Inspection Report Summary
Most inspections found deficiencies related to resident safety, supervision, and documentation, with several complaint investigations substantiated. The most serious event occurred in December 2024 when inadequate supervision led to a resident eloping and sustaining multiple injuries, resulting in citations and a civil penalty for fire safety violations involving locked exit gates posing immediate health risks. Other issues included failure to update resident appraisals, delayed provision of resident records, and lapses in liability insurance coverage, though many of these were addressed through plans of correction. The most recent report from September 15, 2025, found only one remaining fire safety deficiency related to exit gate egress, showing some improvement since the serious findings in late 2024. Several complaint investigations were unsubstantiated or had minor findings, and the facility has demonstrated progress in correcting prior violations.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Plan of Correction
Census: 19
Capacity: 26
Deficiencies: 1
Sep 15, 2025
Visit Reason
An unannounced plan of correction (POC) visit was conducted to follow up on citations issued on 10/17/2024 and 12/23/2024.
Findings
The previously cited fire safety deficiency (delayed egress installation) has been corrected and is now operational. The licensee has complied with the plan of correction and was advised to remain in compliance with previously cited items.
Deficiencies (1)
| Description |
|---|
| Fire Safety, 87203 citation issued on 10/17/2024 and 12/23/2024 |
Report Facts
Capacity: 26
Census: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced plan of correction visit |
| Magali Sanchez | Administrator | Facility administrator met during the inspection |
Inspection Report
Complaint Investigation
Census: 19
Capacity: 26
Deficiencies: 0
Aug 29, 2025
Visit Reason
An unannounced collateral visit was conducted in conjunction with complaint 22-AS-20220304102138 to evaluate the facility's compliance with licensing requirements.
Findings
The Licensing Program Analyst toured the facility, interviewed staff and a resident, but was unable to review facility, resident, and staff records from March 2022 as they were not available. An exit interview was conducted with the Administrator.
Complaint Details
The visit was triggered by complaint 22-AS-20220304102138. No substantiation status is provided in the report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alvaro Ramirez Jr. | Licensing Program Analyst | Conducted the unannounced collateral visit and inspection. |
| Magali Sanchez | Administrator | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
Inspection Report
Annual Inspection
Census: 19
Capacity: 26
Deficiencies: 1
Aug 28, 2025
Visit Reason
This unannounced inspection was conducted as a Required – 1 Year Inspection to evaluate compliance with licensing requirements.
Findings
The inspection found that the facility generally met infection control, safety, and operational standards; however, deficiencies were cited for failure to update pre-admission appraisals for five residents within the past year.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure Residents #1, #2, #3, #4, and #5 had appraisals updated within the past year, posing a potential safety risk. | Type B |
Report Facts
Residents with outdated appraisals: 5
Resident files reviewed: 6
Staff files reviewed: 6
Residents interviewed: 6
Staff interviewed: 4
Medications inspected: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Magali Sanchez | Administrator | Met with Licensing Program Analyst during inspection |
| Sean Haddad | Licensing Program Analyst | Conducted the inspection and signed the report |
| Armando J Lucero | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Plan of Correction
Census: 24
Capacity: 26
Deficiencies: 4
Jan 8, 2025
Visit Reason
Unannounced plan of correction (POC) visit to follow up on citations issued on 12/23/2024.
Findings
All citations issued on 12/23/2024 regarding Basic Services, False Claims, Care of Persons with Dementia, and Storage Space have been cleared with proof of correction provided by the licensee. The licensee has complied with the plan of correction.
Deficiencies (4)
| Description |
|---|
| Citation regarding Basic Services, 87464(f)(1) |
| Citation regarding False Claims, 87207 |
| Citation regarding Care of Persons with Dementia, 87705(j) |
| Citation regarding Storage Space, 87705(h) |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced plan of correction visit. |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 26
Deficiencies: 4
Dec 23, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/06/2023 regarding inadequate supervision, failure to respond to alarms, unsecured exterior gates, and misinformation provided to a resident's authorized representative.
Findings
The investigation substantiated that staff failed to provide adequate supervision resulting in a resident wandering away and sustaining multiple injuries. Staff also failed to respond to facility alarms, did not securely lock the exterior gate, and provided false information to the resident's family. These deficiencies posed immediate health and safety risks to residents.
