Inspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on September 22, 2025, which was perfect and showed the facility well-maintained with proper medication storage and safety equipment. One complaint investigation on that same date found the allegation that staff left residents waiting too long to respond to calls was substantiated, noting excessive response times that could pose risks to residents’ health and safety. Other complaints about cleanliness, communication, and laundry service were unsubstantiated, and several investigations found no evidence to support allegations of neglect or improper care. There were no fines, enforcement actions, or severe deficiencies reported in the available records. The facility’s record shows mostly consistent compliance with some isolated issues related to timely staff response, with no clear pattern of worsening or improvement over time.
Deficiencies per Year
4
3
2
1
0
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 163
Capacity: 220
Deficiencies: 0
Sep 22, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff left a resident unattended on the toilet with no clothes on for an extended amount of time.
Findings
The investigation included interviews, facility and resident file reviews, and a tour. The allegation was found to be unsubstantiated due to insufficient evidence to prove or refute the claim.
Complaint Details
The complaint alleged that staff left a resident unattended on the toilet without clothes for an extended time. Interviews revealed the resident was assisted with toileting when a physical therapist entered without knocking. Staff covered the resident and asked the therapist to wait. The resident confirmed they were not left unattended. The allegation was deemed unsubstantiated.
Report Facts
Facility capacity: 220
Resident census: 163
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Armando J Lucero | Licensing Program Manager | Named in report as Licensing Program Manager |
| Brenda Myers | Interim Executive Director | Met with Licensing Program Analyst during investigation |
| David Armour | Administrator | Facility Administrator named in report |
Inspection Report
Annual Inspection
Census: 163
Capacity: 220
Deficiencies: 0
Sep 22, 2025
Visit Reason
The visit was an unannounced annual required inspection conducted by Licensing Program Analyst Ruth Martinez to evaluate compliance with licensing requirements.
Findings
The inspection found no deficiencies in the areas inspected. The facility was observed to be well-maintained, with proper storage of medications and chemicals, functional safety equipment, adequate resident accommodations, and complete resident and staff files.
Report Facts
Residents on hospice: 10
Fire extinguisher service date: Dec 13, 2024
Smoke detector and sprinkler system test date: Apr 22, 2025
Emergency drill date: Sep 4, 2025
Water temperature range (F): 110.6-116.7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Brenda Myers | Interim Executive Director | Met with Licensing Program Analyst during inspection |
| David Armour | Administrator/Director | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Capacity: 220
Deficiencies: 1
Sep 22, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff do not respond to residents' calls for assistance in a timely manner, do not ensure residents' rooms are clean and sanitary, have language barriers with residents, and do not provide adequate laundry service.
Findings
The allegation that staff do not respond timely to residents' calls was substantiated with evidence of excessive response times ranging from 1 minute 30 seconds to over 95 minutes. Allegations regarding cleanliness, communication barriers, and laundry service were unsubstantiated based on interviews, record reviews, and observations.
Complaint Details
The complaint investigation was substantiated for the allegation that staff do not respond to residents' calls for assistance in a timely manner. Other allegations regarding cleanliness, communication, and laundry service were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Basic services requirement not met due to multiple instances of excessive response times to residents' calls for assistance, posing potential risk to health, safety, and personal rights. | Type B |
Report Facts
Capacity: 220
Response time range (minutes): 95.65
Response time range (minutes): 1.5
Response time example: 40.67
Plan of Correction Due Date: Sep 29, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation |
| Brenda Myers | Interim Executive Director | Facility representative met during the investigation |
| David Armour | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 168
Capacity: 220
Deficiencies: 0
Jul 14, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation that the licensee was violating fire clearance regulations, specifically regarding non-ambulatory residents living or moving into the third and fourth floors of the facility.
Findings
The investigation found the complaint allegation to be unfounded, determining that the allegation was false or without reasonable basis. The facility was approved by the Orange County Fire Authority for 92 ambulatory, 120 non-ambulatory, and 8 bedridden residents with specific room restrictions for bedridden residents, which the facility currently did not have. The facility had no fire clearance restrictions on any floors for ambulatory and non-ambulatory residents.
Complaint Details
The complaint alleged violation of fire clearance related to non-ambulatory residents on the third and fourth floors. The complaint was found to be unfounded and dismissed.
Report Facts
Licensed capacity: 220
Census: 168
Fire Authority approval: 92
Fire Authority approval: 120
Fire Authority approval: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| David Armour | Executive Director/Administrator | Facility administrator interviewed during the investigation |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 220
Deficiencies: 0
Apr 28, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted to follow up on three allegations: the facility not following their Infection Control Plan, failure to provide necessary cleaning services, and inadequate medical care.
Findings
The investigation found the allegations to be unsubstantiated. The Infection Control Plan was reviewed and deemed adequate with appropriate measures taken during a December 2024 outbreak. Cleaning services were found to be sufficient despite some documentation gaps. Medical care was provided appropriately with no failures identified.
Complaint Details
The complaint investigation was triggered by allegations received on 12/30/2024. The allegations included failure to follow the Infection Control Plan, inadequate cleaning services, and inadequate medical care. After review of records, staff and resident interviews, and public health witness statements, the allegations were found unsubstantiated.
