Inspection Reports for Ivy Park at San Ramon
9199 Fircrest Ln, San Ramon, CA 94583, San Ramon, CA, 94583
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related to facility maintenance, medication management, and timely incident reporting, with several substantiated complaints about call button malfunctions, medication errors, and failure to prevent or report resident elopements. The facility received a $500 civil penalty in March 2024 for a fire clearance violation and a $250 fine in August 2025 for repeated hot water temperature issues. Many complaint investigations were unsubstantiated, including allegations of staff misconduct and inadequate care. The most recent inspection on September 16, 2025, substantiated a deficiency for facility disrepair affecting call button functionality but found no issues with staff charging or care plan adherence. While some serious concerns have occurred, recent reports show ongoing attention to these issues without new enforcement actions.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
90% 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: 146
Capacity: 162
Deficiencies: 1
Date: Sep 16, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2025-07-29, including staff not providing timely assistance to residents and facility disrepair.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not provide assistance to a resident in a timely manner and that the facility was in disrepair. The allegations that staff charged residents for services not rendered, did not follow residents' care plans, and spoke inappropriately to residents were unsubstantiated.
Findings
The investigation substantiated that staff did not provide timely assistance to a resident due to a malfunctioning call button and that the facility was in disrepair. Additionally, allegations regarding staff charging residents for services not rendered, not following care plans, and inappropriate communication were found unsubstantiated.
Deficiencies (1)
The premises were not maintained in a state of good repair as evidenced by R1's call button being in disrepair, posing a potential safety and personal rights violation to residents in care.
Report Facts
Civil penalty amount: 250
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alona Gomez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jessica Pryor | Regional OPs Specialist | Met with Licensing Program Analyst during investigation |
| Oreisha Morgan | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 162
Deficiencies: 1
Date: Aug 21, 2025
Visit Reason
The inspection was conducted as a result of a priority 1 complaint to perform a Health & Safety inspection at the facility.
Complaint Details
The visit was triggered by a priority 1 complaint. The complaint was substantiated as the hot water temperature violation was confirmed during the inspection.
Findings
The inspection found that the hot water temperature in one resident room was 126.1 degrees F, exceeding the allowed maximum of 120 degrees F, posing an immediate safety risk. A civil penalty of $250 was assessed for repeat violations.
Deficiencies (1)
Hot water temperature measured at 126.1 degrees F in room 259, exceeding the maximum allowed temperature of 120 degrees F.
Report Facts
Civil penalty amount: 250
Hot water temperature: 126.1
Refrigerator temperature: 39
Census: 143
Total capacity: 162
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Oriesha Morgan | Executive Director | Met with Licensing Program Analysts during inspection. |
| Alona Gomez | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Y Brown | Licensing Program Analyst | Conducted the inspection. |
| Yvonne Flores-Larios | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 162
Deficiencies: 1
Date: Aug 4, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-03-10 regarding medication assistance, refusal to accept a resident back, and denial of access to resident records.
Complaint Details
The complaint investigation was substantiated for improper medication assistance but unsubstantiated for refusal to accept resident back and denial of access to resident's records. The medication error involved marking medication as given when it was not administered due to system and human errors. The other allegations lacked sufficient evidence.
Findings
The investigation substantiated that staff did not provide proper medication assistance to a resident, identifying errors in medication administration documentation. However, allegations that staff refused to accept a resident back and denied access to resident records were unsubstantiated due to lack of evidence.
Deficiencies (1)
Medication was marked as administered when the resident was out of the community and did not receive it.
Report Facts
Capacity: 162
Census: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Oreisha Morgan | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Alona Gomez | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 146
Capacity: 162
Deficiencies: 0
Date: Aug 1, 2025
Visit Reason
The inspection visit was a case management visit conducted as a result of a self-reported incident involving an alleged injury between two residents on 7/23/2025.
Findings
The Licensing Program Analyst found no evidence to support the allegation that resident R2 hurt resident R1. R2 was non-ambulatory and unable to commit the alleged act. The police and responsible party were notified, and R1's condition and care plan were updated. No deficiencies were cited during the visit.
