Deficiencies (last 5 years)
Deficiencies (over 5 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
89% occupied
Based on a February 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Routine
Census: 101
Capacity: 114
Deficiencies: 0
Date: Feb 27, 2026
Visit Reason
The inspection was an unannounced 1-Year Required routine inspection to evaluate compliance with licensing requirements for the assisted living and memory care facility.
Findings
No deficiencies were cited during this visit. Resident and staff files were reviewed and found to be well organized and complete with all required documentation. The Licensing Program Analyst was unable to complete the annual inspection and a continuation visit will be conducted later.
Report Facts
Residents in care: 101
Total licensed capacity: 114
Resident files reviewed: 10
Staff files reviewed: 10
Hospice waiver capacity: 12
Bedridden resident capacity: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Executive Director | Met with Licensing Program Analyst during inspection |
| Robert Frank | Licensing Program Analyst | Conducted the inspection |
| Victoria Bertozzi | Licensing Program Manager | Named in report header |
Inspection Report
Census: 102
Capacity: 114
Deficiencies: 0
Date: Jan 29, 2026
Visit Reason
The visit was an unannounced Case Management - Incident inspection conducted following receipt of an Unusual Incident/Injury Report regarding a resident.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst interviewed the facility Executive Director and conducted an exit interview.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Executive Director | Met with Licensing Program Analyst during the inspection and interviewed regarding the incident report. |
| Robert Frank | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 102
Capacity: 114
Deficiencies: 0
Date: Jan 29, 2026
Visit Reason
The visit was an unannounced Case Management - Incident inspection conducted following receipt of an Unusual Incident/Injury Report regarding a resident.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst interviewed the facility Executive Director and conducted an exit interview with no issues found.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Executive Director | Met with Licensing Program Analyst during the inspection and interviewed regarding the incident. |
| Robert Frank | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 114
Deficiencies: 0
Date: Dec 18, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that staff were not giving resident medications as prescribed and violations of personal rights.
Complaint Details
The complaint allegations included staff not giving resident medications as prescribed and personal rights violations. The allegations were found to be unfounded, meaning they were false or without reasonable basis.
Findings
The investigation found that the involved parties, including the resident in question, do not reside or have never been present at the facility. No deficiencies were identified and the allegations were determined to be unfounded.
Report Facts
Capacity: 114
Census: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Frank | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Limeberg | Administrator | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 114
Deficiencies: 0
Date: Oct 17, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff did not safeguard resident funds, specifically regarding an alleged theft that occurred on 2025-06-09.
Complaint Details
The complaint alleged that staff did not safeguard resident funds with an alleged theft occurring on 2025-06-09. The facility self-reported the incident to Community Care Licensing and the Santa Rosa Police Department. The police did not investigate on-site. Nine staff members had access to the resident's apartment during the time of the alleged theft. The allegation was unsubstantiated due to insufficient evidence.
Findings
The investigation found no preponderance of evidence to prove or disprove the alleged theft due to lack of video or forensic evidence, resulting in the allegation being unsubstantiated. No deficiencies were cited during the visit.
Report Facts
Staff with access to resident apartment: 9
Reported theft amount threshold: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Frank | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Stephanie Limberg | Executive Director | Facility Administrator met during investigation and recipient of report |
Inspection Report
Annual Inspection
Census: 100
Capacity: 114
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
The inspection was an unannounced 1-Year Required annual inspection of the assisted living and memory care facility to evaluate compliance with licensing requirements.
Findings
The facility was found to be clean, orderly, and compliant with regulations including safety, staffing, medication management, and emergency preparedness. No deficiencies were cited during the visit.
Report Facts
Residents in care: 100
Total capacity: 114
Residents bedridden capacity: 14
Hospice waiver capacity: 12
Sample sinks tested for hot water temperature: 9
Staff files reviewed: 10
Resident files reviewed: 10
Resident medications spot checked: 8
Date of last disaster drill: Mar 20, 2025
Date of last fire extinguisher service: Jan 10, 2025
Date of last smoke and CO detector inspection: Dec 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Executive Director | Met with Licensing Program Analyst during inspection and named in report |
| Robert Frank | Licensing Program Analyst | Conducted the inspection |
| Debbie Spencer | Office Director | Greeted Licensing Program Analyst upon arrival |
Inspection Report
Annual Inspection
Census: 100
Capacity: 114
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
The inspection was an unannounced 1-Year Required annual inspection conducted to evaluate compliance with licensing requirements for the assisted living and memory care facility.
