Inspection Report Summary
Most inspections found deficiencies related to resident supervision, safety risks from unsecured exits, and staffing levels, with several substantiated complaints about residents leaving the facility unattended and resulting injuries. The facility received fines totaling $1,000 in November 2024 for failing to prevent resident-on-resident injury. Other common issues included incomplete staff training, improper use of bed rails, and occasional lapses in infection control and documentation. The most recent report from August 18, 2025, was a complaint investigation that found no deficiencies and unsubstantiated allegations regarding resident wandering and verbal altercations. This suggests some improvement in supervision and care practices compared to earlier substantiated findings.
Deficiencies per Year
12
9
6
3
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Capacity: 206
Deficiencies: 0
Aug 18, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff did not prevent a resident from wandering into other residents' rooms, resulting in verbal altercations.
Findings
The investigation found that while some residents, including Resident 2, do wander and enter other residents' rooms when doors are unlocked, staff are aware of this behavior and supervise and redirect Resident 2 regularly. There was no preponderance of evidence to prove the alleged violation occurred, and the allegation was unsubstantiated.
Complaint Details
The complaint alleged that Resident 2 entered Resident 1's room uninvited and refused to leave, leading to verbal altercations. Interviews with staff and residents revealed that wandering behavior occurs but is managed with supervision and redirection. Police conducted a wellness check with no report filed. The allegation was determined to be unsubstantiated.
Report Facts
Facility capacity: 206
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nune Margaryan | Licensing Program Analyst | Conducted the complaint investigation |
| Virginia Garcia | Administrator / Executive Director | Facility administrator present during investigation |
| Wei Siew Ho | Licensing Program Manager | Named in report signature |
| Loei Lackey | Assistant Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 206
Deficiencies: 1
Jul 31, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff were not ensuring resident exercises and not meeting residents' showering needs.
Findings
The allegation that staff were not ensuring resident exercises was substantiated, with evidence that resident R1 was not escorted to daily exercise classes as required. The allegation that staff were not meeting residents' showering needs was unsubstantiated based on interviews, observations, and record reviews.
Complaint Details
The complaint investigation was substantiated for the allegation that staff were not ensuring resident exercises, with sufficient evidence that resident R1 was not escorted to exercise classes on 7/25/2025 and 7/31/2025. The allegation regarding showering needs was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to escort resident R1 to daily exercise classes as required by home health orders and the resident's care plan. | Type B |
Report Facts
Capacity: 206
Census: 141
Staff interviewed: 9
Residents interviewed: 12
Plan of Correction Due Date: Aug 14, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Garcia | Executive Director | Met with during investigation and exit interview |
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw complaint investigation |
| Lori Lackey | Assistant Executive Director | Discussed purpose of visit with Licensing Program Analyst |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 206
Deficiencies: 0
Jul 15, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff did not prevent a resident from being harmed by another resident and did not respond to a resident's request for assistance in a timely manner.
Findings
The investigation included interviews with staff and residents, review of facility records, and observation of staff logs. The allegations were found to be unsubstantiated due to lack of preponderance of evidence to prove the violations occurred.
Complaint Details
The complaint involved allegations that staff failed to prevent harm between residents and did not respond timely to a resident's request for assistance. Interviews and record reviews showed staff responded appropriately and conducted regular room checks. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 206
Census: 143
Room checks: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation |
| Virginia Garcia | Administrator | Facility administrator interviewed during investigation |
| Wei Siew Ho | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 144
Capacity: 206
Deficiencies: 1
Mar 11, 2025
Visit Reason
The inspection was an unannounced continuous annual visit conducted using the CARE inspection tool to evaluate compliance with licensing requirements and facility operations.
Findings
The facility met most regulatory requirements including infection control, staffing, and training. However, a deficiency was noted regarding the use of full bed rails for three residents who are not under hospice care, which poses a potential health and safety risk.
Deficiencies (1)
| Description |
|---|
| Three residents had full bed rails with physician's orders but were not under hospice care, violating postural support regulations. |
Report Facts
Residents with full bed rails not under hospice care: 3
Resident files reviewed: 10
Staff files reviewed: 10
Staff on night shift: 5
Plan of Correction due date: Mar 18, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Virginia Garcia | Administrator | Facility administrator involved in the inspection and exit interview. |
| Rocio Gonzalez | Wellness Director | Met with the Licensing Program Analyst during the inspection. |
| Tony Vasallo | Supervisor | Supervisor named in the report and licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 206
Deficiencies: 0
Mar 11, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2025-02-20 regarding staff not safeguarding resident's personal belongings, not providing a comfortable environment, and not answering resident's call button in a timely manner.
Findings
The investigation included interviews with residents and staff, facility tour, and document review. All allegations were found to be unsubstantiated due to lack of preponderance of evidence proving the violations did or did not occur.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not safeguarding resident belongings, not providing a comfortable environment due to noise, and delayed response to call buttons. Interviews and observations did not provide sufficient evidence to substantiate these claims.
Report Facts
Residents interviewed: 10
Staff interviewed: 8
Residents reporting no lost items: 4
Residents unable to answer due to cognitive skills: 4
Residents reporting lost personal items: 2
Residents reporting no loud noises: 4
Residents reporting loud noises disturbing sleep: 2
Staff reporting no complaints about noise: 9
Staff reporting hearing resident yelling: 1
Residents reporting prompt call button response: 5
Residents reporting delayed call button response: 1
Residents unable to answer about call button response: 4
Call buttons tested with response under 5 minutes: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Virginia Garcia | Administrator | Facility administrator met during investigation and exit interview |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
| Rocio Gonzalez | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 144
Capacity: 206
Deficiencies: 0
Feb 24, 2025
Visit Reason
Licensing Program Analyst Mary Flores conducted an annual inspection visit at the facility using the CARE inspection tool to evaluate compliance with licensing requirements.
Findings
The facility was toured including common areas, bedrooms, and medication review. All observed areas were in good repair with sufficient furniture and supplies. Water temperatures were within required ranges. Medication room was inaccessible to residents. No deficiencies were noted during this visit.
Report Facts
Residents on hospice: 15
Medication review: 10
Water temperature range first floor: 111
Water temperature range first floor: 116.4
Water temperature range second floor: 106.5
Water temperature range second floor: 114.4
Licensed capacity: 206
Current census: 144
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the annual inspection visit |
| Rocio Gonzalez | Wellness Director | Met with Licensing Program Analyst during inspection |
| Virginia Garcia | Administrator | Facility administrator present during exit interview |
| Tony Vasallo | Supervisor | Supervisor named in report |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 206
Deficiencies: 0
Nov 13, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility failed to provide a resident's records.
Findings
The investigation found that the resident in question does not reside or have resided at the facility, and the allegation was deemed unfounded.
Complaint Details
The allegation that the facility failed to provide resident's records was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the unannounced complaint investigation visit. |
| Virginia Garcia | Administrator | Met with the Licensing Program Analyst during the investigation. |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 206
Deficiencies: 1
Nov 13, 2024
Visit Reason
Unannounced complaint investigation visit regarding an allegation that staff did not prevent a resident from being physically abused by another resident while in care.
Findings
The investigation substantiated that staff failed to properly assess and prevent Resident #1's injury caused by Resident #2, despite knowledge of Resident #2's history of aggressive behaviors. An immediate civil penalty of $500 was issued, with an additional $500 penalty for a repeated violation.
Complaint Details
The complaint alleged that staff did not prevent a resident from being physically abused by another resident. The allegation was substantiated based on interviews, observations, and document reviews, confirming Resident #1 sustained injuries due to Resident #2's aggressive behavior.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure Resident #1 was not injured by Resident #2 while in care, violating personal rights and care supervision requirements. | Type A |
Report Facts
Civil penalty amount: 1000
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Virginia Garcia | Administrator | Facility administrator met with Licensing Program Analyst during investigation. |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 138
Capacity: 206
Deficiencies: 0
Jul 29, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff did not meet a resident's toileting needs, did not seek medical attention in a timely manner, and that the facility was in disrepair.
Findings
The investigation found that although the resident had diarrhea and behavioral issues, staff provided assistance and communicated with the physician appropriately. The facility was found to be in good repair with no clogged toilets or showers observed. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint involved allegations that a resident was left soiled due to inadequate toileting assistance, delayed medical attention for diarrhea, and facility disrepair. The investigation included interviews with staff and residents, document reviews, and facility tour. The complaint was unsubstantiated.
Report Facts
Capacity: 206
Census: 138
Dates: Jun 10, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation |
| Virginia Garcia | Administrator | Facility administrator interviewed and participated in exit interview |
| Rocio Gonzalez | Wellness Director | Met with Licensing Program Analyst during investigation |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 206
Deficiencies: 0
Jun 25, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not accept a resident back into care following hospitalization.