Report Facts
Incident report date: Jul 24, 2025
Incident alleged date: Jul 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thaleana Jones | Business Office Director | Met with Licensing Program Analyst during the visit |
| Alona Gomez | Licensing Program Analyst | Conducted the case management visit |
| Oreisha Morgan | Administrator/Director | Named as facility administrator/director |
Inspection Report
Census: 141
Capacity: 162
Deficiencies: 0
Date: Jul 1, 2025
Visit Reason
The visit was a case management visit conducted as a result of delivering an amended complaint report for complaint #15-AS-20241203085000.
Complaint Details
The visit was related to complaint #15-AS-20241203085000 and involved delivery of an amended complaint report.
Findings
No deficiencies were cited during the visit. An exit interview was conducted and a copy of the report was provided to the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Orisha Morgan | Executive Director | Met with Licensing Program Analyst during the case management visit. |
| Alona Gomez | Licensing Program Analyst | Conducted the case management visit and delivered the amended complaint report. |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 162
Deficiencies: 2
Date: Jul 1, 2025
Visit Reason
The inspection visit was conducted as a case management visit following an elopement incident involving a memory care resident (R1) that occurred on 2025-06-25.
Complaint Details
The visit was triggered by a complaint related to an elopement incident of resident R1 on 2025-06-25. The complaint was substantiated as the facility failed to prevent the elopement and failed to report it within 24 hours.
Findings
The facility failed to prevent the elopement of resident R1 and did not report the incident within the required 24-hour timeframe. The elopement posed an immediate safety risk to residents in care.
Deficiencies (2)
Facility did not prevent R1 from eloping
Facility did not report incident in required 24 hour time frame
Report Facts
Census: 141
Total Capacity: 162
Plan of Correction Due Date: Jul 2, 2025
Plan of Correction Due Date: Jul 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Oreisha Morgan | Executive Director | Met with Licensing Program Analyst during inspection and named in findings related to elopement incident |
| Alona Gomez | Licensing Program Analyst | Conducted the inspection visit and signed the report |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 162
Deficiencies: 0
Date: Jun 4, 2025
Visit Reason
The inspection was conducted as a result of a priority 1 complaint to assess health and safety conditions at the facility.
Complaint Details
The visit was triggered by a priority 1 complaint. No deficiencies were cited during the inspection.
Findings
The Licensing Program Analyst toured the facility and found no deficiencies. All safety measures, including hot water temperature, food supplies, medication storage, smoke detectors, carbon monoxide detector, first-aid kit, and fire extinguisher, were in compliance.
Report Facts
Hot water temperature readings: 119.6
Hot water temperature readings: 114.9
Food supply duration: 7
Food supply duration: 2
Refrigerator temperature: 40
Fire extinguisher last serviced: May 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thaleana Jones | Business Director | Met with Licensing Program Analyst during inspection |
| A. Gomez | Licensing Program Analyst | Conducted the health and safety inspection |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 162
Deficiencies: 3
Date: May 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of staff mismanaging residents' medications, failure to notify residents and responsible parties, and untimely response to residents' call buttons.
Complaint Details
The complaint investigation was substantiated based on interviews, record reviews, and observations. The allegations included medication mismanagement, failure to notify residents and responsible parties, untimely response to call buttons, facility disrepair, failure to send incident reports, and noncompliance with residents' care plans.
Findings
The investigation substantiated the allegations, finding multiple medication administration errors, malfunctioning call button systems, failure to notify families about care costs, discrepancies in residents' care plans, and failure to send incident reports as required. The facility was found to be in disrepair and not fully compliant with care and reporting regulations.
Deficiencies (3)
Facility did not comply with reporting incidents as required, posing potential safety and personal rights violations.
Call buttons were in disrepair and not operational, posing potential safety and personal rights violations.
Inaccurate Medication Administration Records (MAR) which questioned the validity of medication entries.