Findings
The facility was found to be clean, orderly, and compliant with safety and health regulations. All staff and resident documentation were in order, emergency supplies and disaster preparedness were adequate, and no deficiencies were cited during the visit.
Report Facts
Residents bedridden capacity: 14
Hospice waiver capacity: 12
Sample size of sinks tested for hot water temperature: 9
Sample size of staff files reviewed: 10
Sample size of resident files reviewed: 10
Sample size of residents' medications spot-checked: 8
Date of last fire extinguisher service: Jan 10, 2025
Date of last disaster drill: Mar 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Executive Director | Met with Licensing Program Analyst during inspection and named as Administrator/Executive Director |
| Robert Frank | Licensing Program Analyst | Conducted the inspection visit |
| Debbie Spencer | Office Director | Greeted Licensing Program Analyst upon arrival |
Inspection Report
Annual Inspection
Census: 102
Capacity: 114
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
The visit was an unannounced 1-Year Required Annual Inspection to evaluate compliance with regulations for an assisted living and memory care facility.
Findings
The facility was found to be clean, well-maintained, and in compliance with regulations including infection control, emergency preparedness, and resident care documentation. No deficiencies were cited during the visit.
Report Facts
Staff on-site: 32
Residents bedridden capacity: 14
Hospice waiver capacity: 12
Hot water temperature range: 105
Hot water temperature range: 120
Fire sprinkler last inspection: 2023
Emergency drill last conducted: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator/Executive Director | Met with Licensing Program Analyst during inspection and named in report |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Annual Inspection
Census: 102
Capacity: 114
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
Unannounced 1-Year Required Visit to evaluate compliance with regulations for an assisted living and memory care facility.
Findings
The facility was found to be clean, well-maintained, and compliant with regulations including infection control, emergency preparedness, and resident care documentation. No deficiencies were cited during the visit.
Report Facts
Staff on-site: 32
Residents bedridden capacity: 14
Hospice waiver capacity: 12
Hot water temperature sample size: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator/Executive Director | Met during inspection and named in report. |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection. |
| Victoria Bertozzi | Licensing Program Manager | Named in report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 114
Deficiencies: 0
Date: Feb 2, 2024
Visit Reason
The inspection was an unannounced case management visit triggered by a reported sexual assault incident involving a resident on 01/31/2024.
Complaint Details
The complaint involved a sexual assault reported by a resident on 01/31/2024. The suspected abuser is unknown. The facility notified the police and the resident's responsible party. Hospital discharge information and police report were requested but not yet available. The resident was discharged to a responsible party and is not currently at the facility.
Findings
The facility reported a sexual assault incident involving a resident, notified authorities, and coordinated with the hospital and police. No deficiencies were cited during this inspection.
Report Facts
Facility capacity: 114
Resident census: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met with Licensing Program Analyst and involved in reporting and managing the sexual assault incident |
| Christi Coppo | Licensing Program Analyst | Conducted the unannounced case management visit and inspection |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 114
Deficiencies: 0
Date: Feb 2, 2024
Visit Reason
The visit was an unannounced case management inspection triggered by a report of sexual assault abuse involving a resident at the facility.
Complaint Details
The complaint involved a sexual assault reported by resident R1 on 1/31/2024. The suspected abuser is unknown. The facility reported the incident to police and the resident's responsible party. Hospital discharge information and police report were not available at the time of inspection.
Findings
The investigation found that a resident reported a sexual assault by an unknown suspect. The administrator notified police and the resident was transported to the hospital. No deficiencies were cited during this inspection.
Report Facts
Residents present: 101
Facility capacity: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met with Licensing Program Analyst and involved in reporting and handling the abuse incident |
| Christi Coppo | Licensing Program Analyst | Conducted the unannounced case management inspection |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Capacity: 114
Deficiencies: 0
Date: Jan 17, 2024
Visit Reason
The visit was an unannounced case management inspection conducted in response to an Incident Report received on 2024-01-08 regarding alleged abuse of a resident by self-neglect, which resulted in hospitalization.
Complaint Details
The complaint involved abuse of a resident by self-neglect, confirmed by the resident's fall and subsequent hospitalization. The incident was cross-reported to police (report #24-271).
Findings
The investigation found that the resident had a fall resulting in a fractured back and hospitalization. The facility took immediate corrective actions including fitting safety restrictors on windows and conducting additional staff training on suicide precautions. No deficiencies were cited during this inspection.