Complaint Details
The complaint investigation was substantiated. Allegations included inadequate supervision causing resident elopement and injuries, failure to respond to alarms, unsecured exterior gates, and providing false information to the resident's authorized representative. The resident sustained multiple fractures and injuries after wandering away from the facility. Staff admitted to turning off alarms and providing false statements under pressure from management.
Severity Breakdown
Type A: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Basic services shall at a minimum include care and supervision as defined in regulations; this requirement was not met resulting in resident elopement and multiple injuries. | Type A |
| Licensee failed to ensure employees did not make false or misleading statements regarding the facility or services provided. | Type A |
| Licensee failed to have an auditory device or staff alert feature to monitor exits, resulting in resident elopement. | Type A |
| Outdoor facility space used for resident recreation was not completely enclosed with self-closing latches and gates to protect resident safety. | Type A |
Report Facts
Facility capacity: 26
Census: 24
Deficiency count: 4
Plan of Correction due date: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Plan of Correction
Census: 24
Capacity: 26
Deficiencies: 1
Dec 23, 2024
Visit Reason
An unannounced plan of correction (POC) visit was conducted to follow up on citations issued on 2024-10-17.
Findings
The citation regarding Maintenance and Operation was cleared with removal of the delayed egress push lever, but the citation regarding Fire Safety was not cleared as exit gates remain secured with locks or keypads, posing an immediate health and safety risk. A civil penalty was assessed.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Exit gates are secured by either a keypad or key locks prohibiting residents from leaving in an emergency, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 26
Census: 24
Plan of Correction Due Date: Dec 24, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced plan of correction visit and authored the report |
| Alisa Ortiz | Licensing Program Manager | Supervisor and named in the report |
Inspection Report
Complaint Investigation
Census: 22
Capacity: 26
Deficiencies: 2
Oct 17, 2024
Visit Reason
An unannounced case management visit was conducted in conjunction with a complaint visit #22-AS-20230906160954 to assess compliance with regulations.
Findings
The inspection found that all exit gates were locked, posing an immediate health and safety risk, and the exit gate on the north side had a broken delayed egress push lever, indicating the facility was not in good repair.
Complaint Details
The visit was conducted in conjunction with complaint visit #22-AS-20230906160954.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| All exit gates are locked posing an immediate health and safety risk to residents in care. | Type A |
| Exit gate on north side of property has a broken delayed egress push lever posing a potential health and safety risk to residents in care. | Type B |
Report Facts
Capacity: 26
Census: 22
Plan of Correction Due Date: Oct 18, 2024
Plan of Correction Due Date: Oct 31, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the inspection and named in the report |
| William Vanegas | Licensing Program Analyst | Conducted the inspection and named in the report |
| Alisa Ortiz | Licensing Program Manager | Supervisor named in the report |
| Wendy Cruz | Interim Administrator | Arrived during the visit |
Inspection Report
Follow-Up
Census: 25
Capacity: 26
Deficiencies: 0
Aug 19, 2024
Visit Reason
This unannounced Plan of Correction (POC) inspection was conducted to verify correction of deficiencies issued during the Required – 1 Year Inspection conducted on August 13, 2024.
Findings
The previously cited Type A violation related to hot water temperatures in three buildings was cleared. Water temperatures were tested and found within acceptable ranges. No deficiencies were observed during this inspection.
Report Facts
Water temperature readings: 111
Water temperature readings: 120
Water temperature readings: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sean Haddad | Licensing Program Analyst | Conducted the inspection |
| Wendy Cruz | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Census: 25
Capacity: 26
Deficiencies: 1
Aug 13, 2024
Visit Reason
This unannounced inspection was conducted by Licensing Program Analyst Sean Haddad for the purpose of a Required – 1 Year Inspection to evaluate compliance with licensing regulations.
Findings
The inspection found that the facility is generally well maintained with adequate supplies, safety measures, and proper operation of appliances. However, a deficiency was cited due to hot water temperatures exceeding the regulatory limits in multiple buildings, posing an immediate safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Hot water temperature controls were not maintained within the required range of 105°F to 120°F, with observed temperatures at 126, 138, 85, and 109 degrees Fahrenheit in various buildings, posing an immediate safety risk to persons in care. | Type A |
Report Facts
Hot water temperature: 126
Hot water temperature: 138
Hot water temperature: 85
Hot water temperature: 109
Capacity: 26
Census: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sean Haddad | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Armando J Lucero | Licensing Program Manager | Supervisor of the inspection |
| Wendy Cruz | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 26
Deficiencies: 1
Jun 20, 2024
Visit Reason
This unannounced inspection was conducted to investigate a complaint alleging that facility staff were not providing records to a resident's responsible person(s).