Report Facts
Capacity: 162
Census: 152
Deficiencies cited: 3
Plan of Correction Due Dates: Due dates for Plan of Correction are May 29, 2025 and June 5, 2025 for different deficiencies
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Oreisha Morgan | Executive Director | Met with Licensing Program Analyst during investigation and named in findings related to facility management and prior staff issues |
| Alona Gomez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| S1 | Staff interviewed regarding medication administration errors | |
| S2 | Staff interviewed regarding medication system and errors | |
| Health and Wellness Director | Former Health and Wellness Director | Named in findings related to changing residents' needs and services without family notification and resignation after discrepancies |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 162
Deficiencies: 1
Date: May 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-02-10 regarding allegations including staff not ensuring a resident has hot water and not abiding by the admission agreement.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not ensure a resident had hot water, but unsubstantiated for the allegation that staff did not abide by the admission agreement.
Findings
The allegation that staff did not ensure a resident had hot water was substantiated; the facility had an issue with hot water in one of the resident's bathrooms for a few months, which was resolved by replacing the boiler system. The allegation that staff did not abide by the admission agreement was unsubstantiated as the admissions agreement did not include wifi, which was a courtesy service.
Deficiencies (1)
Facility did not have hot water in 1 of 2 of R1's showers, violating water supply and plumbing requirements.
Report Facts
Capacity: 162
Census: 152
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Oreisha Morgan | Executive Director | Met during investigation and named in findings related to hot water issue |
| Alona Gomez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 162
Deficiencies: 5
Date: May 14, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to multiple allegations including facility disrepair, staff not following residents' care plans, failure to send incident reports as required, and staff not providing medication as prescribed.
Complaint Details
The complaint investigation was substantiated for allegations of facility disrepair, staff not following care plans, failure to send incident reports, and medication administration errors. The allegations regarding facility cleanliness, adequacy of care, staffing levels, and controlled substance administration were unsubstantiated due to lack of evidence.
Findings
The investigation substantiated the allegations that the facility was in disrepair, staff were not following residents' care plans, incident reports were not sent as required, and medication was not always administered as prescribed. Specific issues included non-operational fireplaces, broken washers and dryers, malfunctioning call button systems, inaccurate medication administration records, and discrepancies in residents' care plans. Some allegations regarding cleanliness, staffing adequacy, and controlled substance administration were found to be unsubstantiated.
Deficiencies (5)
Elevator, fireplace, and washing utilities were in disrepair, violating maintenance requirements.
Failure to send incident reports as required by regulation.
Inaccurate Medication Administration Records (MAR) putting validity of entries into question.
Failure to communicate significant changes and update residents' records appropriately.
Residents' care plans did not always match the care needed or provided.
Report Facts
Capacity: 162
Census: 146
Deficiencies cited: 5
Plan of Correction Due Dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Oreisha Morgan | Executive Director | Met with Licensing Program Analyst during investigation and named in findings related to facility management and care plan discrepancies |
| Alona Gomez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
Inspection Report
Annual Inspection
Census: 140
Capacity: 162
Deficiencies: 2
Date: Feb 20, 2025
Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing regulations.
Findings
The inspection found that the facility's fire clearance was approved for 162 residents, with adequate lighting, temperature, and safety features. However, deficiencies were noted including hot water temperature exceeding regulatory limits and staff lacking current first aid training.
Deficiencies (2)
Hot water temperature measured at 133.6 degrees Fahrenheit, exceeding the maximum allowed temperature of 120 degrees Fahrenheit, posing an immediate safety risk.
Six out of six staff files reviewed did not have current first aid training, posing a potential health and safety risk to persons in care.
Report Facts
Residents' census: 140
Total licensed capacity: 162
Staff files without current first aid training: 6
Hot water temperature: 133.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alona Gomez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Yvonne Flores-Larios | Licensing Program Manager | Supervisor overseeing the inspection |
| Thaleana Jones | Business Office Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 162
Deficiencies: 0
Date: Jan 13, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-10-07 regarding staff privacy violations and theft of resident items.