Findings
The investigation found that staff and residents denied the allegation, and there was no documentation supporting refusal of the resident's return. The resident was discharged to a skilled nursing facility and staff are awaiting discharge to accept the resident back. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff did not accept resident R1 back into care following hospitalization. Interviews with staff and residents did not corroborate the allegation. The resident was hospitalized on 2024-05-31 and later discharged to a skilled nursing facility on 2024-06-20. Staff denied refusing to take the resident back and are awaiting discharge from the skilled nursing facility. The resident's responsible party was not informed of any refusal. Facility still holds the resident's personal belongings. The allegation was unsubstantiated.
Report Facts
Facility capacity: 206
Census: 137
Complaint control number: 28-AS-20240620150052
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Villalobos | Licensing Program Analyst | Conducted the complaint investigation visit |
| Virginia Garcia | Administrator | Met with Licensing Program Analyst during investigation |
| Fernando Fierros | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 206
Deficiencies: 0
Jun 24, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that staff did not prevent a resident from harming another resident in care.
Findings
The investigation found insufficient evidence to substantiate the allegation. Staff were observed redirecting residents exhibiting wandering behavior, proper reporting and follow-up were confirmed, and interviews with staff and residents did not corroborate the allegation.
Complaint Details
The allegation was that on 06/21/2024, staff saw resident R2 twisting resident R1's arm causing a fracture and dislocation. Staff and residents interviewed denied the allegation or were unable to corroborate it. The facility was properly staffed and followed reporting procedures. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 206
Census: 137
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Gonzalez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lori Lackey | Assistant Administrator | Interviewed during the investigation and received a copy of the report |
| Virginia Garcia | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 206
Deficiencies: 1
Apr 23, 2024
Visit Reason
The visit was an unannounced case management inspection triggered by an incident report regarding Resident #1 who jumped over the facility fence and left unattended, posing a safety risk.
Findings
The facility failed to ensure Resident #1 did not leave unattended, which posed an immediate risk to the health, safety, and personal rights of the resident. Deficiencies were cited under Title 22 regulations.
Complaint Details
The visit was complaint-related due to an incident where Resident #1 jumped over a 6ft fence and left the facility unattended. The complaint was substantiated by the finding that the facility failed to prevent this incident.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not ensure Resident #1 left the facility unattended, posing an immediate risk to health, safety, or personal rights. | Type A |
Report Facts
Facility capacity: 206
Resident census: 143
Fence height: 6
Plan of Correction due date: Apr 24, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Lori Lackey | Assistant Administrator | Met with Licensing Program Analyst during the visit and involved in incident discussion |
| Tony Vasallo | Supervisor | Named as supervisor in the report |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 206
Deficiencies: 0
Apr 23, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff sexually abused a resident while in care.
Findings
The investigation included interviews, review of video footage, medical records, and police reports. The allegation was found to be unsubstantiated due to lack of evidence and the resident's cognitive impairment.
Complaint Details
The complaint alleged that a staff member sexually assaulted resident #1 by entering their bedroom. Investigations revealed no corroborating evidence; staff and resident's conservator did not believe the allegation. Video footage and police investigation did not support the claim. The resident was noted to have mild cognitive impairment and confusion. The allegation was determined to be unsubstantiated.
Report Facts
Facility capacity: 206
Resident census: 143
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
| Lori Lackey | Assistant Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Heidy Bendana | Investigator | Assigned by Investigation Bureau Department to conduct interviews and investigation |
Inspection Report
Annual Inspection
Census: 140
Capacity: 206
Deficiencies: 2
Mar 28, 2024
Visit Reason
An unannounced case management visit was conducted for an annual continuation inspection using the CARE inspection tool to evaluate compliance with regulatory requirements.
Findings
Deficiencies were noted related to staff training not including required hospice care, postural support, and restricted health conditions, as well as outdated appraisal needs and service plans for residents #6 and #9. Plans of correction were requested with due dates.
Deficiencies (2)
| Description |
|---|
| Staff training did not include training on postural support, hospice care, restricted conditions or health services. |
| Appraisal Needs and Service Plan for resident #6 was last updated on 9/1/22 and for resident #9 was last updated 1/6/23, not updated within the last 12 months. |
Report Facts
Training hours observed: 20
Residents files reviewed: 10
Staff files reviewed: 10
Residents interviewed: 5
Staff interviewed: 5
Plan of Correction due date: Apr 10, 2024
Plan of Correction due date: Apr 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lori Lackey | Assistant Administrator | Met with Licensing Program Analyst during inspection and exit interview |
| Tony Vasallo | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 140
Capacity: 206
Deficiencies: 3
Mar 26, 2024
Visit Reason
An unannounced annual inspection visit was conducted to evaluate the facility's compliance with licensing regulations, including a tour of the physical plant and medication review.
Findings
The inspection identified deficiencies including accessible disinfectant spray in a resident's bathroom, water temperatures in multiple rooms below the required range, and a non-functioning exit gate tied with a rope. Medication review was conducted for 14 residents, and the facility was found to have sufficient furniture and clean common areas.
Severity Breakdown
Type A: 1
Type B: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Disinfectant spray was observed in room #107's bathroom cabinet accessible to the resident, posing an immediate health and safety risk. | Type A |
| Water temperature in rooms #114, #119, #134, #259, #240, and #204 was below the required 105-120 degrees F, posing a potential health and safety risk. | Type B |
| Exit gate to El Molino street was tied with a rope and not functioning properly, posing a potential health and safety risk. | Type B |
Report Facts
Residents on hospice: 17
Medication review: 14
Plan of Correction Due Date: Mar 27, 2024
Plan of Correction Due Date: Apr 2, 2024
Plan of Correction Due Date: Apr 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lori Lackey | Assistant Administrator | Met with Licensing Program Analyst during inspection and exit interview |
| Tony Vasallo | Supervisor | Supervisor overseeing the inspection |
| Virginia Garcia | Administrator | Facility administrator mentioned in report header |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 206
Deficiencies: 0
Jan 11, 2024
Visit Reason
An unannounced case management visit was conducted due to an incident reported on 2024-01-09 involving an allegation of staff sexual abuse against a resident.
Findings
The investigation included review of video footage, interviews, and documentation. The alleged staff member was placed on suspension pending further investigation by the police and hospital evaluation.
Complaint Details
The complaint involved an allegation by Resident #1 that Staff #1 entered the resident's room and raped them. The facility reported the incident to Community Care Licensing, the Local Ombudsman, and the Pasadena Police Department. Further investigation is pending police and hospital reports.
Report Facts
Staff work hours: 8.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Flores | Licensing Program Analyst | Conducted the unannounced case management visit |
| Lori Lackey | Assistant Administrator | Interviewed during the investigation and involved in incident response |
| Virginia Garcia | Administrator | Reviewed video footage and submitted incident report |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 206
Deficiencies: 0
Oct 31, 2023
Visit Reason
Unannounced complaint investigation visit regarding an allegation that staff attempted to financially abuse a resident while in care.
Findings
The investigation found that staff assisted the resident with accessing financial accounts and did not attempt to financially abuse the resident. The allegation was unsubstantiated due to lack of preponderance of evidence.
Complaint Details
Allegation was that staff attempted to financially abuse resident while in care. Investigation included interviews with staff, residents, and review of resident's records. The allegation was found unsubstantiated.
Report Facts
Facility capacity: 206
Census: 129
Complaint control number: 28-AS-20231024124234
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Virginia Garcia | Administrator | Facility administrator interviewed and present at exit interview |
| Malou Bernardo | Business Office Manager | Met with Licensing Program Analyst during investigation |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 206
Deficiencies: 3
Oct 31, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that a resident wandered from the facility due to lack of staff supervision and sustained a fall resulting from lack of staff supervision.
Findings
The investigation substantiated that Resident #1 left the facility unsupervised, fell three blocks away, and was hospitalized. Staff failed to ensure the resident was supervised, and a staff member forgot to lock the front door, posing an immediate risk to resident safety.
Complaint Details
The complaint investigation was substantiated. The resident wandered from the facility unsupervised and sustained a fall. Staff failed to supervise adequately, and a staff member was suspended for three days for failing to lock the front door.
Severity Breakdown
Type A: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Licensee did not ensure Resident #1 left the facility unassisted and obtained a fall while unsupervised, posing an immediate risk to health, safety, or personal rights of persons in care. | Type A |
| Licensee did not ensure delayed egress devices were not substituted for trained staff to meet supervision needs and escort residents who leave the facility. | Type A |
| Licensee did not ensure Resident #1 left the facility unassisted through the front door while a staff was at the front desk, posing an immediate risk to health, safety, or personal rights of persons in care. | Type A |
Report Facts
Capacity: 206
Census: 129
Suspension duration: 3
Deficiencies cited: 3
Plan of Correction due date: Nov 1, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted complaint investigation and interviews |
| Virginia Garcia | Administrator | Facility administrator interviewed during investigation |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 206
Deficiencies: 0
Oct 19, 2023
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff do not safeguard resident's personal belongings.