Report Facts
Window safety restrictor opening limit: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met with Licensing Program Analyst during inspection and involved in incident response |
| Christi Coppo | Licensing Evaluator | Conducted the case management inspection |
| Bethany Moellers | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Capacity: 114
Deficiencies: 0
Date: Jan 17, 2024
Visit Reason
The visit was an unannounced case management inspection regarding an incident report received on 2024-01-08 involving alleged abuse of a resident by self-neglect, which resulted in hospitalization.
Complaint Details
The complaint involved abuse of resident (R1) by self-neglect leading to a 72-hour hold and hospitalization. The incident was cross-reported to police (report #24-271). The resident remains hospitalized with a fractured back and will not be returning to the facility. The complaint was investigated with no deficiencies cited.
Findings
The investigation found that the resident had jumped from a second-floor window resulting in a fractured back and hospitalization. The facility took immediate corrective actions including fitting safety window restrictors and conducting additional staff training on suicide precautions. No deficiencies were cited during this inspection.
Report Facts
Facility capacity: 114
Incident date: Jan 6, 2024
Incident report received date: Jan 8, 2024
Window restrictor opening limit: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met with Licensing Program Analyst and involved in incident response |
| Christi Coppo | Licensing Program Analyst | Conducted the case management inspection |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 114
Deficiencies: 0
Date: Jan 4, 2024
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report received on 12/15/2023 regarding alleged theft of a resident's cellphone.
Complaint Details
The complaint involved alleged abuse in the form of theft of a resident's cellphone. The incident was reported to the ombudsman and police. The facility and licensing agency conducted an investigation, but no deficiencies were found.
Findings
The investigation found that the resident's cellphone was missing and believed stolen after staff accidentally washed it and returned it to the resident. The facility conducted an investigation, cross-reported the incident to appropriate parties, and filed a police report. No deficiencies were cited during this investigation.
Report Facts
Approximate value of missing cellphone: 400
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Named as facility administrator involved in the investigation and interview |
| Christi Coppo | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
| Bethany Moellers | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 114
Deficiencies: 0
Date: Jan 4, 2024
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report received on 12/15/2023 regarding alleged abuse of a resident in the form of theft of a cellphone.
Complaint Details
The complaint involved alleged theft of a resident's cellphone. The incident was substantiated by the facility's investigation and police report filing. The resident's apartment was searched without locating the phone, and the cellphone carrier was unable to locate it remotely.
Findings
The investigation found that the resident's cellphone was missing and presumed stolen after staff accidentally washed it and returned it to the resident. The facility conducted an investigation, cross-reported the incident to appropriate parties, and filed a police report. No deficiencies were cited during this investigation.
Report Facts
Approximate value of stolen cellphone: 400
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Named in relation to the incident report and investigation |
| Christi Coppo | Licensing Program Analyst | Conducted the case management visit and investigation |
| Bethany Moellers | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 114
Deficiencies: 1
Date: Oct 20, 2023
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report received on 2023-10-06 regarding a resident who was found missing from the facility.
Complaint Details
The complaint was substantiated based on the incident where resident R1 eloped from the locked memory care unit, posing a potential health, safety, or personal rights risk to residents.
Findings
The resident with dementia eloped from a locked memory care unit and was found at a hospital emergency room without injuries. The facility conducted additional staff training and increased monitoring of the resident. A deficiency was cited for inadequate staffing to support the resident's needs.
Deficiencies (1)
Failure to have an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal, evidenced by a resident eloping a locked memory care unit.
Report Facts
Census: 103
Total Capacity: 114
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Named in relation to increased staff training and monitoring following the incident |
| Christi Coppo | Licensing Evaluator | Conducted the inspection and signed the report |
| Victoria Bertozzi | LPA who arrived unannounced to conduct case management | |
| Bethany Moellers | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 114
Deficiencies: 1
Date: Oct 20, 2023
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report received on 2023-10-06 regarding a resident who was found missing from the facility.
Complaint Details
The visit was complaint-related, triggered by an incident report about resident R1 eloping from the facility. The resident was found safe at a hospital ER. The complaint was substantiated by the cited deficiency.
Findings
The investigation found that resident R1, diagnosed with dementia and residing in Memory Care, eloped from a locked memory care unit and was later found at a hospital emergency room with no injuries or new diagnoses. The facility increased staff monitoring and conducted additional staff training following the incident. A deficiency was cited for failing to meet the requirement of adequate direct care staff to support residents' needs.
