Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally appropriate care and compliance with regulations. The most recent report from August 13, 2025, was a complaint investigation with no deficiencies found. Earlier reports identified a few isolated issues, including medication documentation errors and staff yelling in residents’ presence, but no fines, license suspensions, or severe enforcement actions were noted. One substantiated finding in May 2025 involved staff not providing timely medical attention related to a pain patch replacement, which posed a health risk. The facility’s record shows some improvement over time, with the latest inspections free of deficiencies and most complaints unsubstantiated.
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not ensure that resident's grooming needs were met.
Findings
The investigation revealed that beauty salon services were provided by independent contractors, not facility employees, and no residents or family members reported concerns about staff care. There was insufficient evidence to substantiate the allegation, which was deemed unsubstantiated.
Complaint Details
The complaint alleged that staff did not ensure residents' grooming needs were met, including concerns about a beautician sending residents back with wet hair and accepting cash payments. The allegation was found unsubstantiated after interviews and record reviews.
Report Facts
Facility capacity: 175Census: 137
Employees Mentioned
Name
Title
Context
Lea Bogoyevac
Executive Director
Met with Licensing Program Analyst during the investigation
The inspection visit was conducted as a complaint investigation following allegations received on 10/30/2024 regarding neglect, lack of care and supervision, and failure to meet residents' incontinence and dietary needs.
Findings
The investigation found insufficient evidence to substantiate the allegations of neglect, failure to meet incontinence needs, and failure to meet dietary needs. Interviews, record reviews, and observations indicated that resident care was appropriate and no intentional harm or neglect was identified.
Complaint Details
The complaint was unsubstantiated. Allegations included unexplained bruises on a resident, failure to meet incontinence needs, and failure to meet dietary needs. The investigation included interviews with staff, residents, and the resident's power of attorney, as well as review of medical and care records. No evidence supported the allegations.
Report Facts
Capacity: 175Census: 132
Employees Mentioned
Name
Title
Context
Lea Bogoyevac
Executive Director
Met with Licensing Program Analyst during investigation
Martha Arroyo
Licensing Program Analyst
Conducted complaint investigation visit and authored report
The inspection was an unannounced complaint investigation visit triggered by allegations including staff not providing timely medical attention to a resident, resident sustaining pressure injuries, lack of supervision resulting in a fall, staff not assisting with daily needs, and staff not checking resident's blood pressure as required.
Findings
The investigation substantiated the allegation that staff did not provide timely medical attention related to a pain patch replacement for Resident 2. Other allegations including pressure injuries due to neglect, lack of supervision causing a fall, failure to assist with daily needs, and failure to check blood pressure were deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not provide medical attention to a resident in a timely manner, specifically failing to replace a Fentanyl pain patch on schedule. Other allegations including pressure injury due to neglect, lack of supervision causing a fall, failure to assist with daily needs, and failure to check blood pressure were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by the facility staff not providing confirmation that Resident 2’s pain patch was replaced as prescribed, posing an immediate health and safety risk.
Type A
Report Facts
Capacity: 175Census: 160Deficiency due date: May 20, 2025
Employees Mentioned
Name
Title
Context
Brian Balisi
Licensing Program Analyst
Conducted the complaint investigation and subsequent visits
Lea Bogoyevac
Executive Director
Met with Licensing Program Analyst during the investigation
Desaree Perera
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
The visit was an unannounced complaint investigation conducted in response to allegations received on 2024-12-03 regarding chemical restraint and medication administration without a doctor's prescription at the facility.
Findings
The investigation found no discrepancies in medication records and no evidence supporting the allegations. Staff and hospice records confirmed proper care and medication administration. Random resident interviews reported satisfaction with care. The allegations were deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that staff chemically restrained a resident for financial gain and administered medication without a doctor's prescription. The investigation included interviews, record reviews, and facility tours. The allegations were found unsubstantiated.