Report Facts
Resident records reviewed: 6
Staff interviews conducted: 10
Date of complaint received: Dec 30, 2024
Date of initial complaint investigation visit: Jan 8, 2025
Date of follow-up visit: Mar 17, 2025
Facility capacity: 220
Facility census: 171
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Armour | Administrator | Facility administrator who assisted with the visit. |
| Kevin Saborit-Guasch | Licensing Program Analyst | Investigator who conducted the complaint investigation. |
| Sheila Santos | Licensing Program Manager | Manager overseeing the licensing program. |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 220
Deficiencies: 0
Apr 2, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff discarded residents' meals and gave medication to residents without a prescription order.
Findings
The investigation found the allegations to be unfounded. Interviews with residents and staff indicated that food was only discarded after residents finished eating and that residents had options for food substitutions. Medication records confirmed that residents taking Ativan had valid prescription orders, and no discrepancies were found.
Complaint Details
The complaint investigation was initiated based on allegations received on 2025-03-27. The allegations were determined to be unfounded, meaning they were false or without reasonable basis.
Report Facts
Capacity: 220
Census: 171
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Armour | Administrator | Met with Licensing Program Analyst during the investigation and exit interview |
| Alvaro Ramirez Jr. | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sheila Santos | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 166
Capacity: 220
Deficiencies: 0
Feb 19, 2025
Visit Reason
This unannounced case management visit was conducted to follow up on an incident reported to the Community Care Licensing Division on February 5, 2025, involving a resident who left the premises and was hospitalized.
Findings
During the visit, no deficiencies were noted and no immediate or safety risks were observed in or out of the facility. The facility was in contact with the hospital, skilled nursing, and the resident's DPOA for updates.
Report Facts
Incident date: Feb 4, 2025
Incident report received: Feb 5, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Armour | Executive Director | Met with Licensing Program Analyst during visit and informed about incident |
| Ruth Martinez | Licensing Program Analyst | Conducted the case management visit and investigation |
| Armando J Lucero | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 162
Capacity: 220
Deficiencies: 0
Oct 21, 2024
Visit Reason
The visit was an unannounced required annual inspection conducted by Licensing Program Analysts to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be operating within its license with no deficiencies cited. The inspection included tours of resident rooms, kitchen, memory care unit, and common areas, with all safety and operational standards met.
Report Facts
Licensed capacity: 220
Current census: 162
Non-ambulatory capacity: 120
Bedridden capacity: 8
Hospice waiver capacity: 25
Emergency drill date: Oct 17, 2024
Fire suppression test date: Apr 26, 2024
Hot water temperature range: Measured between 110.0 to 116.6 degrees Fahrenheit
Pool fence height (feet): 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Armour | Executive Director | Met with Licensing Program Analysts during inspection |
| Joseph Alejandre | Licensing Program Analyst | Conducted the inspection |
| Brandon Lopez | Licensing Program Analyst | Conducted the inspection |
| Nancy Guillen | Licensing Program Analyst | Conducted the inspection |
| Sheila Santos | Licensing Program Manager | Named in report header |
Inspection Report
Follow-Up
Census: 150
Capacity: 220
Deficiencies: 0
Feb 12, 2024
Visit Reason
The inspection was an unannounced Case Management Incident Follow Up to investigate unusual incident reports submitted on 2024-01-24 regarding a married couple residing at the facility.
Findings
The couple had been paying to rent a room since August 31, 2023, but resided at a private residence and only visited the facility for meals. A health and safety check noted two ceiling panels missing due to water damage, with repairs scheduled. The couple's room contained minimal furniture and no personal items. The facility froze the couple's account after a declined payment and conducted a wellness check at their private residence where a Coroner's seal was observed.
Report Facts
Meal visits: 21
Meal visits: 14
Meal visits: 5
Meal visits: 1
Date account frozen: Jan 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dwayne Mason Jr. | Licensing Program Analyst | Conducted the inspection and exit interview |
| Kathleen Olson | Interim Executive Director | Facility representative met during inspection and exit interview |
| Jessica Bacca | Senior Sales Manager | Contacted the couple and conducted wellness check at private residence |
| Iberia Tarin | Business Office Director | Called the couple following declined payment |
Inspection Report
Original Licensing
Census: 161
Capacity: 220
Deficiencies: 0
Sep 26, 2023
Visit Reason
The inspection was conducted as a pre-licensing inspection for a change of ownership with persons in care, to evaluate the facility's readiness for licensure as a Residential Care Facility for the Elderly.
Findings
The facility was found to be structurally sound and well-equipped with appropriate safety features, clean and operational bathrooms, stocked linens and hygiene supplies, and secured medications and toxins. Resident and staff files were reviewed, fire clearance was approved, and outdoor areas were deemed safe and suitable for residents. The facility was deemed ready for licensure pending final approval.
Report Facts
Resident files reviewed: 5
Staff files reviewed: 5
Fire clearance date: Jul 2, 2023
Food supply duration: 2
Food supply duration: 7
Bedrooms in memory care unit: 21
Bedrooms in assisted living section: 155
Bathroom faucets temperature range: 114
Bathroom faucets temperature range: 118.9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Monica Castilo | Applicant / Administrator | Met with Licensing Program Analyst during inspection |
| Sean Haddad | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Armando J Lucero | Licensing Program Manager | Named as Licensing Program Manager on report |
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