Findings
The investigation found that 5 out of 8 residents stated their personal belongings had not disappeared, while 2 residents reported missing items. Staff explained that items were being cleaned before being provided to a resident to prevent bug infestation. There was insufficient evidence to prove the alleged violation, so the complaint was unsubstantiated.
Complaint Details
The complaint alleged that staff do not safeguard resident's personal belongings. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Residents interviewed: 8
Staff interviewed: 5
Resident move-in date: Aug 9, 2023
Personal property items listed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
| Elizabeth Kirk | Supervisor | Met with Licensing Program Analyst during investigation |
| Lori Lackey | Assistant Administrator | Participated in exit interview and received copy of report |
| Virginia Garcia | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 138
Capacity: 206
Deficiencies: 1
Sep 5, 2023
Visit Reason
An unannounced case management visit was conducted regarding deficiencies found during a complaint investigation triggered by a resident's report of verbal threats by another resident on 08/27/2023.
Findings
The investigation found that the licensee did not provide or submit an incident report regarding the 08/27/2023 incident within seven days as required, posing a potential risk to the health, safety, or personal rights of residents.
Complaint Details
The visit was complaint-related, investigating a resident's report of verbal threats by another resident on 08/27/2023. The complaint was substantiated by the finding that no incident report was filed or provided.
Deficiencies (1)
| Description |
|---|
| Failure to ensure a copy of the incident report was provided during the visit or submitted to the department within seven days of the incident on 08/27/2023. |
Report Facts
Census: 138
Total Capacity: 206
Plan of Correction Due Date: Sep 8, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Lori Lackey | Assistant Administrator | Met with the Licensing Program Analyst during the visit |
| Tony Vasallo | Supervisor | Named as supervisor in the report |
Inspection Report
Complaint Investigation
Census: 138
Capacity: 206
Deficiencies: 0
Sep 5, 2023
Visit Reason
Unannounced complaint investigation visit regarding an allegation that staff did not intervene in a resident-on-resident dispute.
Findings
The investigation found that staff were aware of the verbal threats made by one resident towards another and took action by moving the threatened resident to a different room the same day the police arrived. There was no preponderance of evidence to prove the alleged violation occurred, and the allegation was unsubstantiated.
Complaint Details
Allegation that staff did not intervene in resident-on-resident dispute. Investigation revealed staff addressed the situation by relocating the resident after verbal threats. Incident report was not available or submitted within required timeframe. Allegation was unsubstantiated.
Report Facts
Residents interviewed: 10
Staff interviewed: 5
Capacity: 206
Census: 138
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Virginia Garcia | Administrator | Facility administrator contacted during investigation |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
| Alejandra Cevallos | Front desk | Met with Licensing Program Analyst during visit |
| Lori Lackey | Assistant Administrator | Participated in exit interview |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 206
Deficiencies: 0
Aug 15, 2023
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff were not providing adequate service to a resident in care.
Findings
The investigation included interviews with residents, staff, and review of relevant documents. Although some concerns were noted, there was insufficient evidence to prove the alleged violation occurred, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged that resident R1 had issues such as wearing two layers of clothes, uncombed hair, incorrectly applied pressure socks, and uncut toenails during a family visit. Interviews and document reviews showed staff provide assistance with activities of daily living and podiatry services are regularly provided. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 206
Census: 137
Residents interviewed: 11
Dates of podiatrist services: Foot and Ankle Care logs dated 2/3/22, 3/3/22, 5/3/22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Virginia Garcia | Administrator | Facility administrator met during investigation |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Capacity: 206
Deficiencies: 0
Jul 6, 2023
Visit Reason
An unannounced case management visit was conducted to follow up on an incident report submitted regarding a resident who sustained a fall during a seizure episode.
Findings
The facility staff is following the hospice care plan and healthcare designated agent's request to provide comfort care for the resident. No deficiencies were noted during this visit.
Report Facts
Facility capacity: 206
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Garcia | Administrator | Met with Licensing Program Analyst during the visit and involved in the incident follow-up |
| Mary G Flores | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Annual Inspection
Census: 135
Capacity: 206
Deficiencies: 1
Feb 27, 2023
Visit Reason
An unannounced annual visit was conducted focusing on infection control, medication, and food review.
Findings
The facility was generally compliant with infection control and food supply requirements, but water temperatures in resident bathrooms were below the required range, posing a potential health risk.
Deficiencies (1)
| Description |
|---|
| Water temperature in bathrooms of rooms #130 and #239 tested below the required 105-120 degrees F range, posing a potential health, safety, or personal rights risk to residents. |
Report Facts
Residents on hospice: 12
Rooms observed: 5
Residents medication checked: 5
POC due date: Mar 6, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the inspection and authored the report |
| Rocio Gonzalez | Wellness Director | Met with Licensing Program Analyst during inspection and assisted with facility tour |
| Virginia Garcia | Administrator | Administrator certificate observed and responsible for facility operations |
| Lori Lackey | Assistant Administrator | Received the report and appeal rights during exit interview |
| Tony Vasallo | Supervisor | Supervisor named in the report |
Inspection Report
Routine
Census: 135
Capacity: 206
Deficiencies: 2
Feb 27, 2023
Visit Reason
An unannounced case management visit was conducted regarding COVID-19 guidelines compliance during an annual visit on 02/27/2023.
Findings
The licensee did not ensure staff were following COVID-19 guidelines, specifically staff were observed without face masks and supplies were not replenished overnight, posing a potential risk to health and safety.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to include an Infection Control Plan in the Plan of Operation and staff not demonstrating knowledge and skill in infection control as evidenced by safe and effective job performance. | Type B |
| Licensee did not ensure staff were following COVID-19 guidelines and supplies were not replenished overnight, posing a potential risk to health, safety, or personal rights of persons in care. | Type B |
Report Facts
Capacity: 206
Census: 135
Plan of Correction Due Date: Mar 6, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Lackey | Assistant Administrator | Met with during the visit and participated in exit interview |
| Conrad Garcia | Staff/Administration | Observed in dining room on phone call without face mask |
| Rocio Gonzalez | Wellness Director | Observed without face mask at the facility |
| Tony Vasallo | Supervisor | Supervisor named in the report |
| Mary G Flores | Licensing Evaluator | Conducted the inspection and signed the report |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 206
Deficiencies: 1
Jan 25, 2023
Visit Reason
The visit was conducted as a complaint investigation related to allegation #28-AS-20210303163807 concerning a resident sustaining a fracture while in care and additional concerns about staff behavior.
Findings
The complaint was substantiated with evidence that resident #1 sustained a fracture while in care. Additional deficiencies included staff #2 using a resident's private bathroom, which violated residents' personal rights and posed potential health and safety risks.
Complaint Details
Complaint #28-AS-20210303163807 was substantiated regarding a resident sustaining a fracture while in care. Additional findings included staff misuse of a resident's private bathroom.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff #2 used Resident #1's private bathroom, violating residents' personal rights and posing potential health and safety risks. | Type A |
Report Facts
Capacity: 206
Census: 127
Deficiency Type Count: 1
Plan of Correction Due Date: Jan 21, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Garcia | Administrator | Met during the inspection and discussed findings and plan of correction |
| Mary G Flores | Licensing Evaluator | Conducted the inspection and signed the report |
| Tony Vasallo | Licensing Program Manager / Supervisor | Conducted the inspection and signed the report |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 206
Deficiencies: 1
Jan 25, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including a resident suffering a fracture while in care, failure to notify responsible party of change in condition, and insufficient staff at the facility.
Findings
The investigation substantiated the allegation that a resident (R1) suffered a left hip fracture while in care, posing an immediate health and safety risk. The facility failed to ensure safe care practices, including a two-person assist during showering. The allegation of failure to notify the responsible party of the resident's change in condition and the allegation of insufficient staffing were both found to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was substantiated for the allegation that a resident suffered a fracture while in care. The investigation found that on 2/23/21, staff did not follow the required two-person assist protocol during showering, which may have contributed to the injury. The allegation that the facility failed to notify the responsible party of the resident's change in condition and the allegation of insufficient staffing were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee failed to ensure resident did not sustain a hip fracture while in care, violating personal rights to safe, healthful, and comfortable accommodations. | Type A |
Report Facts
Capacity: 206
Census: 127
Civil Penalty: 500
Caregivers on duty: 8
Caregivers on duty: 7
Caregivers on duty: 4
Residents per caregiver: 12
Residents per caregiver: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Garcia | Administrator | Met with during investigation and exit interviews; involved in internal investigation |
| Mary G Flores | Licensing Program Analyst | Conducted investigation and delivered findings |
| Tony Vasallo | Licensing Program Manager | Conducted investigation and delivered findings |
| Edward Hector | Investigator | Conducted interviews and collected documents during investigation |
| S1 | Staff member involved in showering resident alone against protocol, related to fracture allegation | |
| S2 | Staff member providing consistent care, interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 206
Deficiencies: 0
Jan 20, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that facility staff did not provide residents' meals in a timely manner and that residents were given unsanitary or dirty fruit.