Deficiencies (1)
Failure to have an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs, evidenced by resident R1 eloping a locked memory care unit.
Report Facts
Census: 103
Total Capacity: 114
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Named in relation to the incident and facility response |
| Christi Coppo | Licensing Program Analyst | Conducted the inspection and signed the report |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 100
Capacity: 114
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
The inspection was an unannounced Case Management-Incident visit to discuss three incidents reported by the facility, including a missing resident's jewelry, a resident's fall resulting in a hip fracture, and a rodent sighting in an apartment.
Findings
No deficiencies were observed or cited during the Case Management-Incident inspection. The facility took appropriate actions including contacting responsible parties, reassessing resident needs, and pest control measures.
Report Facts
Incident reports: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met during the inspection and involved in incident reporting and follow-up |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection |
| Hope DeBenedetti | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 114
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
The inspection was an unannounced Case Management-Incident visit to discuss three incidents reported by the facility, including a missing resident's jewelry, a resident's fall resulting in a hip fracture, and a rodent sighting in an apartment.
Complaint Details
The visit was complaint-related to three incidents: missing jewelry reported on September 20, 2023; a resident's left hip fracture from a fall on September 25, 2023; and a rodent sighting on September 27, 2023. The facility responded appropriately to each incident. No deficiencies were cited.
Findings
No deficiencies were observed or cited during the inspection. The facility took appropriate actions including contacting responsible parties, reassessing the resident after the fall, and eradicating the rodent issue with pest control measures.
Report Facts
Incident dates: September 20, 2023; September 25, 2023; September 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met with during inspection and involved in incident reporting and response |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the Case Management-Incident inspection |
| Hope DeBenedetti | Licensing Program Manager | Named in report header |
Inspection Report
Census: 114
Capacity: 114
Deficiencies: 1
Date: Aug 30, 2023
Visit Reason
The inspection was an unannounced Case Management - Incident visit conducted to investigate an incident involving inappropriate photos of two residents sent via cellular device and email to the Administrator.
Findings
The Licensing Program Analyst found that a staff member sent inappropriate photos of residents to the Administrator, which was a violation of residents' rights under Health and Safety Code 1569.269(a)(3). The facility was cited with a Type B deficiency and educated on prohibiting photography of residents on personal cell phones.
Deficiencies (1)
Violation of Health and Safety Code 1569.269(a)(3) regarding confidential treatment of residents' records and personal information; inappropriate photos of residents were sent to the Administrator via cellular device and email.
Report Facts
Plan of Correction Due Date: Aug 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Interviewed during the inspection and involved in the incident regarding inappropriate photos |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection and authored the report |
Inspection Report
Capacity: 114
Deficiencies: 1
Date: Aug 30, 2023
Visit Reason
The inspection was an unannounced Case Management - Incident visit conducted to investigate an incident involving inappropriate photos of two residents sent via cellular device and email to the Administrator.
Findings
The Licensing Program Analyst found that a staff member sent inappropriate photos of two residents to the Administrator, which posed an immediate health, safety, and personal rights risk. The staff member was written up and the Administrator was educated on the prohibition of resident photography on personal cell phones.
Deficiencies (1)
Failure to ensure confidential treatment of residents' records and personal information, as emails depicting inappropriate photos of two residents were sent to the Administrator via cellular device and email.
Report Facts
Capacity: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met during inspection and involved in incident |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection and authored the report |
| Hope DeBenedetti | Licensing Program Manager | Supervisor of the Licensing Program Analyst |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 114
Deficiencies: 0
Date: Jun 22, 2023
Visit Reason
The inspection was conducted as a Case Management-Incident Inspection following an incident report of a resident fall, injury, and subsequent hospital visit.
Complaint Details
The visit was complaint-related due to an incident report forwarded on June 10, 2023, regarding a resident fall and injury. The complaint was investigated and no deficiencies were found.
Findings
No deficiencies were observed or cited during the inspection. The resident involved in the incident was reported to be doing well and prescribed medication for pain. The Care Plan will be updated with the family.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met with Licensing Program Analyst during inspection and provided information about the incident and care plan. |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the Case Management-Incident Inspection. |
| Hope DeBenedetti | Supervisor | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 114
Deficiencies: 0
Date: Jun 22, 2023
Visit Reason
The inspection was conducted as a Case Management-Incident Inspection following an incident report of a resident fall, injury, and subsequent hospital visit.