Report Facts
Capacity: 175Census: 135Residents interviewed: 8
Employees Mentioned
Name
Title
Context
Zabel Chochian
Licensing Program Analyst
Conducted the complaint investigation and interviews
Lea Bogoyevac
Executive Director
Facility administrator involved in investigation discussions
Joseph Bautista
Health Services Director
Met with Licensing Program Analyst during investigation
Amy Curtis
Marketing Director
Met with Licensing Program Analyst during investigation
The visit was conducted to investigate a complaint alleging that facility staff were providing medications to a resident without physician's orders.
Findings
The investigation found insufficient evidence to support the allegation that staff administered medication without a valid prescription. Interviews, record reviews, and hospital testing confirmed no medications were given without physician orders. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that Resident #1 was given prescription medications without a valid physician's order, including attempts to chemically sedate the resident causing mental distress and behavioral changes. The investigation included interviews, file reviews, medication reviews, and hospital testing. The allegation was found unsubstantiated.
Report Facts
Facility capacity: 175Census: 142
Employees Mentioned
Name
Title
Context
Martha Arroyo
Licensing Program Analyst
Conducted the complaint investigation and visits
Lea Bogoyevac
Executive Director
Met with Licensing Program Analyst during the investigation
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2024-08-13 regarding hygiene, medication administration, staff responsiveness, blood pressure monitoring, incontinence care, and staff behavior at the facility.
Findings
The investigation found insufficient evidence to substantiate allegations related to hygiene needs, clean clothing, medication administration, timely response to calls, blood pressure monitoring, and incontinence care. However, the allegation that facility staff yelled in the presence of residents was substantiated, resulting in a cited deficiency related to residents' personal rights.
Complaint Details
The complaint investigation was triggered by allegations including failure to meet hygiene needs, failure to ensure clean clothing, failure to dispense medications as prescribed, failure to respond to resident calls timely, failure to check blood pressure as required, failure to meet incontinence care needs, and staff yelling in the presence of residents. All allegations except the last were found unsubstantiated. The yelling allegation was substantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by facility staff yelling in the presence of residents.
Type B
Report Facts
Capacity: 175Census: 142Deficiency Type B: 1
Employees Mentioned
Name
Title
Context
Martha Arroyo
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Lea Bogoyevac
Executive Director
Met with Licensing Program Analyst during investigation and mentioned in findings
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and ensure the facility meets health and safety standards.
Findings
The facility was found to be in compliance with Title 22 regulations, with clean and appropriately furnished resident rooms, sufficient food supplies, well-maintained common and outdoor areas, and proper medication management. No citations were issued during the inspection.
Report Facts
Resident rooms observed: 11Resident records reviewed: 10Staff records reviewed: 10Staff interviewed: 6Residents interviewed: 5Fire extinguisher last serviced: Nov 6, 2024Last fire safety inspection date: Apr 23, 2024Last emergency disaster drill date: Feb 5, 2025
Employees Mentioned
Name
Title
Context
Lea Bogoyevac
Executive Director
Met with during inspection and involved in entrance interview and facility tour.
Vana Dunn
Memory Care Director
Met with upon arrival and explained reason for visit.
The visit was conducted to investigate complaints alleging that staff were not practicing proper hand hygiene and that staff did not ensure the kitchen was clean.
Findings
The investigation found insufficient evidence to support the allegations. Staff were observed and interviewed, and records reviewed showed compliance with hand hygiene protocols and kitchen cleanliness. Both allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included improper hand hygiene and unclean kitchen. After interviews, observations, and record reviews, the Department found insufficient evidence to support these allegations.
Report Facts
Capacity: 175Census: 140
Employees Mentioned
Name
Title
Context
Lea Bogoyevac
Executive Director
Met during the inspection and involved in entrance interview
An unannounced complaint investigation visit was conducted in response to an allegation that staff handled a resident in a rough manner resulting in injury.
Findings
The investigation found no evidence to support the allegation. Interviews with staff and residents indicated no aggressive or rough behavior by staff, and no physical injuries were observed on the resident. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that staff handled a resident roughly causing injury, including scratching the resident during bathing. The investigation included interviews with staff and residents, a review of pertinent documents, and assessment of the resident. The allegation was found unsubstantiated due to lack of evidence.