Findings
The investigation included interviews with staff and residents, review of menus and rosters, and observations of meal service and food preparation. Both staff and residents consistently reported timely meal service and fresh, sanitary food. Observations during the visit supported these statements. There was insufficient evidence to substantiate the allegations.
Complaint Details
The complaint was unsubstantiated. Allegations included delayed meal service and serving unsanitary fruit. Interviews with 6 staff and 11 residents, as well as observations, did not support the allegations. Staff denied serving food that fell on the floor, and residents expressed satisfaction with food service.
Report Facts
Capacity: 206
Census: 127
Staff interviewed: 6
Residents interviewed: 11
Food supply duration: 7
Food supply duration: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Gonzalez | Licensing Program Analyst | Conducted the complaint investigation |
| Virginia Garcia | Administrator | Facility administrator interviewed during investigation |
| Lori Lackey | Assistant Administrator | Assistant administrator interviewed during investigation |
| Wei Siew Ho | Licensing Program Manager | Named in report as licensing program manager |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 206
Deficiencies: 0
Jan 17, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the facility was in disrepair and unkempt.
Findings
The investigation found that most residents and staff reported the facility was in good repair and well kept despite a recent flooding incident affecting part of the first floor. No evidence was found to substantiate the allegations, and the flooding was promptly addressed.
Complaint Details
The complaint was unsubstantiated after interviews with 11 residents and 6 staff, facility tour, and observations. The flooding incident was acknowledged but did not affect residents significantly and was resolved quickly.
Report Facts
Residents interviewed: 11
Staff interviewed: 6
Flooded rooms: 2
Facility capacity: 206
Facility census: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Garcia | Administrator | Administrator who assisted with the visit and provided information about the flooding |
| Christine Wong | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| David Sicairos | Licensing Program Manager | Manager overseeing the complaint investigation |
| Lori Lakcey | Assistant Administrator | Assistant administrator who assisted with the visit |
| Denise Miller | Office Coordinator | Staff member who met with the Licensing Program Analyst and explained the reason for the visit |
Inspection Report
Complaint Investigation
Census: 124
Capacity: 206
Deficiencies: 2
Dec 8, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to allegations including resident assault by another resident, resident care needs not being met, and facility disrepair.
Findings
The investigation substantiated that a resident was assaulted by another resident due to wandering behavior and inadequate care planning. It was also substantiated that resident care needs were not met when a resident was fed prior to surgery despite physician instructions to fast. The allegation of facility disrepair related to sewage leaks and toilet overflows was unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations that a resident was assaulted by another resident and that resident care needs were not met. The allegation regarding facility disrepair was unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee failed to provide adequate direct care staff to support R1's needs identified in physician's report, posing potential risk to health, safety, or personal rights of persons in care. | Type B |
| Licensee failed to ensure residents are regularly observed for changes in physical, mental, emotional and social functioning and provide appropriate assistance when such observation reveals unmet needs. | Type B |
Report Facts
Capacity: 206
Census: 124
Resident interviews: 12
Staff interviews: 6
Plan of Correction Due Date: Dec 22, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation |
| Tony Vasallo | Licensing Program Manager | Oversaw complaint investigation and signed report |
| Virginia Garcia | Administrator | Facility administrator involved in investigation |
| Lori Lackey | Assistant Administrator | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 206
Deficiencies: 2
Nov 29, 2022
Visit Reason
Licensing Program Analyst Mary Flores conducted a case management visit to follow up on an incident report sent to the department on 11/4/22 regarding Resident #1 leaving the facility unattended.
Findings
The facility failed to ensure Resident #1 did not leave the facility unattended on two occasions, posing an immediate risk to health and safety. The facility door did not lock behind visitors, allowing Resident #1 to exit unassisted. Deficiencies were cited related to personal rights and personnel requirements.
Complaint Details
The visit was triggered by a complaint incident report regarding Resident #1 leaving the facility unattended on 10/31/22 and again on 11/27/22. The complaint was substantiated based on review of incident reports and video evidence.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility did not ensure Resident #1 did not leave the facility unattended, posing immediate risk to health, safety, or personal rights. | Type A |
| Facility personnel were not sufficient in numbers and competent to meet resident needs. | Type B |
Report Facts
Deficiencies cited: 2
Plan of Correction Due Date: Nov 30, 2022
Plan of Correction Due Date: Dec 6, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Evaluator | Conducted case management visit and file review |
| Lori Lackey | Assistant Administrator | Met with Licensing Program Analyst during visit and exit interview |
| Stefanie Coronel | Supervisor | Supervisor of licensing evaluation |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 206
Deficiencies: 0
Nov 29, 2022
Visit Reason
An unannounced complaint investigation visit was conducted regarding allegations that a resident sustained unexplained bruising while in care, was handled in a rough manner, and that the resident's representative was not notified of the injury.
Findings
The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, all allegations were unsubstantiated.
Complaint Details
The complaint involved three allegations: unexplained bruising of a resident, rough handling of the resident, and failure to notify the resident's representative. The investigation included interviews with staff, review of facility documents, and contact with medical facilities. The findings were unsubstantiated due to insufficient evidence.
Report Facts
Facility capacity: 206
Resident census: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lori Lackey | Assistant Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Virginia Garcia | Administrator | Provided statements regarding resident transfer and bruising |
| Edward Hector | Investigator | Investigation Bureau investigator who conducted interviews and document reviews |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 206
Deficiencies: 1
Aug 10, 2022
Visit Reason
The visit was conducted as a complaint investigation following an allegation that the facility failed to report a resident with scabies to the local public health department.
Findings
The investigation found that the allegation was unsubstantiated. The resident diagnosed with suspected scabies was isolated, and the facility did not have an obligation to report the case since only one incident was documented. The facility later reported the condition to the Public Health Department as a precaution.
Complaint Details
The complaint alleged the facility failed to report a resident with scabies to the local public health department. The allegation was found to be unsubstantiated based on evidence and interviews.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report suspected scabies to the Public Health Department as required by reporting regulations. | Type B |
Report Facts
Capacity: 206
Census: 120
Plan of Correction Due Date: Aug 24, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Ceniceros | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Virginia Garcia | Administrator | Facility administrator involved in interviews regarding the scabies allegation |
| Lorie Lackey | Assistant Administrator | Interviewed during the investigation and received the complaint report copy |
| Malou Bernardo | Business Office Manager | Staff member interviewed during the investigation |
| Elizabeth Kirk | Nursing Supervisor | Staff member interviewed during the investigation |
| Manuel Ardon | Former A.M. Nursing Supervisor | Staff member interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 206
Deficiencies: 1
Aug 2, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including resident care needs not being met, resident assault by another resident, and facility disrepair.
Findings
The investigation substantiated that a resident was fed prior to surgery contrary to physician instructions due to staff communication failures. The allegation of resident assault was unsubstantiated due to insufficient evidence, and the allegation of facility disrepair related to sewage leaks was also unsubstantiated as the facility took corrective actions.
Complaint Details
The complaint investigation was substantiated for the allegation that resident care needs were not met, specifically regarding feeding a resident prior to surgery. The allegations that a resident was assaulted by another resident and that the facility was in disrepair were unsubstantiated.
Deficiencies (1)
| Description |
|---|
| Licensee failed to ensure resident did not have food intake in the morning prior to surgery, posing a potential health, safety or personal rights risk. |
Report Facts
Residents interviewed: 11
Staff interviewed: 6
Capacity: 206
Census: 119
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Virginia Garcia | Administrator | Facility administrator involved in investigation and document review |
| Lori Lackey | Assistant Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Stefanie Coronel | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 105
Capacity: 206
Deficiencies: 0
Apr 6, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on COVID-19 related recommendations.
Findings
The facility was observed to have proper COVID-19 protocols in place including screening logs, staff wearing face masks, hand sanitizer accessibility, social distancing among residents, and designated quarantine areas. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Flores | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Lori Lackey | Assistant Administrator | Met with Licensing Program Analyst during the visit and participated in the facility tour. |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 206
Deficiencies: 0
Apr 6, 2022
Visit Reason
The visit was a case management follow-up on an incident report and adult abuse report faxed to the department on 04/06/2022.