Complaint Details
The complaint involved allegations that staff did not accord residents' privacy and stole items from residents. The investigation found no disciplinary actions against the accused employee, no police records, and no reports of missing items. The employee resigned after harassment. The allegations were unsubstantiated due to lack of evidence.
Findings
The investigation included interviews, file reviews, and evidence requests. No substantiated evidence was found to support the allegations, and no deficiencies were cited. The allegations were determined to be unsubstantiated.
Report Facts
Complaint Control Number: 15-AS-20241007150646
Capacity: 162
Census: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Oreisha Morgan | Executive Director | Met with Licensing Program Analyst during investigation |
| Alona Gomez | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 162
Deficiencies: 0
Date: Aug 19, 2024
Visit Reason
The visit was conducted as a case management visit resulting from an Unusual Incident Report received on 2024-08-09 regarding a resident's unsafe behaviors shortly after admission.
Complaint Details
The complaint involved a resident climbing walls, entering neighboring homes, running into the street, and other unsafe behaviors shortly after moving in. The resident was found to have a prior physician's report indicating independence, but was later diagnosed with unspecified schizophrenia and no longer resides at the facility.
Findings
The investigation found that the resident exhibited unsafe behaviors inconsistent with prior assessments, was diagnosed with unspecified schizophrenia, and no injuries occurred. The facility retrained staff on elopement procedures. No deficiencies were cited during the visit.
Report Facts
Census: 140
Total Capacity: 162
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alona Gomez | Licensing Program Analyst | Conducted the case management visit |
| Pari Manouchehri | Regional Operations Specialist | Met with during the visit |
| Anlisse Ramirez | Health Service Director | Met with during the visit |
Inspection Report
Census: 140
Capacity: 162
Deficiencies: 0
Date: Aug 19, 2024
Visit Reason
The inspection was an unannounced case management visit conducted as a result of an Unusual Incident Report received on 2024-07-22 regarding a theft incident involving a resident's personal belongings.
Findings
The investigation found that a staff member (S1) stole a resident's (R1) purse, phone, wallet, and contents. S1 has been terminated. No deficiencies were cited during the visit. The facility retrained staff on reporting requirements and procedures.
Report Facts
Census: 140
Total Capacity: 162
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer S Coons | Administrator/Director | Named as facility administrator |
| Pari Manouchehri | Regional Operations Specialist | Met with during inspection |
| Anlisse Ramirez | Health Service Director | Met with during inspection |
| Alona Gomez | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 155
Capacity: 162
Deficiencies: 1
Date: Jun 13, 2024
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2024-06-03 regarding blocked fire exits and other safety concerns.
Complaint Details
The complaint investigation was substantiated for the allegation that the fire exit was blocked. Other allegations about emergency disaster plan, evacuation chairs, and emergency drills were unsubstantiated.
Findings
The investigation substantiated that a fire exit in the stairwell behind door 6 was blocked by a shampoo machine, posing an immediate health and safety risk. Other allegations regarding emergency disaster plans, evacuation chairs, and emergency drills were found unsubstantiated.
Deficiencies (1)
Fire exit in stairwell behind door six was blocked by an industrial shampoo machine posing an immediate health and safety risk.
Report Facts
Facility Capacity: 162
Census: 155
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Fountain | Director of Transitions & Acquisitions | Met with during inspection and involved in findings discussion |
| Alona Gomez | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Annual Inspection
Census: 153
Capacity: 162
Deficiencies: 3
Date: Mar 27, 2024
Visit Reason
The inspection was an unannounced continuation of the 1-Year Annual Required inspection to evaluate compliance with licensing regulations and fire clearance.
Findings
The inspection found multiple deficiencies including a resident designated as bedridden residing in a room not cleared for bedridden persons, staff lacking required first aid training, and missing health screenings or TB results in staff files. An immediate $500 civil penalty was assessed for the fire clearance violation.
Deficiencies (3)
Resident R1 designated as bedridden residing in a room not cleared for bedridden persons.
Staff S2 and S3 do not have first aid training and requirements on file.
Staff S2 and S4 do not have a health screen or TB result on file.