Findings
The investigation found that the facility did not timely provide Resident #1's Resident File in response to a request dated December 28, 2023, failing to meet the requirement to provide access within two business days. The allegation was substantiated based on interviews, document reviews, and a witness statement.
Complaint Details
The complaint alleged that facility staff were not providing records to resident's responsible person(s). The allegation was substantiated after investigation, with evidence showing the facility did not provide the requested Resident File within the required timeframe.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide Resident #1 access to their records within two business days of the request dated December 28, 2023, violating CCR 87468.2(a)(19) regarding Additional Personal Rights. | Type B |
Report Facts
Capacity: 26
Census: 24
Deficiency count: 1
Plan of Correction Due Date: Jun 27, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sean Haddad | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation |
| Lupe Harvey | Administrator | Facility administrator not present during inspection |
| Rosalba Maldonado | Facility staff interviewed during investigation |
Inspection Report
Census: 19
Capacity: 26
Deficiencies: 0
Jun 19, 2023
Visit Reason
This unannounced Case Management – Other inspection was conducted for the purpose of delivering amended findings for Complaint Control No. 22-AS-20221212121518 based on appeal.
Findings
During the inspection, the Licensing Program Analyst and the Administrator discussed the previously delivered findings and the amended findings. The amended report was delivered and discussed with the facility representative.
Complaint Details
Inspection was related to Complaint Control No. 22-AS-20221212121518 and involved delivery of amended findings based on appeal.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lupe Harvey | Administrator | Appeared via telephone during the inspection and discussed amended findings. |
| Rosalba Maldonado | Staff #1 | Met with Licensing Program Analyst during the inspection. |
| Sean Haddad | Licensing Program Analyst | Conducted the inspection and delivered amended findings. |
| Armando J Lucero | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 22
Capacity: 26
Deficiencies: 1
May 17, 2023
Visit Reason
This unannounced complaint investigation was conducted due to allegations that the licensee had liability insurance that did not include required coverage for resident injuries and misrepresented to the Department that they had liability insurance.
Findings
The investigation found that between 08/26/2022 and 12/06/2022, the facility did not have its own liability insurance coverage compliant with Title 22 Regulations due to policy exclusions and shared coverage with other facilities. The allegation that the licensee misrepresented having liability insurance was substantiated, while the allegation that the licensee had no current liability insurance was unsubstantiated.
Complaint Details
The complaint was substantiated regarding the licensee not having required liability insurance coverage between 08/26/2022 and 12/06/2022. The allegation that the licensee misrepresented having liability insurance was substantiated. The allegation that the licensee had no current liability insurance was unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars per occurrence and three million dollars in the total annual aggregate, caused by negligent acts or omissions by the licensee. | Type A |
Report Facts
Capacity: 26
Census: 22
Insurance coverage limits: 1000000
Insurance coverage limits: 3000000
Deficiency due date: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sean Haddad | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation |
| Rosalba Maldonado | Facility staff met with during inspection |
Inspection Report
Plan of Correction
Census: 17
Capacity: 26
Deficiencies: 2
Jan 19, 2023
Visit Reason
This unannounced Plan of Corrections inspection was conducted to verify correction of deficiencies issued during the post licensing inspection conducted on 2022-12-13.
Findings
Two Type B violations related to staff training and resident files were cited and have been cleared based on documentation provided by the licensee prior to the due date.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Type B Violation under Health and Safety Code section 1569.625(b)(2) pertaining to staff training | Type B |
| Type B Violation under Title 22 Regulation 87506(b)(15) pertaining to resident files | Type B |
Report Facts
Staff training documentation: 12
Resident appraisals documentation: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lupe Harvey | Administrator | Met with Licensing Program Analyst during inspection |
| Sean Haddad | Licensing Program Analyst | Conducted the Plan of Corrections inspection |
| Armando J Lucero | Licensing Program Manager | Named in report header |
Inspection Report
Follow-Up
Census: 17
Capacity: 26
Deficiencies: 0
Dec 16, 2022
Visit Reason
This unannounced case management inspection was conducted to follow up on a self-reported incident involving Resident #1 attacking Resident #2 with a dresser drawer on 11/13/22.