Findings
The investigation reviewed staff files, incident reports, and resident records related to an incident where a resident struck a staff member and the staff member responded by hitting back. The facility terminated the staff member involved. No injuries were observed and no deficiencies were cited during this visit.
Complaint Details
The visit was triggered by a complaint involving an incident on 04/03/2022 where resident #1 struck staff #1, who then hit back. The facility concluded to terminate staff #1 after internal investigation. No injuries were observed and further investigation was required.
Report Facts
Incident date: Apr 3, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the case management visit and investigation |
| Lori Lackey | Assistant Administrator | Met with Licensing Program Analyst during visit and exit interview |
| Virginia Garcia | Administrator | Named as facility administrator |
Inspection Report
Census: 110
Capacity: 206
Deficiencies: 0
Mar 28, 2022
Visit Reason
The visit was a case management follow-up related to COVID-19 to provide guidance and recommendations regarding infection control.
Findings
The Licensing Program Analyst observed proper infection control measures including visitor screening, quarantine/isolation areas, PPE availability, social distancing, staff mask and face shield use, and posted cleaning logs and quarantine posters. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Lackey | Assistant Administrator | Met with Licensing Program Analyst during the visit and participated in the tour and exit interview. |
Inspection Report
Plan of Correction
Census: 110
Capacity: 206
Deficiencies: 2
Mar 28, 2022
Visit Reason
The visit was a plan of correction (POC) follow-up conducted to verify correction of deficiencies cited during the annual visit on 2022-03-11.
Findings
The deficiencies related to freezer temperature and medication administration were found to be corrected as of the follow-up visit on 2022-03-28.
Deficiencies (2)
| Description |
|---|
| Freezer temperature was observed at 10 degrees, not within the required 0 degrees. |
| Medication sheets were not initialed upon providing medication to residents. |
Report Facts
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Flores | Licensing Program Analyst | Conducted the plan of correction visit and reviewed deficiencies. |
| Lori Lackey | Assistant Administrator | Met with Licensing Program Analyst during the visit and participated in exit interview. |
Inspection Report
Annual Inspection
Census: 206
Capacity: 206
Deficiencies: 4
Mar 11, 2022
Visit Reason
An unannounced annual visit was conducted focusing on infection control, food, and medication review.
Findings
The facility was generally clean and in good repair, but several deficiencies were noted including freezer temperature above required level, missing staff initials on medication sheets for some residents, water temperatures below required range in resident bathrooms, and missing skid mats in showers.
Severity Breakdown
Type A: 2
Type B: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Freezer temperature was observed at 10 degrees F, not within the required 0 degrees F. | Type A |
| Medication sheets for 6 out of 11 residents were missing staff initials next to doses provided. | Type A |
| Water temperature in 5 out of 11 resident bathrooms tested below the required 105-120 degrees F range. | Type B |
| 3 out of 11 resident bathrooms were missing skid mats in the showers. | Type B |
Report Facts
Residents missing staff initials on medication sheets: 6
Residents with water temperature below required range: 5
Residents missing skid mats in showers: 3
Facility capacity: 206
Facility census: 206
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Evaluator | Conducted the inspection and signed the report |
| Stefanie Coronel | Supervisor | Supervisor overseeing the inspection |
| Malou Bernardo | Business Office Manager | Met with inspectors during the visit |
| Rocio Gonzalez | Wellness Coordinator | Arrived during the inspection visit |
| Lori Lackey | Assistant Administrator | Participated in exit interview |
Inspection Report
Routine
Census: 107
Capacity: 206
Deficiencies: 0
Mar 3, 2022
Visit Reason
An unannounced case management visit was conducted regarding COVID-19 recommendations and guidelines.
Findings
The facility was observed to be following COVID-19 infection control recommendations, including staff wearing face masks and goggles, residents maintaining social distancing, and having sufficient PPE supplies and designated isolation areas. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Flores | Licensing Program Analyst | Conducted the unannounced case management visit and observations. |
| Rocio Gonzalez | Wellness Coordinator | Met with Licensing Program Analyst during the visit and assisted with the facility tour. |
Inspection Report
Routine
Census: 107
Capacity: 206
Deficiencies: 0
Feb 9, 2022
Visit Reason
An unannounced case management COVID-19 visit was conducted to follow up with COVID-19 recommendations at the facility.
Findings
The inspection found compliance with COVID-19 protocols including screening, social distancing, mask usage, hand sanitizing, and cleaning procedures. No deficiencies were cited during the visit.
Report Facts
Sanitizer buckets observed: 3
Staff per break room use: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Garcia | Administrator | Met with Licensing Program Analyst during the visit and participated in the facility tour |
| Mary Flores | Licensing Program Analyst | Conducted the unannounced case management COVID-19 visit |
Inspection Report
Census: 108
Capacity: 206
Deficiencies: 0
Jan 19, 2022
Visit Reason
An unannounced case management visit was conducted regarding COVID-19 guidelines compliance at the facility.
Findings
The facility was observed to have proper COVID-19 screening, staff wearing appropriate PPE, disinfecting protocols in place, and designated red zones for isolation. No deficiencies were cited during the visit.
Report Facts
Capacity: 206
Census: 108
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Garcia | Administrator | Administrator present during the visit and involved in the exit interview |
| Rocio Gonzalez | Wellness Director | Met with Licensing Program Analyst and Health Facility Evaluators during the visit |
Inspection Report
Monitoring
Capacity: 206
Deficiencies: 0
Jan 5, 2022
Visit Reason
Licensing Program Analyst Mary Flores conducted a case management visit to follow up on the facility's COVID-19 recommendations and guidelines.
Findings
The facility was observed to be following all COVID-19 recommendations, including visitor screening, social distancing, staff PPE use, cleaning protocols, and availability of disinfecting supplies. No deficiencies were cited during this visit.
Report Facts
Cleaning log entries per day: 3
Cleaning log entries per day: 6
Facility capacity: 206
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Flores | Licensing Program Analyst | Conducted the case management visit and observations. |
| Virginia Garcia | Administrator | Met with Licensing Program Analyst and participated in the visit. |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 206
Deficiencies: 0
Dec 17, 2021
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that a resident sustained injury due to lack of supervision.
Findings
The investigation found insufficient evidence to substantiate the allegation that the resident's fall was due to staff neglect or lack of supervision. Interviews with staff and residents, review of records, and observations indicated adequate supervision and timely response to emergencies.
Complaint Details
The complaint alleged that on 12/10/21, Resident #1 was found lying on the hallway floor and sustained a brain bleed injury. The investigation included interviews, record reviews, and facility tour. The allegation was determined to be unsubstantiated due to lack of evidence.
Report Facts
Facility capacity: 206
Resident census: 105
Investigation date: Dec 17, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Sicairos | Licensing Program Analyst | Conducted the complaint investigation |
| Virginia Garcia | Administrator | Facility administrator interviewed during investigation |
| Rebecca Orendain | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 102
Capacity: 206
Deficiencies: 0
Dec 14, 2021
Visit Reason
Licensing Program Analyst Mary Flores conducted a case management visit to follow up on COVID-19 guidelines.
Findings
The analyst observed screening questionnaires, temperature checks, social distancing during meals, posted signs, and staff disinfecting shared equipment. No deficiencies were observed during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Flores | Licensing Program Analyst | Conducted the case management visit and observations related to COVID-19 guidelines. |
| Virginia Garcia | Administrator | Facility administrator met with the analyst and participated in the exit interview. |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 206
Deficiencies: 2
Dec 14, 2021
Visit Reason
Unannounced complaint investigation visit conducted due to allegations including dead alarm batteries and pest infestations at the facility.
Findings
The investigation substantiated that the alarm batteries for the courtyard door were not working and that there was a current bed bug infestation in 9 rooms. Pest control services were ongoing. Other allegations such as inadequate staff supervision and failure to report infestations were found unsubstantiated.
Complaint Details
The complaint investigation was substantiated for dead alarm batteries and pest infestations including bed bugs. Other allegations such as inadequate supervision and failure to report infestations were unsubstantiated.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility did not ensure it was free of bed bugs in 9 rooms, posing an immediate health and safety risk. | Type A |
| Facility did not ensure alarm system batteries were working properly on exit doors, posing an immediate health and safety risk. | Type A |
Report Facts
Immediate Civil Penalty: 250
Rooms with bed bugs: 9
Facility capacity: 206
Census: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Virginia Garcia | Administrator | Facility administrator interviewed during investigation and exit interview. |
| Rebecca Orendain | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Capacity: 206
Deficiencies: 1
Dec 8, 2021
Visit Reason
The visit was an unannounced case management inspection triggered by an incident report regarding a resident who was noted missing and left the facility unattended through an open patio door used by contractors.