Report Facts
Capacity: 162
Census: 153
Staff records reviewed: 5
Resident records reviewed: 8
Civil penalty amount: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caroline Frangieh | Executive Director | Met with Licensing Program Analyst during inspection |
| Alona Gomez | Licensing Program Analyst | Conducted the inspection and signed the report |
| Yvonne Flores-Larios | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 153
Capacity: 162
Deficiencies: 1
Date: Mar 27, 2024
Visit Reason
The visit was an unannounced Case Management visit in response to an unusual incident report received on 2024-02-06 regarding an alleged physical abuse incident involving a resident in memory care.
Complaint Details
The visit was complaint-related due to an unusual incident report alleging physical abuse of a resident by a staff member. The allegation was substantiated based on interviews and reports.
Findings
It was found that on 2024-01-31, a staff member (S1) pushed a resident (R1) in memory care, constituting physical abuse. The resident had no visible injuries and was unable to recall the event. The facility provided training to staff on mandated reporting requirements following the incident.
Deficiencies (1)
S1 was observed physically abusing R1
Report Facts
Capacity: 162
Census: 153
Plan of Correction Due Date: Mar 28, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer S Coons | Administrator | Facility administrator named in the report header |
| Caroline Frangieh | Executive Director | Met with Licensing Program Analyst during the visit and discussed reporting requirements |
| Anelisse Ramirez | Health Services Director, LVN | Assessed resident for injuries and assisted with translation during interviews |
| Alona Gomez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Yvonne Flores-Larios | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 140
Deficiencies: 0
Date: Feb 28, 2024
Visit Reason
The visit was conducted as a Case Management visit in response to an unusual incident report received on 2024-02-06 regarding an alleged staff push of a resident in memory care.
Complaint Details
The complaint involved an allegation that a staff member pushed a resident. The resident was assessed with no visible injuries and was unable to recall the event. The staff member was terminated. The investigation is ongoing with a planned return visit.
Findings
The investigation found that the resident had no injuries or recollection of the event, and the staff member alleged of abuse was terminated effective 2024-02-12. No deficiencies were cited at this time.
Report Facts
Date of incident report: Feb 6, 2024
Date of alleged incident: Feb 2, 2024
Date of staff termination: Feb 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caroline Frangieh | Executive Director | Met with Licensing Program Analyst during visit |
| Anelisse Ramirez | Health Services Director, LVN | Assessed resident for possible injuries after alleged incident |
| Alona Gomez | Licensing Program Analyst | Conducted the case management visit |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 142
Capacity: 140
Deficiencies: 0
Date: Feb 28, 2024
Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.
Findings
The Licensing Program Analyst toured the facility and found adequate lighting, appropriate temperature, safe hot water temperatures, and proper safety equipment in residents' bathrooms. No citations were issued during the inspection. The annual inspection was incomplete and will be continued at a later date.
Report Facts
Hot water temperature measurements: 114.1
Hot water temperature measurements: 112
Hot water temperature measurements: 113.7
Hallway temperature: 78
Facility capacity: 140
Facility census: 142
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caroline Frangieh | Executive Director | Met with Licensing Program Analyst during inspection |
| Alona Gomez | Licensing Program Analyst | Conducted the inspection |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report header |
Inspection Report
Census: 144
Capacity: 140
Deficiencies: 0
Date: Jan 17, 2024
Visit Reason
The visit was an unannounced Case Management visit conducted in response to an unusual incident report received on 11/11/2023 regarding a resident who went AWOL from the facility.
Findings
The Licensing Program Analyst reviewed the resident's physician report and care plan, which stated the resident was able to leave the facility unassisted. The incident involved the resident leaving their apartment and being found in the parking lot shortly after the door alarm sounded.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caroline Frangieh | Executive Director | Met with Licensing Program Analyst during the visit and involved in the incident discussion. |
| Alona Gomez | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Yvonne Flores-Larios | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 140
Deficiencies: 0
Date: Oct 20, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations of facility disrepair and malodorous conditions.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included facility disrepair and malodorous conditions. The facility was found to be taking corrective actions such as contacting repair services and ventilating the kitchen area.