Complaint Details
The visit was complaint-related due to an incident report forwarded on June 10, 2023, concerning a resident fall and injury. The complaint was investigated and no deficiencies were found.
Findings
No deficiencies were observed or cited during the inspection. The resident was reported to be doing well and prescribed medication for pain. The Care Plan will be updated with the family.
Report Facts
Capacity: 114
Census: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Facility Administrator present during the inspection |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the Case Management-Incident Inspection |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 114
Deficiencies: 0
Date: May 8, 2023
Visit Reason
The inspection was conducted as a Case Management-Incident Inspection following incident reports submitted on April 22, 2023, and May 5, 2023, including a resident-to-resident altercation.
Complaint Details
The visit was complaint-related due to incident reports submitted on April 22, 2023, and May 5, 2023. The complaint was investigated, and it was found that residents involved had no recollection of the altercation and had assimilated back into the community. Care Plans will be updated accordingly.
Findings
The facility followed all proper procedures related to the incidents, including reviewing the LIC 602 form and updating Care Plans. No deficiencies were observed or cited during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met with Licensing Program Analyst during inspection and interviewed regarding incidents. |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the Case Management-Incident Inspection. |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 114
Deficiencies: 0
Date: May 8, 2023
Visit Reason
The inspection was conducted as a Case Management-Incident Inspection following incidents submitted to the Community Care Licensing on April 22, 2023, and May 5, 2023, including a resident-to-resident altercation.
Complaint Details
The visit was complaint-related, triggered by incident reports submitted on April 22, 2023, and May 5, 2023. The complaint was investigated and found to be unsubstantiated as no deficiencies were cited and residents had no recollection of the altercation.
Findings
The facility was found to have followed all proper procedures related to the incidents reviewed, including confirming that a resident was not on a Special Diet and that care plans will be updated for involved residents. No deficiencies were observed or cited during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met with Licensing Program Analyst during inspection and interviewed regarding incident reports. |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the Case Management-Incident Inspection and reviewed incident reports. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 114
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff interfered with resident visiting at the facility.
Complaint Details
The allegation was that staff interfered with resident visiting. The investigation included attempts to contact the resident's Durable Power of Attorney, interviews with family and staff, and observation of the resident. The allegation was determined to be unfounded.
Findings
The investigation found the allegation to be unfounded after reviewing records, conducting interviews, and observing the resident. No deficiencies were observed during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lydia Gravelyn | Administrator | Met with during the investigation and exit interview. |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and delivered the amended report. |
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the original complaint investigation. |
| Debbie Spencer | Business Office Manager | Greeted Licensing Program Analyst upon arrival and granted access to the facility. |
Inspection Report
Annual Inspection
Census: 90
Capacity: 114
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
The inspection was a required unannounced 1-year inspection focused on infection control practices and procedures at the facility.
Findings
The facility was found to be clean and in good repair with sufficient food supplies, operational safety equipment, and proper infection control measures including staff training and resident/staff vaccination. No deficiencies were observed during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Lydia Gravelyn | Administrator | Met with the Licensing Program Analyst during the inspection. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 114
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to an allegation that staff interfered with resident visiting at the facility.
Complaint Details
The allegation that staff interfered with resident visiting was investigated and found to be unfounded, meaning the allegation was false, could not have happened, and/or was without a reasonable basis.
Findings
The investigation found the allegation to be unfounded after reviewing records, conducting interviews, and observing the resident. No one was denied entry to visit the resident, and no deficiencies were observed during the inspection.
Report Facts
Facility capacity: 114
Census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lydia Gravelyn | Administrator | Met with during inspection and exit interview |
| Farhaan Sarangi | Licensing Program Analyst | Conducted amended report and investigation |
| Erik Gonzalez Campos | Evaluator | Conducted initial complaint investigation visit |
Inspection Report
Annual Inspection
Census: 90
Capacity: 114
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
The inspection was an unannounced required 1-year inspection focused on infection control practices and procedures at the facility.
Findings
The facility was found to be clean and in good repair with sufficient food supplies, operational safety equipment, and proper infection control measures including staff training and COVID-19 precautions. No deficiencies were observed during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lydia Gravelyn | Administrator | Met with Licensing Program Analyst during inspection and discussed resident/staff record keeping. |
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the unannounced required 1-year inspection. |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 81
Capacity: 114
Deficiencies: 0
Date: Dec 28, 2022
Visit Reason
Licensing Program Analyst Erik Gonzalez Campos arrived unannounced to conduct a case management inspection regarding a self-reported SOC341 received by Community Care Licensing on 12/20/2022. The facility conducted an internal investigation and reported the incident to the Santa Rosa Police Department.
