | Licensing Program Manager | Oversaw complaint investigation |
| Chad Rogers | Administrator | Facility administrator met during inspection and involved in interviews |
| Jessica Pryor | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 140
Deficiencies: 0
Oct 12, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-10-06 regarding insect infestation and overcharging a resident.
Findings
The allegation that staff did not keep the facility free of insects was found unsubstantiated after inspection and interviews. The allegation that the facility was overcharging a resident was found unfounded after review of billing statements and confirmation of a proper rental increase notice.
Complaint Details
Two allegations were investigated: 1) Staff did not keep facility free of insects, which was unsubstantiated. 2) Facility is overcharging a resident in care, which was unfounded after review of billing and rental increase documentation.
Report Facts
Capacity: 140
Census: 121
Rental increase percentage: 6
Dates: Oct 6, 2023
Dates: Oct 12, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Chad Rogers | Administrator | Met with Licensing Program Analyst during inspection and provided information |
| Jessica Pryor | Administrator | Named as facility administrator in report header |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 140
Deficiencies: 0
Oct 5, 2023
Visit Reason
Unannounced visit to investigate complaints alleging that facility staff is not ensuring the kitchen is kept in a sanitary condition and that the facility did not issue a refund to a resident in care.
Findings
The investigation found the kitchen to be clean and sanitary, resulting in the first allegation being unfounded. The second allegation regarding failure to issue a refund was found to be unsubstantiated as the facility refunded the resident for unauthorized charges.
Complaint Details
Two complaints were investigated: 1) Facility staff not maintaining kitchen sanitation, found to be unfounded. 2) Facility did not issue a refund to a resident, found to be unsubstantiated after confirmation of refund issuance.
Report Facts
Capacity: 140
Census: 122
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation |
| Chad Rogers | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Original Licensing
Census: 102
Capacity: 140
Deficiencies: 0
Dec 15, 2022
Visit Reason
The inspection was conducted as a pre-licensing visit for a change in ownership (CHOW) of the facility currently licensed as Sierra Pointe.
Findings
The facility met all pre-licensing components including proper furnishing and maintenance of resident bedrooms, clean and sanitary bathrooms, adequate food supply, operational smoke and carbon monoxide detectors, functional fire extinguisher, presence of grab bars, unobstructed exits, and secure storage of toxins, medications, and sharps. The disaster drill was current and the administrator holds a valid certificate.
Report Facts
Food supply duration: 2
Food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Pryor | Administrator | Met with Licensing Program Analyst during pre-licensing visit |
| Talwinder Bains | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Laura Munoz | Licensing Program Manager | Named in report header |
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