Findings
The facility failed to maintain one designated entrance point, allowing contractors access through a patio door which was left open, posing an immediate health, safety, and personal rights risk to residents. Deficiencies were cited under Title 22 regulations.
Complaint Details
The visit was complaint-related due to an incident report about Resident #1 leaving the facility unattended. The resident was found to have left through a patio door used by contractors. The resident's physician report noted the resident is able to leave unattended. The complaint investigation included review of police contact, employee warning notices, and observation of the patio door.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure to maintain one entrance point at the facility which poses an immediate health, safety, or personal rights risk for persons in care. | Type A |
Report Facts
Facility capacity: 206
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the unannounced case management visit and evaluation |
| Virginia Garcia | Administrator | Facility administrator met during the visit and provided information |
| Rebecca Orendain | Supervisor | Supervisor named in the deficiency report |
Inspection Report
Census: 112
Capacity: 206
Deficiencies: 0
Nov 17, 2021
Visit Reason
The visit was a case management COVID-19 unannounced inspection to assess the facility's compliance with CDC, public health, and department recommendations related to COVID-19.
Findings
No deficiencies were observed during the visit. The licensing program analyst observed proper screening logs, staff presence, signage in English and Spanish, and disinfection practices in the break room.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Lackey | Assistant Administrator | Met with licensing program analyst during the visit and explained the reason for the visit. |
| Rocio Gonzalez | Wellness Director | Accompanied the licensing program analyst during the tour and exit interview. |
Inspection Report
Monitoring
Census: 113
Capacity: 206
Deficiencies: 0
Nov 12, 2021
Visit Reason
A case management COVID-19 visit was conducted to assess the facility's compliance with CDC, Department of Public Health, and other department recommendations related to COVID-19.
Findings
The Licensing Program Analysts observed proper screening logs, staff and visitor screening procedures, disinfecting protocols, hand hygiene practices, and emergency exits. No deficiencies were observed during this visit.
Report Facts
Capacity: 206
Census: 113
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Garcia | Administrator | Met with Licensing Program Analysts during the visit |
| Mary Flores | Licensing Program Analyst | Conducted the case management COVID-19 visit |
| Jewel Baptiste | Licensing Program Analyst | Conducted the case management COVID-19 visit |
Inspection Report
Annual Inspection
Census: 121
Capacity: 206
Deficiencies: 0
Nov 4, 2021
Visit Reason
The visit was a case management - annual continuation inspection focusing on Disaster Preparedness, Residents with Special Health Needs, and Residents Rights Information domains.
Findings
No deficiencies were found during this visit. The facility was observed to be following current COVID-19 guidelines and recommendations. Technical assistance was provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Flores | Licensing Program Analyst | Conducted the case management - annual continuation visit. |
| Lori Lackey | Assistant Administrator | Met with Licensing Program Analyst during the visit and assisted with the tour. |
| Virginia Garcia | Administrator | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
Inspection Report
Annual Inspection
Census: 114
Capacity: 206
Deficiencies: 3
Oct 27, 2021
Visit Reason
The visit was a case management continuation annual inspection focusing on Personnel Records/Staff Training, Operational Requirements, Staffing, and Planned Activities.
Findings
The inspection found deficiencies related to staff training, including lack of required 20 hours annual training, missing current CPR/First Aid training for some staff, and incomplete health screening/TB test documentation for one staff member. Infection control practices were observed and found compliant during the visit.
Deficiencies (3)
| Description |
|---|
| 9 out of 9 staff files reviewed did not have 20 hours of required annual training including dementia care and other specified topics. |
| 4 out of 9 staff files (S1, S2, S5, S9) did not have current CPR training. |
| 1 out of 9 staff files (S6) did not have a health screening and TB test on file. |
Report Facts
Staff files reviewed: 9
Staff without required training: 9
Staff without current CPR training: 4
Staff without health screening/TB test: 1
Facility capacity: 206
Facility census: 114
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Garcia | Administrator | Named in relation to certification and plan of correction responsibilities |
| Mary G Flores | Licensing Evaluator | Conducted the inspection and signed the report |
| Rebecca Orendain | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Plan of Correction
Census: 141
Capacity: 206
Deficiencies: 1
Oct 27, 2021
Visit Reason
The visit was a plan of correction (POC) visit conducted to verify correction of a previously cited deficiency related to medication labeling.
Findings
The deficiency regarding PRN medication provided to residents without labels was cleared as labels were observed on PRN medication during the visit.
Deficiencies (1)
| Description |
|---|
| PRN medication provided to residents without labels |
Report Facts
Facility capacity: 206
Census: 141
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Garcia | Administrator | Met during the visit and involved in exit interview |
| Mary Flores | Licensing Program Analyst | Conducted the plan of correction visit |
| Jewel Baptiste | Licensing Program Analyst | Conducted the plan of correction visit |
Inspection Report
Annual Inspection
Census: 121
Capacity: 206
Deficiencies: 1
Oct 19, 2021
Visit Reason
The visit was a case management - annual continuation inspection focusing on incidental medical and dental care, residents' records, and incident reports.
Findings
The inspection found deficiencies related to non-prescription PRN medications for four residents that did not have labels, which poses a potential health, safety, or personal rights risk. Deficiencies were cited under Title 22 Regulations section 8 chapter 6.
Deficiencies (1)
| Description |
|---|
| Non-prescription PRN medication for 4 out of 12 residents reviewed did not have labels. |
Report Facts
Residents reviewed for medication files: 12
Residents with unlabeled PRN medication: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Garcia | Administrator | Met with Licensing Program Analysts during the visit and named in the exit interview. |
| Rocio Gonzalez | Wellness Director | Met with Licensing Program Analysts during the visit. |
| Mary G Flores | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Jewel Baptiste | Licensing Program Analyst | Conducted the inspection. |
| Rebecca Orendain | Supervisor | Named as supervisor on the report. |
Inspection Report
Plan of Correction
Census: 121
Capacity: 206
Deficiencies: 1
Oct 19, 2021
Visit Reason
The visit was a plan of correction (POC) inspection conducted to verify correction of deficiencies cited on 2021-10-11.
Findings
The facility corrected the deficiency related to emergency call response in rooms #134, 239, and 217, with a caregiver responding within 3 minutes. Infection control measures were observed to be in compliance with CDC guidelines, including updated visitor logs, posted signs in English and Spanish, disinfecting wipes availability, closed lid trash cans, and staff presence in common areas.
Deficiencies (1)
| Description |
|---|
| Facility staff did not respond to emergency call in rooms #134, 239, 217. |
Report Facts
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Garcia | Administrator | Met with Licensing Program Analysts during the plan of correction visit and named in relation to the emergency call response deficiency. |
| Mary Flores | Licensing Program Analyst | Conducted the plan of correction visit. |
| Jewel Baptiste | Licensing Program Analyst | Conducted the plan of correction visit and tested emergency call service. |
Inspection Report
Annual Inspection
Census: 121
Capacity: 206
Deficiencies: 3
Oct 11, 2021
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and assess the facility's physical plant, food service, and infection control practices.
Findings
The inspection identified deficiencies related to storage of hazardous items accessible to residents, water temperature below required levels in multiple rooms, and inadequate emergency call light response. Infection control measures were observed with recommendations for improvement.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Storage of disinfectants and cleaning solutions accessible to clients in rooms #223 and #122. | Type A |
| Water temperature in resident rooms and dining area sinks below the required 105-120 degrees F range. | Type B |
| Emergency call lights in rooms #134, 239, and 217 did not summon staff as staff at front desk could not visually see the signal. | Type A |
Report Facts
Capacity: 206
Census: 121
Deficiencies cited: 3
Water temperature readings: 98.5
Water temperature readings: 103
Refrigerator temperature: 40
Freezer temperature: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Evaluator | Conducted the inspection and signed the report |
| Rebecca Orendain | Supervisor | Supervised the inspection process |
| Virginia Garcia | Administrator | Facility administrator present during inspection and exit interview |
| Rocio Gonzalez | Wellness Director | Met with LPAs during inspection and involved in facility tour |
Inspection Report
Census: 121
Capacity: 206
Deficiencies: 10
Oct 4, 2021
Visit Reason
An unannounced case management COVID-19 visit was conducted to assess compliance with COVID-19 related health and safety protocols.
Findings
The facility had several COVID-19 related deficiencies including outdated screening questionnaires and signage, improper social distancing in dining areas, inconsistent mask usage among residents, and unlabeled or non-functioning trash cans. PPE supplies were adequate but needed to be ensured for all types. Disinfecting logs were maintained but no disinfecting observed in the break room, where disinfecting wipes were recommended.