Findings
The investigation found that the exhaust fans in the kitchen were broken for about a week, causing odors. The facility has taken actions to alleviate the odor and is awaiting repairs. Based on observations and interviews, the allegations were determined to be unsubstantiated as the facility is actively addressing the issues.
Report Facts
Facility capacity: 140
Census: 143
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Del Dosso | Executive Director | Met with Licensing Program Analysts during the complaint investigation |
| Paris Watson | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 143
Capacity: 140
Deficiencies: 1
Date: Oct 20, 2023
Visit Reason
The inspection was an unannounced Case Management visit conducted to evaluate compliance with facility regulations, specifically related to fire clearance capacity.
Findings
The facility was found to be over its approved fire clearance capacity, housing 143 residents while the approved capacity is 140. This posed an immediate health, safety, or personal rights risk and resulted in a civil penalty.
Deficiencies (1)
Facility has an approved fire clearance capacity for 140 residents, however the facility's current census is 143, exceeding the approved limit.
Report Facts
Civil penalty amount: 500
Capacity: 140
Census: 143
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Del Dosso | Executive Director | Met with Licensing Program Analysts during the inspection. |
| Paris Watson | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Yvonne Flores-Larios | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 140
Deficiencies: 1
Date: Jul 20, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff do not ensure residents' special dietary needs are being met.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The allegation was that staff do not ensure resident's special dietary needs are met, specifically regarding gluten and lactose free diets.
Findings
The investigation found that the facility does not provide gluten free options such as gluten free breads and pastas, and was unable to accommodate all prescribed diets, including a doctor's order for a resident's gluten and lactose free diet. The allegation was substantiated.
Deficiencies (1)
General Food Service Requirements. Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidence by failure to provide R1 with diet prescribed by physician which poses a potential health and safety risk.
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Aug 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Coons | Executive Director | Met with Licensing Program Analyst during investigation and named in findings regarding dietary needs |
| Grace Luk | Licensing Program Analyst | Conducted complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 140
Deficiencies: 1
Date: May 10, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-03-15 regarding allegations including medication not administered timely, insufficient staff, staff yelling at residents, and inadequate care.
Complaint Details
The complaint investigation was substantiated for the allegation that facility staff did not administer medication in a timely manner. Other allegations including insufficient staff, staff yelling at residents, and inadequate care were unsubstantiated.
Findings
The investigation substantiated that facility staff failed to administer a resident's medication as ordered, posing an immediate health and safety risk. Other allegations regarding insufficient staff, staff yelling at residents, and inadequate care were unsubstantiated based on interviews, observations, and record reviews.
Deficiencies (1)
Failure to administer resident R6's over-the-counter medication as ordered from February 1, 2023, to February 28, 2023.
Report Facts
Capacity: 140
Census: 119
Deficiencies cited: 1
Plan of Correction Due Date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Leslie Ibo | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jennifer Coons | Executive Director | Met with Licensing Program Analyst during the investigation |
| Eugenia Smith | Administrator | Named in relation to medication administration deficiency |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 140
Deficiencies: 0
Date: Apr 12, 2023
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation regarding allegations that facility staff engaged in food preparation and service did not protect resident meals from contamination.
Complaint Details
The complaint alleged that facility staff did not protect resident meals from contamination. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that although there was an outbreak of norovirus at the facility, interviews with residents indicated symptoms were not due to food poisoning. There was insufficient evidence to substantiate the allegation, and it was determined to be unsubstantiated.
Report Facts
Capacity: 140
Census: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Malek | Regional Director of Health Services | Met with Licensing Program Analyst during the investigation and exit interview |
| Lizette Francisco | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 140
Deficiencies: 0
Date: Apr 12, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that the facility failed to provide a safe environment for a resident, did not report an incident to an authorized representative in a timely manner, and did not call 911 in a timely manner.