Findings
The inspection found that Resident #2 had minor bruises but was otherwise in good health and able to walk. Resident #1 had a history of dementia with behavioral disturbances and was sometimes agitated and aggressive. The facility had attempted to have Resident #1's medications reassessed but did not receive a response. Further investigation may be required.
Report Facts
Facility capacity: 26
Resident census: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sean Haddad | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lupe Harvey | Administrator | Facility administrator interviewed during inspection |
| Rosalba Maldonado | Staff | Interviewed during inspection regarding incident |
Inspection Report
Original Licensing
Census: 17
Capacity: 26
Deficiencies: 2
Dec 13, 2022
Visit Reason
This unannounced inspection was conducted for the purpose of a post licensing inspection of the facility.
Findings
The inspection found the facility to be generally clean, organized, and compliant with safety requirements, but deficiencies were cited related to staff training documentation and resident appraisal records.
Deficiencies (2)
| Description |
|---|
| 4 out of 5 staff files did not contain documentation of staff training, posing a potential health and safety risk. |
| 4 out of 5 resident files reviewed did not contain a current appraisal, posing a potential health and safety risk. |
Report Facts
Staff files missing training documentation: 4
Resident files missing current appraisal: 4
Staff present during inspection: 4
Residents present during inspection: 17
Facility capacity: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sean Haddad | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Armando J Lucero | Licensing Program Manager | Supervisor and named in report |
| Lupe Harvey | Administrator | Facility administrator appearing via telephone during inspection |
| Rosalba Maldonado | Staff #1 | Met with Licensing Program Analyst during inspection |
| Wendy Cruz Andrade | Facility Manager | Present during inspection and met with Licensing Program Analyst |
Inspection Report
Complaint Investigation
Census: 16
Capacity: 26
Deficiencies: 0
Nov 17, 2022
Visit Reason
This unannounced case management inspection was conducted to follow up on a self-reported incident involving Resident #1 attacking Resident #2 with a dresser drawer on 2022-11-13.
Findings
The inspection found that Resident #2 had minor bruises but was otherwise in good health and able to walk. No health and safety issues were observed during the visit. Further investigation may be required.
Complaint Details
The incident involved Resident #1 attacking their roommate Resident #2, resulting in police involvement and Resident #1's removal from the facility. Resident #2 did not remember the incident and was interviewed by the Long Term Care Ombudsman.
Report Facts
Facility capacity: 26
Census: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Ramos | Staff #1 | Met with Licensing Program Analyst and discussed the incident |
| Sean Haddad | Licensing Program Analyst | Conducted the inspection and investigation |
| Armando J Lucero | Licensing Program Manager | Named in report header |
| Jeannie Noh | Long Term Care Ombudsman | Interviewed Resident #2 in Korean during inspection |
Inspection Report
Original Licensing
Census: 11
Capacity: 26
Deficiencies: 0
Jul 22, 2022
Visit Reason
The inspection was conducted as a pre-licensing inspection for a Residential Care Facility for the Elderly, following an application submitted on 05/11/2022 and a change of ownership with persons in care.
Findings
The facility was inspected and found to be a small commercial facility with 13 bedrooms and 5 bathrooms, all in good condition with operational fixtures and safety equipment. Resident and staff files were reviewed, and fire clearance was approved. The facility was deemed ready for licensure pending final approval.
Report Facts
Capacity: 26
Census: 11
Bedrooms: 13
Bathrooms: 5
Water temperature: 107
Water temperature: 110
Food supply duration: 2
Food supply duration: 7
Fire clearance date: Jun 9, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lupe Harvey | Administrator | Met during inspection and discussed inspection purpose |
| Wendy Cruz Andrade | Facility Manager | Met during inspection and discussed inspection purpose |
| Sean Haddad | Licensing Program Analyst | Conducted the inspection |
| Peggy Castenada | Fullerton Fire Department Inspector | Approved fire clearance on 06/09/2022 |
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