Deficiencies (10)
| Description |
|---|
| Screening questionnaire needs to be updated to show current symptoms. |
| COVID-19 signage must be updated to show current symptoms in applicable languages and posted throughout the facility. |
| Hand washing signs must be updated and posted in all common sinks with proper steps. |
| Social distancing must be observed in dining areas; alternative options may be needed to ensure 6 feet distance. |
| Staff must wear proper face masks (surgical mask, N95 when necessary) and be aware of proper usage. |
| Facility must ensure all PPE supplies including surgical masks, N95s, face shields, gowns, gloves, hand sanitizer, and disinfectant spray are provided. |
| Logs for disinfecting surface areas must be maintained current. |
| Residents observed without face masks; facility to encourage surgical mask use in common areas. |
| Trash can in dining room next to sink was not working and trash cans in yellow zone were not labeled; facility to ensure trash cans are working and labeled. |
| No disinfecting observed in break room; recommended to provide disinfecting wipes for surfaces after each use. |
Report Facts
PPE supply duration: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Flores | Licensing Program Analyst | Conducted the unannounced case management COVID-19 visit and discussed findings. |
| Araceli Ramirez | Program Regional Manager | Conducted the unannounced case management COVID-19 visit and discussed findings. |
| Sharon Evangelista | Pasadena Department of Public Health Nurse | Participated in the unannounced case management COVID-19 visit. |
| Whitney Frame | Pasadena Department of Public Health Nurse | Participated in the unannounced case management COVID-19 visit. |
| Lori Lackey | Assistant Administrator | Facility representative met during the visit and participated in the exit interview. |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 206
Deficiencies: 0
Sep 15, 2021
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that the facility was not reporting documentation as required by a public agency.
Findings
The investigation revealed that the facility failed to submit required documentation within 24 hours of admission for five out of eleven new residents. However, the facility submitted the documents upon receiving them, and the allegation was found to be unsubstantiated.
Complaint Details
The complaint alleged the facility was not reporting documentation as required by a public agency. The investigation found the allegation unsubstantiated based on the preponderance of evidence standard.
Report Facts
New residents with delayed documentation submission: 5
Facility capacity: 206
Census: 119
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Virginia Garcia | Administrator | Met with the Licensing Program Analyst during the investigation and provided information. |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 206
Deficiencies: 0
Aug 3, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2021-06-14 regarding staff causing bruising, hitting, and handling a resident in a rough manner.
Findings
After interviews with residents, staff, and a Pasadena Police Department representative, there was no preponderance of evidence to substantiate the allegations of staff causing bruising, hitting, or handling the resident roughly. The investigation concluded that the allegations were unsubstantiated.
Complaint Details
The complaint involved allegations that facility staff caused bruising to a resident, hit the resident, and handled the resident in a rough manner. The investigation included interviews with residents, staff, and police representatives. No bruises or physical harm were observed or substantiated. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 206
Census: 112
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Virginia Garcia | Administrator | Facility administrator present during the investigation |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 206
Deficiencies: 1
Jul 14, 2021
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 04/21/2021 alleging that the facility is understaffed.
Findings
The investigation found that the facility did not ensure sufficient staffing, with caregivers assigned between 13-18 residents and housekeepers assigned up to 36 rooms daily, causing potential health, safety, or personal rights risks. The allegation of understaffing was substantiated based on interviews and documentation.
Complaint Details
The complaint alleging understaffing was substantiated based on interviews with staff and residents, review of personnel reports, and observations during the onsite visit.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel were not sufficient in numbers, with one caregiver assigned between 13-18 residents and one housekeeper cleaning up to 36 rooms daily, posing potential health, safety, or personal rights risks. | Type B |
Report Facts
Caregivers: 27
Cleaning staff: 12
Residents per caregiver: 13
Residents per caregiver: 18
Rooms per housekeeper: 36
Deficiency due date: Jul 21, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Garcia | Administrator | Named in relation to staffing allegation and exit interview |
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Lisa Hicks | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Lori Lackey | Assistant Administrator | Interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 206
Deficiencies: 0
Jul 9, 2021
Visit Reason
An unannounced complaint investigation was conducted following allegations that residents were not assisted with incontinence care, did not receive adequate daily food intake, and were not provided adequate hygiene supplies.
Findings
The investigation included interviews, document reviews, and facility tours. The allegations were found unsubstantiated as sufficient supplies and assistance were observed and documented, and residents and staff interviews supported adequate care and food provision.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included lack of assistance with incontinence care, inadequate food intake, and insufficient hygiene supplies. Evidence showed adequate supplies of diapers and wipes, sufficient food for residents, and staff assistance with feeding and toileting as needed.
Report Facts
Capacity: 206
Census: 109
Invoices reviewed: 9
Invoices reviewed: 8
Residents interviewed: 10
Staff interviewed: 7
Residents needing toileting assistance: 8
Residents not needing toileting assistance: 4
Residents needing feeding assistance: 4
Residents not needing feeding assistance: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Garcia | Administrator | Met with during investigation and exit interview |
| Mary G Flores | Licensing Program Analyst | Conducted telephone interviews and investigation |
| Luis Mora | Licensing Program Analyst | Conducted facility tour and interviews |
| Rebecca Orendain | Licensing Program Manager | Named as Licensing Program Manager overseeing investigation |
Inspection Report
Census: 112
Capacity: 206
Deficiencies: 1
Jun 29, 2021
Visit Reason
Licensing Program Analyst Mary Flores conducted a case management visit due to deficiencies related to required reporting requirements that must be reported to Pasadena Department of Public Health (PDPH).
Findings
The facility failed to submit required documentation within 24 hours of admission for seven new residents as required by PDPH under COVID-19 recommendations and guidelines, posing a potential health, safety, or personal rights risk to persons in care.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Administrator failed to submit required documentation for 7 new admissions to the facility based on PDPH evaluation which poses a potential Health, Safety, or Personal Rights risk to persons in care. | Type B |
Report Facts
Number of new admissions with missing documentation: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Evaluator | Conducted the case management visit and authored the report |
| Rebecca Orendain | Supervisor | Supervisor overseeing the licensing evaluation |
| Virginia Garcia | Administrator | Facility administrator named in relation to failure to submit required documentation |
| Lori Lackey | Assistant Administrator | Met during the visit and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 206
Deficiencies: 0
Jun 17, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that residents developed pressure injuries while in care and that staff did not seek medical attention for residents in a timely manner.
Findings
The investigation included interviews with residents and staff, and review of relevant documents. It was found that some residents had pressure injuries but the facility had procedures to identify and address these issues, including contacting Hospice, Home Health Care, or Physicians as appropriate. Staff training on pressure injury prevention was provided. There was insufficient evidence to substantiate the allegations.
Complaint Details
The complaint investigation was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred. Allegations involved pressure injuries and delayed medical attention. Interviews and document reviews did not support the allegations.
Report Facts
Residents interviewed: 14
Staff interviewed: 10
Residents receiving hospice services: 7
Residents receiving home health care services: 4
Residents not receiving hospice or home health care: 5
Caregiver resident assignment: 13
Caregiver resident assignment (when caregiver is out): 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation |
| Rebecca Orendain | Licensing Program Manager | Oversaw the complaint investigation |
| Lori Lackey | Assistant Administrator | Facility representative interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 206
Deficiencies: 0
Jun 9, 2021
Visit Reason
Unannounced complaint investigation due to an allegation of a physical altercation between two residents caused by lack of supervision.
Findings
The investigation included interviews with residents, staff, and review of relevant documents. The allegation that Resident #2 assaulted Resident #1 was found unsubstantiated based on the preponderance of evidence.
Complaint Details
The complaint alleged a physical altercation between two residents where Resident #2 ran over Resident #1's feet with a wheelchair and punched Resident #1 in the face. The investigation found no substantiation for the allegation.
Report Facts
Residents interviewed: 11
Staff interviewed: 7
Police report number: 21005733
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Virginia Garcia | Administrator | Facility administrator met with investigators and was involved in the investigation |
| Rebecca Orendain | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 206
Deficiencies: 2
May 28, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 10/09/2020 regarding pest infestation, meal delivery delays due to staffing, and untimely resident hygiene care.
Findings
The investigation substantiated allegations that the facility was not free from pests, with cockroach sightings confirmed, and that residents were not always receiving meals on time due to insufficient staffing. However, the allegation regarding untimely care for residents' hygiene needs was unsubstantiated based on interviews and document review.
