Inspection Report Summary
Most inspections found no deficiencies, with several complaint investigations determined to be unfounded or unsubstantiated. The most recent report from July 17, 2025, was a complaint investigation that found no issues related to staff criminal background clearances. The only cited deficiency occurred in December 2024, when four staff members did not have criminal record clearances on file, which was considered an immediate risk. Since then, the facility has shown improvement, with no deficiencies noted in subsequent inspections. Other complaints about medication management, lighting, room safety, refunds, and safeguarding belongings were all found to be without merit or lacking evidence.
Deficiencies per Year
4
3
2
1
0
High
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 74
Capacity: 120
Deficiencies: 0
Jul 17, 2025
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that staff were not criminally record cleared.
Findings
The investigation found that all 16 staff members observed and reviewed were background cleared and associated with the facility. The allegation was deemed unfounded as there was no evidence supporting it.
Complaint Details
The complaint alleged that staff were not criminally record cleared. The allegation was investigated and found to be unfounded.
Report Facts
Staff observed: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation visit |
| David Alvarado | Executive Director | Met with Licensing Program Analyst during the investigation |
| Sheila Santos | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 120
Deficiencies: 0
Apr 9, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff did not ensure residents' lights worked properly, medications were not properly managed, and residents' rooms were not set up safely.
Findings
All allegations were investigated and determined to be either unfounded or unsubstantiated. The lighting allegation was unfounded as the resident's room had adequate lighting. The medication management allegation was unfounded after review of medication records and staff interviews. The room setup allegation was unsubstantiated due to conflicting information and lack of evidence of a violation.
Complaint Details
The complaint investigation was triggered by allegations regarding lighting, medication management, and room safety. The lighting and medication allegations were found to be unfounded, meaning false or without reasonable basis. The room setup allegation was unsubstantiated, meaning there was no preponderance of evidence to prove the violation occurred.
Report Facts
Capacity: 120
Census: 73
Medication records reviewed: 7
Staff interviewed: 4
Residents interviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| David Alvarado | Administrator / Executive Director | Facility administrator met with the Licensing Program Analyst during the investigation |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 78
Capacity: 120
Deficiencies: 0
Feb 19, 2025
Visit Reason
Licensing Program Analyst Joseph Alejandre made an unannounced visit to follow up on a report received by the Agency and met with the Health Services Director to explain the reason for the visit.
Findings
The Health Services Director reported compliance with instructions from Orange County Health Care Agency, no issues to report, full staffing, and ample PPE supply. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the unannounced follow-up visit and met with the Health Services Director. |
| David Alvarado | Administrator | Named as facility administrator. |
| Veronika Labastida | Met with Licensing Program Analyst during the visit. |
Inspection Report
Annual Inspection
Census: 69
Capacity: 120
Deficiencies: 1
Dec 7, 2024
Visit Reason
The visit was an unannounced annual required inspection conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations.
Findings
The facility was found to be clean, sanitary, and appropriately furnished with no discrepancies in medication administration records. However, a deficiency was cited for not having criminal record clearances on file for 4 staff members, posing an immediate risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have criminal record clearance on file for 4 staff members. | Type A |
Report Facts
Residents' service files reviewed: 5
Staff personnel files reviewed: 4
Medication Administration Records reviewed: 3
Fire/Disaster Drills last conducted: Oct 22, 2024
Facility Annual Fees overdue since: Nov 30, 2024
Plan of Correction Due Date: Dec 9, 2024
Approved hospice waiver beds: 15
Resident rooms on first floor: 54
Resident rooms on second floor: 43
Non-ambulatory residents allowed: 120
Bed-ridden residents allowed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Alvarado | Executive Director | Met with Licensing Program Analyst during inspection and received report |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Eva M Alvarez | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 65
Capacity: 120
Deficiencies: 0
Nov 13, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted by Licensing Program Analysts to evaluate compliance with licensing requirements.
Findings
The facility was found to be in compliance with no deficiencies observed. The kitchen, resident rooms, bathrooms, medication storage, and safety equipment were all inspected and found to meet required standards. Staff files and resident records showed no discrepancies.
Report Facts
Licensed capacity: 120
Current census: 65
Fire drill date: Oct 10, 2024
Fire sprinkler inspection date: Jul 8, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Alvarado | Executive Director/Administrator | Met with Licensing Program Analysts during inspection |
| Joseph Alejandre | Licensing Program Analyst | Conducted the inspection |
| Hanna Gough | Licensing Program Analyst | Conducted the inspection |
| Brandon Lopez | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Jan 29, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that the facility did not issue a full refund to a prospective resident.
Findings
The investigation found that the facility issued a full refund to the prospective resident as per the signed community fee receipt and final account statement, and the allegation was determined to be unfounded.
Complaint Details
The complaint alleged that the facility did not issue a full refund. The investigation concluded the allegation was unfounded, meaning it was false or without reasonable basis.
Report Facts
Community fee payment: 3995
Refund amount: 3995
Capacity: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Patricia Rager | Administrator | Facility Administrator named in the report |
| Peggy | Business Office Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 120
Deficiencies: 0
Jun 1, 2023
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that facility staff did not safeguard residents' belongings.
Findings
The investigation found no evidence to support the allegation that facility staff failed to safeguard residents' belongings. The allegation was deemed unsubstantiated due to lack of evidence.
Complaint Details
The complaint alleged that facility staff did not safeguard residents' belongings, specifically that Resident 1's belongings were damaged. Resident 1 reported a theft to the Orange County Sheriff, but no report number was provided and no action was taken. Resident 1 declined to have personal property inventoried and has moved out of the facility. The facility is not responsible for belongings not put in their care. The allegation was unsubstantiated.
Report Facts
Capacity: 120
Census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tammy Ojwang | Executive Director | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Original Licensing
Census: 46
Capacity: 120
Deficiencies: 0
Nov 3, 2022
Visit Reason
The visit was an announced pre-licensing inspection to evaluate the facility's readiness to operate as a Residential Care Facility for the Elderly (RCFE) with a capacity of 120 residents.
Findings
No deficiencies were observed during the visit. The facility meets Title 22 requirements and is ready to be licensed. The fire clearance was approved for the full capacity, and all safety and operational systems were found to be in compliance.
Report Facts
Capacity: 120
Census: 46
Hot water temperature: 119
Food supply duration: 2
Food supply duration: 7
Fire clearance approval date: Sep 6, 2022
Hospice waiver capacity: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Mensah | Executive Director | Met during inspection and involved in facility operations |
| Daniel Lines | Administrator | Met during inspection and involved in facility operations |
| Joseph Alejandre | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Luz Adams | Licensing Program Manager | Named in report as Licensing Program Manager |
| Nathan Bobbitt | Orange County Fire Authority Inspector | Approved fire clearance for the facility |
Inspection Report
Original Licensing
Capacity: 120
Deficiencies: 0
Sep 12, 2022
Visit Reason
The visit was conducted as part of the original licensing process (CHOW application) for the facility to verify the applicant/administrator's understanding of California Code Title 22 Regulations and readiness for licensing.
Findings
The applicant/administrator successfully completed Component II, demonstrating understanding of facility operation, admission policies, staffing requirements, restrictive health conditions, emergency preparedness, complaints and reporting, and pre-licensing readiness. Identification was verified and required documentation was obtained.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Mensah | Administrator | Participated in Component II interview and verified as applicant/administrator. |
| Mirella Quaranta | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Susan Nguyen | Licensing Program Analyst | Named as Licensing Program Analyst on the report. |
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