Findings
No deficiencies were cited during the inspection. The Licensing Program Analyst will follow up by requesting the police report related to the incident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the case management inspection |
| Lydia Gravelyn | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 114
Deficiencies: 0
Date: Dec 28, 2022
Visit Reason
The inspection was a case management visit conducted due to a self-reported SOC341 incident received by Community Care Licensing on 2022-12-20. The facility conducted an internal investigation and reported the incident to the Santa Rosa Police Department.
Complaint Details
The visit was complaint-related based on a self-reported incident (SOC341) received on 2022-12-20. The facility conducted an internal investigation and reported the incident to the police. Follow-up includes requesting the police report.
Findings
No deficiencies were cited during the inspection. The Licensing Program Analyst will follow up by requesting the police report related to the incident.
Report Facts
Capacity: 114
Census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lydia Gravelyn | Administrator | Met with Licensing Program Analyst during inspection |
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the case management inspection |
| Kimberley Mota | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 114
Deficiencies: 0
Date: Dec 16, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations of neglect, failure to address change in resident's health condition, and failure to report death, fall, and pressure injury.
Complaint Details
The complaint involved allegations of neglect/lack of care causing an unstageable pressure injury, failure to address a resident's change in condition, and failure to report death, fall, and pressure injury. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations regarding neglect, failure to address health condition changes, and failure to report incidents. No deficiencies were cited during the inspection.
Report Facts
Capacity: 114
Census: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Teresa Weerts | Health Services Director | Met with Licensing Program Analyst during inspection and exit interview |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 114
Deficiencies: 0
Date: Dec 16, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 08/16/2022 regarding neglect, failure to address change in resident's condition, and failure to report incidents including death, fall, and pressure injury.
Complaint Details
The complaint involved allegations of neglect/lack of care causing an unstageable pressure injury, failure to address a resident's change in health condition, and failure to report death, fall, and pressure injury. The investigation concluded all allegations were unsubstantiated.
Findings
The investigation found no preponderance of evidence to substantiate the allegations of neglect, failure to address change in condition, or failure to report incidents. The allegations were determined to be unsubstantiated and no deficiencies were cited during the inspection.
Report Facts
Complaint Control Number: 21-AS-20220816152630
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Teresa Weerts | Health Services Director | Met with Licensing Program Analyst during inspection and exit interview |
| Kimberley Mota | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 114
Deficiencies: 1
Date: Nov 22, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 05/31/2022 regarding resident care issues including falls, skin tears, delayed medical attention, physical abuse, hygiene neglect, malnutrition, and failure to inform representatives of condition changes.
Complaint Details
The complaint investigation was triggered by allegations including unwitnessed fall with injuries, skin tears, delayed medical attention, physical abuse, hygiene neglect resulting in wound/infection, improper medical documentation, malnutrition, and failure to inform resident's representative of condition changes. The complaint was partially substantiated with one deficiency cited related to podiatric care, while other allegations were found unsubstantiated or unfounded.
Findings
The investigation found some allegations substantiated, specifically failure to arrange timely podiatric care resulting in excessive toenail length and dry cracked skin posing immediate risk. Other allegations such as unwitnessed falls, skin tears, physical abuse, infected wounds, medical documentation issues, malnutrition, and failure to inform representatives were found to be unsubstantiated or unfounded based on evidence reviewed.
Deficiencies (1)
Facility failed to arrange timely podiatric care for resident resulting in excessively long nails and toes in need of care, posing immediate risk to health and personal rights.
Report Facts
Capacity: 114
Census: 79
Deficiencies cited: 1
Plan of Correction Due Date: Nov 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kevin Booth | Administrator | Facility administrator named in report |
| Lydia Gravelyn | Facility representative met during investigation | |
| Carla Martinez | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 114
Deficiencies: 1
Date: Nov 22, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations including resident falls, skin tears, delayed medical attention, physical abuse, hygiene neglect, improper medical documentation, malnutrition, and failure to inform representative of condition changes.