An unannounced complaint investigation was conducted in response to an allegation that staff did not ensure the facility was free from pests.
Findings
The investigation found no evidence of pests in the facility despite reports from a resident about earwigs. Staff inspections and monthly pest control services were documented, and other residents denied pest issues. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that staff did not ensure the facility was free from pests, specifically that a resident was being bitten by earwigs. The investigation included interviews, observations, and record reviews. The allegation was found unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 175Census: 142
Employees Mentioned
Name
Title
Context
Lea Bogoyevac
Executive Director
Met with Licensing Program Analyst during the investigation
The visit was an unannounced complaint investigation regarding an allegation that the licensee did not provide the responsible party with a refund.
Findings
The investigation found that the responsible party had paid a preadmission fee of $3,500 but later canceled the admission process. The facility issued a refund check within the agreed 60 business days timeframe. The allegation was deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that the licensee did not provide the responsible party with a refund. The allegation was found unsubstantiated after review of documents and interviews.
The visit was an unannounced complaint investigation triggered by an allegation that staff handled a resident in a rough manner.
Findings
The investigation found insufficient evidence to substantiate the allegation of rough handling of the resident. Interviews, record reviews, and observations did not corroborate the claim, and no citations were issued.
Complaint Details
The complaint alleged that two caregivers were rough with Resident #1, resulting in bruises on the resident's arms. The resident has osteoarthritis and mild cognitive impairment. Staff reported the resident has a personal companion 24 hours a day due to prior allegations. Observations and interviews did not find bruising or consistent statements to support the allegation. The complaint was deemed unsubstantiated.
Report Facts
Capacity: 175Census: 146Complaint Control Number: 29-AS-20241014190246Dates referenced: Complaint received 2024-10-14, initial visit 2024-10-17, report date 2024-10-22
The inspection was an unannounced complaint investigation visit triggered by allegations of neglect and lack of care and supervision, specifically that a resident died as a result of facility neglect and that staff did not provide timely medical attention resulting in sepsis.
Findings
The investigation found insufficient evidence to substantiate the allegations of neglect or failure to provide timely medical attention. Medical records, interviews, and the coroner's report indicated no trauma or neglect associated with the resident's death, and the facility was deemed to have provided adequate care.
Complaint Details
The complaint involved two allegations: 1) Facility Resident #1 died due to facility neglect; 2) Staff did not provide medical attention in a timely manner resulting in sepsis. The allegations were investigated through interviews, medical record reviews, and facility logbook examination. The findings were unsubstantiated based on evidence from the coroner, physicians, home health nurses, and facility staff.
Report Facts
Facility capacity: 175Census: 145Complaint received date: Apr 19, 2024Resident death date: Jan 23, 2024
Employees Mentioned
Name
Title
Context
Lea Bogoyevac
Executive Director
Met with Licensing Program Analyst during investigation
Brian Balisi
Licensing Program Analyst
Conducted complaint investigation visit and authored report
Dennis Seng
Investigator
Assigned to complaint investigation and conducted interviews
The visit was conducted as a Case Management - Deficiencies visit in conjunction with a complaint investigation to issue a citation for a deficiency observed during the initial complaint investigation.
Findings
The investigation revealed a discrepancy between staff statements and a physician's report regarding Resident #1's ability to leave the facility unassisted and manage activities of daily living. A deficiency was cited related to this issue, which had already been cited under the initial complaint control number.
Complaint Details
The visit was triggered by Complaint Control # 29-AS-20231208092110. The deficiency cited was related to the complaint and had already been cited under this complaint control number.
Deficiencies (1)
Description
Deficiency related to Resident #1's care needs and ability to leave the facility unassisted, contrary to staff statements.
Report Facts
Capacity: 175Census: 145
Employees Mentioned
Name
Title
Context
Martha Arroyo
Licensing Program Analyst
Conducted the Case Management - Deficiencies visit
The visit was an unannounced complaint investigation conducted in response to allegations received on 2023-11-03 regarding staff not meeting residents' toileting needs, not ensuring adequate feeding, and mismanaging resident medication.