Complaint Details
The complaint investigation addressed allegations of pest infestation, delayed meals due to staffing shortages, and inadequate hygiene care. The pest and meal-related allegations were substantiated, while the hygiene care allegation was unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility was not kept free of cockroaches and bed bugs, posing a health and safety risk. | Type B |
| Insufficient staff to provide adequate personal assistance and care to residents, leading to potential health and safety risks. | Type B |
Report Facts
Residents under hospice care: 6
Bedridden residents: 0
Non-ambulatory residents: 23
Staff to resident ratio: 1
Plan of Correction due date: Jun 11, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation |
| Luis Mora | Licensing Program Analyst | Conducted the complaint investigation |
| Virginia Garcia | Administrator | Facility administrator involved in the investigation |
| Lori Lackey | Assistant Administrator | Facility assistant administrator involved in the investigation |
| Rebecca Orendain | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 206
Deficiencies: 0
May 28, 2021
Visit Reason
The inspection was conducted as a complaint investigation following allegations that the facility did not follow a resident's care plan and that staff were not meeting the showering needs of residents.
Findings
The investigation found that caregivers prioritize care for residents' incontinence, meals, and showers given every other day as agreed in care plans. Interviews and document reviews showed that the allegations were unsubstantiated based on the preponderance of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to follow resident care plans and unmet showering needs. Interviews with residents and staff, as well as document reviews, supported that showers were provided every other day as agreed and care needs were met within staffing limitations.
Report Facts
Residents interviewed: 10
Staff interviewed: 8
Residents needing assistance with daily living: 7
Residents needing assistance with showers: 6
Staff unfamiliar with resident needs: 2
Staff providing assistance to caregivers: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation |
| Luis Mora | Licensing Program Analyst | Conducted the complaint investigation |
| Virginia Garcia | Administrator | Facility administrator present during the investigation |
| Lori Lackey | Assistant Administrator | Met with investigators and participated in interviews |
| Rebecca Orendain | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 206
Deficiencies: 0
May 4, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that residents developed pressure injuries while in care and that staff did not seek medical attention for residents in a timely manner.
Findings
The investigation found that many residents had pressure ulcers at varying stages that were not being treated. Interviews with residents and staff revealed mixed awareness and responses to pressure injuries. Documentation showed some residents were receiving hospice or home health care services, while others were not. Staff training on pressure prevention and wound care was provided. The complaint was ultimately unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included residents developing pressure injuries and staff failing to seek timely medical attention. Interviews and document reviews were conducted, including with residents, staff, and facility administrators. The investigation concluded that the allegations were not substantiated.
Report Facts
Residents interviewed: 14
Staff interviewed: 10
Residents receiving hospice services: 7
Hospice notes reviewed with care for altered skin: 1
Residents receiving home health care services: 4
Residents not receiving hospice or home health care: 5
Average residents per caregiver per day: 13
Average residents per caregiver on days a caregiver is out: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation |
| Lori Lackey | Assistant Administrator | Interviewed during the investigation and participated in exit interview |
| Virginia Garcia | Administrator | Facility administrator interviewed by phone during investigation |
Inspection Report
Census: 109
Capacity: 206
Deficiencies: 0
Apr 22, 2021
Visit Reason
The visit was an unannounced office visit conducted via Microsoft Teams to review the facility's timely submission of documentation related to new admissions to the Pasadena Public Health Department (PPHD), particularly in the context of COVID-19 mitigation measures.
Findings
The facility was found to be consistent in submitting lab test results for all testing but was reminded of concerns regarding the timely and consistent submission of required admission documents. The facility was warned that subsequent citations would be assessed if documentation submission did not comply with requirements.
Report Facts
Capacity: 206
Census: 109
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Garcia | Administrator | Met during the visit and involved in discussion regarding documentation submission |
| Lori Lackey | Assistant Administrator | Participated in the Microsoft Teams meeting during the visit |
| Mary Flores | Licensing Program Analyst | Conducted the office visit |
| Rebecca Orendain | Licensing Program Manager | Conducted the office visit |
| Araceli Ramirez | Regional Manager | Conducted the office visit and discussed concerns about documentation |
| Whitney Frame | Pasadena Public Health Department Nurse | Provided information on testing and documentation requirements |
Inspection Report
Complaint Investigation
Capacity: 206
Deficiencies: 0
Apr 13, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that a resident received an unexplained injury while in care.
Findings
The investigation found no evidence to substantiate the allegation. Staff and administrator reported no falls or injuries to the resident during the relevant period, and no deficiencies or citations were issued.
Complaint Details
The allegation was that a resident received an unexplained injury while in care. After interviews, document reviews, and a police report review, the allegation was found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 206
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Garcia | Administrator | Met during investigation and participated in interviews |
| Christine Wong | Licensing Program Analyst | Conducted the complaint investigation |
| Christine Yee | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 206
Deficiencies: 2
Mar 27, 2021
Visit Reason
The inspection was an unannounced complaint investigation initiated due to allegations including lack of supervision resulting in resident AWOLing multiple times and other resident care concerns.
Findings
The investigation substantiated the allegation of lack of supervision resulting in resident AWOLing multiple times, citing incidents where the resident left undetected and was found by police. Other allegations regarding resident restraint, soiled clothing, access to food and water, and staff response to calls were found to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for lack of supervision resulting in resident AWOLing multiple times. Other allegations including restraint in bed, soiled clothing, access to food and water, and staff response to calls were unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure that resident was accorded safe and healthful accommodations due to resident AWOLing and staff not being aware, posing immediate health, safety and personal rights risk. | Type A |
| Failed to furnish a LIC624 Unusual Incident/Injury Report when client AWOL from facility when initially admitted, posing immediate health, safety or personal rights risk. | Type B |
Report Facts
Capacity: 206
Census: 107
Deficiency count: 2
Plan of Correction Due Date: Mar 29, 2021
Plan of Correction Due Date: Apr 2, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Garcia | Executive Director | Interviewed regarding allegations and investigation findings |
| Rocio Gonzalez | Caregiver Supervisor | Interviewed regarding allegations and investigation findings |
| Alma Gonzalez | Licensing Program Analyst | Conducted the complaint investigation |
| Rebecca Orendain | Licensing Program Manager | Oversaw the complaint investigation |
| Mariam Mangyan | Director of Patient Care, CareMark Healthcare (Hospice Agency) | Interviewed regarding resident care and allegations |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 206
Deficiencies: 1
Mar 1, 2021
Visit Reason
The inspection was an unannounced complaint investigation conducted due to multiple allegations including the presence of cockroaches, bed bugs, inadequate activities, urine odor, unmet resident needs, inadequate food service, and lack of staff assistance with hygiene.
Findings
The allegation of cockroach presence was substantiated with evidence from staff interviews and pest control records. All other allegations including bed bugs, lack of activities, urine odor, unmet resident needs, inadequate food service, and lack of hygiene assistance were found to be unsubstantiated based on staff and resident interviews and observations.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility had cockroaches. Other allegations including bed bugs, no activities, urine odor, residents not getting their needs met, inadequate food service, and staff not assisting residents with hygiene were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This standard is not met as evidenced by the presence of cockroaches. | Type B |
Report Facts
Capacity: 206
Census: 102
Deficiency count: 1
Plan of Correction Due Date: Mar 8, 2021
Inspection Report
Routine
Census: 97
Capacity: 206
Deficiencies: 2
Nov 23, 2020
Visit Reason
The visit was conducted to discuss ongoing compliance issues at the facility regarding Personal Protective Equipment (PPE) use and COVID-19 policies and procedures, including observations of improper PPE use by staff and incomplete documents submitted to Pasadena Public Health.
Findings
The facility was found to have ongoing issues with improper use of PPE by staff and incomplete or incorrectly formatted documents submitted to Pasadena Public Health. Deficiencies related to these issues were issued and are under appeal.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Additional Personal Rights of Residents in Privately Operated Facilities (a) Personal Rights.... (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. | Type A |
| Administrator - Qualifications and Duties (h) The administrator shall have the responsibility to: (8) the personal characteristics, physical energy and competence to provide care and supervision and, where applicable, to work effectively with social agencies. | Type A |
Report Facts
Deficiencies cited: 2
PPE training sessions: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Garcia | Administrator | Named in relation to PPE compliance issues and facility administration |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 206
Deficiencies: 0
Nov 3, 2020
Visit Reason
The inspection was conducted as a complaint investigation following an allegation that a resident sustained unexplained bruising while in care.
Findings
The investigation found that the bruising was due to a fall that occurred at a different facility prior to the resident's transfer. There was insufficient evidence to corroborate the allegation, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged that a resident sustained unexplained bruising while in care. The investigation included interviews and review of records, but due to insufficient evidence and the resident's cognitive impairment, the allegation was unsubstantiated.
Report Facts
Capacity: 206
Census: 101
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Sicairos | Licensing Program Analyst | Conducted the complaint investigation |
| Virginia Garcia | Administrator | Facility Administrator interviewed during investigation |
| Rebecca Orendain | Supervisor | Supervisor overseeing the investigation |
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