Complaint Details
Complaint investigation was conducted based on allegations received on 05/31/2022. The complaint included multiple allegations such as unwitnessed fall, skin tears, delayed medical attention, physical abuse, hygiene neglect, improper medical documentation, malnutrition, and failure to inform resident's representative. The investigation concluded the complaint was partially substantiated (podiatric care issue) and partially unsubstantiated or unfounded for other allegations.
Findings
The investigation found one allegation substantiated regarding failure to arrange timely podiatric care resulting in excessive toenail length and dry cracked skin, posing immediate risk to resident health. Other allegations including unwitnessed fall, skin tears, delayed medical attention, physical abuse, hygiene neglect, improper documentation, malnutrition, and failure to inform representative were found unsubstantiated or unfounded based on evidence reviewed.
Deficiencies (1)
Facility failed to arrange timely podiatric care for resident resulting in excessively long nails and toes in need of care, posing immediate risk to health and personal rights.
Report Facts
Capacity: 114
Census: 79
Deficiencies cited: 1
Plan of Correction Due Date: Nov 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Carla Martinez | Licensing Program Manager | Oversaw complaint investigation |
| Kevin Booth | Administrator | Facility administrator named in report |
| Lydia Gravelyn | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 114
Deficiencies: 1
Date: Jun 24, 2022
Visit Reason
The inspection was conducted as a Case Management Inspection regarding an incident report received by Community Care Licensing on 2022-06-09 about a resident eloping from memory care.
Complaint Details
The visit was complaint-related due to an incident on June 8, 2022, where a resident eloped from memory care and was found outside the facility. The complaint was substantiated by observation and record review.
Findings
The inspection found that a resident was able to exit one alarmed door and one delayed egress door, posing an immediate health and safety risk. Deficiencies were cited related to safety measures for residents with dementia, specifically addressing wandering and elopement risks.
Deficiencies (1)
Care of Persons with Dementia: The plan of operation did not adequately address safety measures to prevent residents from exiting the building, posing an immediate health and safety risk.
Report Facts
Residents in care: 31
Deficiency count: 1
Plan of Correction Due Date: Jul 1, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Tammy Kirby | Regional Memory Care Specialist | Met with the Licensing Program Analyst during inspection and participated in exit interview |
| Kimberley Mota | Supervisor | Named as supervisor in the report |
Inspection Report
Original Licensing
Census: 73
Capacity: 114
Deficiencies: 1
Date: Jun 24, 2022
Visit Reason
The inspection was an unannounced Post Licensing Inspection conducted to evaluate the facility's compliance following licensing. The visit included assessment of infection control, safety measures, and administrative changes.
Findings
The facility was found to be clean and in good repair with proper infection control measures in place, including COVID screening and staff vaccination. Medications and toxins were securely stored. However, a deficiency was noted regarding fire extinguisher access in the memory care unit, requiring a written plan to be submitted by July 1, 2022.
Deficiencies (1)
Fire extinguishers behind locked cases in memory care are inaccessible to staff; a written plan for access is required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the Post Licensing Inspection and noted findings. |
| Tammy Kirby | Regional Memory Care Specialist | Met with Licensing Program Analyst during inspection and participated in exit interview. |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 114
Deficiencies: 1
Date: Jun 24, 2022
Visit Reason
The inspection was conducted as a Case Management Inspection regarding an incident report received by Community Care Licensing on 2022-06-09 involving a resident eloping from memory care.
Complaint Details
Inspection was triggered by an incident report of a resident eloping from memory care on June 8, 2022. The complaint was substantiated as deficiencies were found.
Findings
The Licensing Program Analyst observed that exits to outdoor patio areas and the front entrance were armed with alarms, but a resident was able to exit one alarmed door and one delayed egress door, posing an immediate health and safety risk. Deficiencies were cited related to care of persons with dementia and safety measures for wandering behaviors.
Deficiencies (1)
Failure to meet requirements for safety measures addressing behaviors such as wandering, aggressive behavior, and ingestion of toxic materials, evidenced by a resident exiting an alarmed door and a delayed egress door.
Report Facts
Residents in care during inspection: 31
Census: 73
Total Capacity: 114
Deficiency count: 1
Plan of Correction Due Date: Due date stated as 07/01/2022 (converted date not numeric)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Tammy Kirby | Regional Memory Care Specialist | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Kimberley Mota | Licensing Program Manager | Supervisor and Licensing Program Manager named in report |
Inspection Report
Original Licensing
Census: 73
Capacity: 114
Deficiencies: 1
Date: Jun 24, 2022
Visit Reason
The visit was an unannounced Post Licensing Inspection conducted to evaluate the facility's compliance following licensing.