Findings
The investigation found the allegations regarding toileting needs and adequate feeding to be unsubstantiated due to insufficient evidence. However, the allegation of staff mismanaging resident medication was substantiated, with findings that medication documentation was not properly maintained and medication lists were not updated before being provided to medical providers.
Complaint Details
The complaint investigation was triggered by allegations that staff did not meet residents' toileting needs, did not ensure adequate feeding, and mismanaged resident medication. The toileting and feeding allegations were unsubstantiated, while the medication mismanagement allegation was substantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
The licensee did not comply with the requirement to properly document medications on the Centrally Stored Medication and Destruction Record (CSMDR), posing an immediate health and safety concern.
An unannounced complaint investigation was conducted to investigate allegations that staff did not prevent a resident's room from having bed bugs.
Findings
The investigation found evidence of bed bugs in a resident's room with multiple treatments conducted, but interviews with residents and staff, as well as pest control reports, showed no ongoing infestation or failure by staff to prevent bed bugs. The allegation was deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that staff did not prevent a resident's room from having bed bugs. The investigation included interviews, physical plant inspection, and review of pest control records. The allegation was found unsubstantiated as there was no preponderance of evidence to prove the violation.
Report Facts
Capacity: 175Census: 131Dates of pest control visits: Monthly visits on 01/18/2024, 02/16/2024, 03/07/2024, 04/04/2024 with no evidence of pest activityBed bug treatment dates: Treatment visits on 03/05/2024, 03/06/2024, 04/25/2024 and scheduled heat treatment on 05/01/2024Residents interviewed: 6Resident relocation: 1
Employees Mentioned
Name
Title
Context
Brian Balisi
Licensing Program Analyst
Conducted the complaint investigation and inspection
Lea Bogoyevac
Administrator
Met with Licensing Program Analyst during the investigation
The inspection was an unannounced required annual visit to ensure the facility's compliance with Title 22 Regulations and to check for health and safety hazards.
Findings
The facility was found to be generally in compliance with regulations, with clean and properly supplied resident bedrooms and bathrooms, functional safety features, adequate emergency preparedness, and proper medication storage and documentation. However, a prohibited health condition was identified in one resident without an exception request submitted.
Deficiencies (1)
Description
Resident 1 was admitted with a prohibited health condition without an exception request submitted to admit and retain the resident.
Report Facts
Resident records reviewed: 10Staff interviewed: 5Residents interviewed: 5Bedrooms inspected: 10Emergency disaster drill date: Mar 15, 2024
Employees Mentioned
Name
Title
Context
Lea Bogoyevac
Executive Director
Met with Licensing Program Analysts during the inspection.
Brian Balisi
Licensing Program Analyst
Conducted the inspection and signed the report.
Desaree Perera
Licensing Program Manager
Named in the report as Licensing Program Manager.
Inspection Report Original LicensingCensus: 84Capacity: 175Deficiencies: 0Mar 16, 2023
Visit Reason
Licensing Program Analyst Martha Arroyo conducted a pre-licensing visit to the facility due to a change of ownership and to inspect for fire safety, personal accommodations and services, and food service.
Findings
The facility was found to be in compliance with Title 22 regulations, with adequate accommodations, safety measures, and proper storage and maintenance of medications, food, and supplies. Fire safety systems and emergency plans were functional and properly posted.
Report Facts
Non-ambulatory residents fire clearance: 165Bedridden residents fire clearance: 10Resident bedrooms: 147Freezer temperature: 0Refrigerator temperature: 40Hot water temperature range: 105-120Minimum heating temperature: 68Maximum cooling temperature: 85
Employees Mentioned
Name
Title
Context
Lea Bogoyevac
Administrator
Applicant met during pre-licensing visit
Martha Arroyo
Licensing Program Analyst
Conducted the pre-licensing visit and inspection
Desaree Perera
Licensing Program Manager
Named in report header and signature
Report
December 20, 2024
File
report_7_565850299_inx6_2024-12-20.pdf
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