Complaint Details
The complaint was unsubstantiated as there was no preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found that maintenance for heating and air conditioning units was conducted quarterly, with the last maintenance on 7/30/22. Staff interviews and record reviews showed that the facility contacted the responsible party and emergency contacts appropriately and called 911 immediately upon being informed of the incident. There was insufficient evidence to substantiate the allegations, and the complaint was deemed unsubstantiated.
Report Facts
Capacity: 140
Census: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lizette Francisco | Licensing Program Analyst | Conducted the complaint investigation |
| Melissa Malek | Regional Director of Health Services | Met with Licensing Program Analyst during investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 140
Deficiencies: 1
Date: Apr 12, 2023
Visit Reason
The inspection was conducted as a Case Management visit resulting from complaint #15-AS-20221104082159 to investigate compliance with fire safety regulations.
Complaint Details
The visit was triggered by complaint #15-AS-20221104082159. The deficiency related to fire safety was substantiated based on record review and interview.
Findings
A deficiency was found where the facility did not have smoke detectors monitored by a fire alarm company, posing a potential health and safety risk to residents. The facility was cleared by the Fire Marshall on 11/10/22.
Deficiencies (1)
Licensee did not comply with the regulation by not having smoke detectors monitored by fire alarm company which poses a potential health and safety risk to residents in care.
Report Facts
Capacity: 140
Census: 118
Plan of Correction Due Date: Apr 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Malek | Regional Director of Health Services | Met with Licensing Program Analyst during inspection |
| Harpreet Humpal | Licensing Program Manager | Supervisor named in report |
| Lizette Francisco | Licensing Program Analyst | Conducted the inspection and authored the report |
Inspection Report
Original Licensing
Capacity: 140
Deficiencies: 0
Date: Mar 15, 2022
Visit Reason
The visit was an unannounced pre-licensing inspection conducted to evaluate the facility's readiness for licensing.
Findings
No issues were noted during the inspection. The facility was found to be ready to be licensed, with proper furniture, safety equipment, and fire clearance in place.
Report Facts
Fire clearance capacity: 62
Fire clearance capacity: 64
Fire clearance capacity: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eugenia Smith | Executive Director | Met with Licensing Program Analyst during inspection |
| Lizette Francisco | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Harpreet Humpal | Licensing Program Manager | Named in report header |
Inspection Report
Original Licensing
Census: 40
Capacity: 140
Deficiencies: 0
Date: Mar 3, 2022
Visit Reason
The visit was conducted as part of a Change of Ownership (CHOW) application process for licensing evaluation of the facility.
Findings
The applicant and administrator participated in a telephone call to confirm understanding of Title 22 regulations, facility operation, staff qualifications, program policies, and other licensing requirements. The evaluation included review of application documents, health screening, fire clearance, and COVID-19 mitigation plan discussion.
Report Facts
Capacity: 140
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eugenia Smith | Applicant/administrator | Participated in the licensing evaluation and telephone call |
| Joseph Villanueva | Administrator | Named as facility administrator |
| Jude De La Concepcion | Licensing Program Manager | Named as licensing program manager |
| Maria Ejaz | Licensing Program Analyst | Named as licensing program analyst |
Inspection Report
Original Licensing
Census: 99
Capacity: 140
Deficiencies: 0
Date: Nov 16, 2021
Visit Reason
The visit was conducted as part of a Change of Ownership (CHOW) application process for licensing evaluation of the facility.
Findings
The applicant and administrator demonstrated understanding of Title 22 requirements including facility operation, staff qualifications, program policies, and COVID-19 mitigation plan. The evaluation included review of health screening, fire clearance, certifications, financial verification, and compliance history.
Report Facts
Capacity: 140
Census: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Villanueva | Administrator | Facility administrator mentioned in the report |
| Robert Jakini | Applicant/Administrator | Participant in COMP II telephone call |
| Susan McPherson | Applicant/Administrator | Participant in COMP II telephone call |
| Jude De La Concepcion | Licensing Program Manager | Named in report header |
| Maria Ejaz | Licensing Program Analyst | Named in report header |
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