Findings
The facility was found to be clean and in good repair. Infection control measures including COVID screening and staff vaccination were in place. Medications and toxins were securely stored. However, a written plan was requested to provide fire extinguisher access to memory care staff by July 1, 2022.
Deficiencies (1)
Fire extinguishers were behind locked cases with access only by maintenance coordinator; facility requested to submit a written plan to provide access to memory care staff.
Report Facts
Capacity: 114
Census: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the Post Licensing Inspection and noted findings |
| Tammy Kirby | Regional Memory Care Specialist | Met with Licensing Program Analyst during inspection and participated in exit interview |
Inspection Report
Census: 73
Capacity: 114
Deficiencies: 0
Date: Jun 2, 2022
Visit Reason
The visit was an unannounced case management visit to return the file for resident (R1) and confirm the file was returned complete and undamaged per regulation.
Findings
The Executive Director reviewed the contents of the resident file and confirmed it was returned complete and undamaged. An exit interview was conducted with the administrator, and a copy of the report was emailed to the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the unannounced visit and file review |
| Safoora Ahmed | Executive Director | Met with Licensing Program Analyst and reviewed resident file |
Inspection Report
Census: 73
Capacity: 114
Deficiencies: 0
Date: Jun 2, 2022
Visit Reason
The visit was conducted as a Case Management - Other type of visit, specifically to return the file for a resident (R1).
Findings
The Executive Director reviewed the contents of the resident file and confirmed it was returned complete and undamaged per regulation. An exit interview was conducted with the administrator and a copy of the report was emailed to the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Safoora Ahmed | Executive Director | Met with Licensing Program Analyst during the visit and reviewed resident file. |
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the unannounced visit and file return. |
Inspection Report
Original Licensing
Census: 64
Capacity: 114
Deficiencies: 0
Date: Apr 15, 2022
Visit Reason
The inspection was an unannounced pre-licensing visit conducted to evaluate the facility for licensing approval.
Findings
The facility was found to have appropriate furnishings, safety features such as grab bars, smoke alarms, sprinkler system, and secured medications. Records including resident files and staff CPR certificates were reviewed and found compliant. No deficiencies were noted.
Report Facts
CPR certificates observed: 10
Fire extinguisher inspection date: Jan 22, 2022
Water temperature: 112.2
Resident files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Teresa Weerts | Health Services Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Original Licensing
Census: 64
Capacity: 114
Deficiencies: 0
Date: Apr 15, 2022
Visit Reason
The inspection was an unannounced pre-licensing visit conducted to evaluate the facility for initial licensing approval.
Findings
The facility was found to have appropriate furnishings, safety features such as grab bars, smoke alarms, sprinkler systems, and locked medication storage. Staff CPR and First Aid certifications were current, and sufficient food supplies were observed. No deficiencies or violations were noted in the report.
Report Facts
Resident files reviewed: 5
Current CPR certificates: 10
Water temperature: 112.2
Fire extinguisher inspection date: Jan 22, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Weerts | Health Services Director | Met with Licensing Program Analyst during inspection |
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the pre-licensing inspection |
Inspection Report
Capacity: 114
Deficiencies: 0
Date: Feb 24, 2022
Visit Reason
The visit was an office type evaluation related to a Change of Ownership (CHOW) application, including a Component II telephone call to verify the applicant and administrator's understanding of Title 22 regulations and facility operation.
Findings
The applicant and administrator successfully completed Component II via telephone, confirming understanding of facility operation, staff qualifications, program policies, and application document review including criminal record clearance, health screening, and other licensing requirements.
Inspection Report
Original Licensing
Capacity: 114
Deficiencies: 0
Date: Feb 24, 2022
Visit Reason
The visit was conducted as a Component II (COMP II) telephone call to evaluate the applicant/administrator's understanding of licensing requirements and facility operation as part of the original licensing process.
Findings
The applicant/administrator successfully completed the COMP II telephone call, demonstrating understanding of facility operation, staff qualifications, program policies, and application document requirements. No deficiencies or violations were noted in the report.
Report Facts
Capacity: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Burke | Administrator | Named as facility administrator |
| Mirella Quaranta | Supervisor | Supervisor overseeing the licensing evaluation |
| Stefania Fonteno | Licensing Evaluator | Licensing evaluator conducting the facility evaluation |
| Kathleen Olson | Participant in COMP II telephone call |
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