Inspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on September 22, 2025, which was clean with no issues noted. Earlier reports included some deficiencies related to medication management, such as missed medications for multiple residents and a medication error involving a double dose, as well as outdated medical assessments in resident files. A substantiated complaint in February 2023 found a resident sustained a fracture due to improper care and failure to report the injury, but no fines or enforcement actions were listed in the available reports. Several complaint investigations were unsubstantiated, including allegations about staff conduct, facility odor, and pest control, though occasional cockroach sightings were reported. The facility’s record shows improvement over time, with recent inspections consistently meeting standards and no new deficiencies noted.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 50
Capacity: 66
Deficiencies: 0
Sep 22, 2025
Visit Reason
The inspection was an unannounced required annual visit conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements.
Findings
The facility was found to be in compliance with no deficiencies noted. The physical plant, emergency preparedness, infection control, medication administration, and documentation were all satisfactory.
Report Facts
Licensed capacity: 66
Current census: 50
Hospice residents present: 3
Fire extinguishers: 8
Evacuation chairs: 3
Medication records reviewed: 6
Resident files reviewed: 6
Staff files reviewed: 6
Emergency food kit servings: 12
Emergency food kit servings: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Kashani | Executive Director | Assisted with the facility inspection and exit interview |
| Putri Tarigan | Director of Health Services | Assisted with the facility inspection and physical plant tour |
| Jenifer Tirre | Licensing Program Analyst | Conducted the inspection visit |
| Eboni Bentley | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Annual Inspection
Census: 45
Capacity: 66
Deficiencies: 1
Aug 21, 2024
Visit Reason
The inspection was an unannounced Required Annual Inspection conducted by Licensing Program Analysts to evaluate compliance with regulations at the facility.
Findings
The facility was found generally compliant with safety and operational standards, including secure medication storage, emergency preparedness, and resident accommodations. However, one Type B deficiency was issued for outdated medical assessments in resident files, and two Technical Assistance advisory notes were given regarding staff association and hand-washing facilities.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Two out of six resident files reviewed included an outdated medical assessment for residents with an indication of dementia, posing a potential health, safety, or personal rights risk. | Type B |
Report Facts
Residents receiving hospice care: 6
Residents in assisted living: 16
Residents in memory care: 29
Plan of Correction due date: Sep 21, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the inspection and signed the report |
| William Vanegas | Licensing Program Analyst | Conducted the inspection |
| Sheila Santos | Licensing Program Manager | Supervised the inspection |
| Megan Blacher | Executive Director | Facility representative who assisted during the inspection |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 66
Deficiencies: 1
May 8, 2024
Visit Reason
The visit was an unannounced case management inspection conducted due to an incident report received on April 24, 2024, regarding a medication error that occurred on April 22, 2024.
Findings
The inspection found that resident 1 (R1) received a medication error involving a double dose of prescribed medication, posing a potential health and safety risk. Citations were issued per Title 22 Division 6 of the California Code of Regulations.
Complaint Details
The visit was triggered by a complaint/incident report regarding a medication error involving resident 1 (R1). The error was substantiated by interviews and document review. Resident 1 was placed on a 48-hour observation and assessed by a physician. No health and safety concerns were expressed by the resident during the interview.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident 1 (R1) had a medication error due to being given double the dose of the prescribed medication, posing a potential health and safety risk. | Type B |
Report Facts
Plan of Correction Due Date: May 17, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the unannounced case management visit and evaluation |
| Megan Blacher | Executive Director | Met with the Licensing Program Analyst during the visit and participated in the exit interview |
| Sheila Santos | Licensing Program Manager / Supervisor | Named as Licensing Program Manager and Supervisor in the report |
| Zehra Syed | Administrator/Director | Facility Administrator/Director |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 66
Deficiencies: 0
May 8, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2024-05-03 regarding staff safeguarding resident personal items, facility odor, staff conduct, provision of daily activities, and pest control.
Findings
The investigation found no corroboration for most allegations based on resident and staff interviews, observations, and documentation review. However, some residents reported occasional sightings of cockroaches, though pest control measures were in place. Overall, there was insufficient evidence to substantiate the allegations, and the complaint was deemed unsubstantiated.
Complaint Details
The complaint included allegations that staff did not safeguard residents' personal items, failed to keep the facility free from marijuana odor, posed risks to residents, did not provide daily activities, and did not keep the facility free from pests. The investigation found these allegations unsubstantiated due to lack of corroborating evidence.
Report Facts
Resident interviews conducted: 5
Staff interviews conducted: 2
Facility capacity: 66
Facility census: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Megan Blacher | Executive Director | Facility representative met during investigation and exit interview |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 66
Deficiencies: 2
Mar 20, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that the facility did not provide medications to residents as prescribed and failed to follow reporting requirements of missed medications to the department.
Findings
The investigation substantiated that the facility missed medications for 9 residents on 12/16/2023 and delayed reporting the incidents to the department until 12/29/2023. Interviews with residents and staff confirmed the missed medications and failure to report in a timely manner, posing immediate and potential health and safety risks.
Complaint Details
The complaint was substantiated based on interviews, document reviews, and observations. The facility missed medications for 9 residents and failed to report the incidents within the required timeframe due to management and staffing changes.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility did not give medications to 9 residents according to physician's directions, evidenced by medication logs and incident reports. | Type A |
| Facility failed to report incidents of missed medications to the licensing department within seven days as required. | Type B |
Report Facts
Residents with missed medications: 9
Days delayed in reporting: 13
Facility capacity: 66
Facility census: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Alexis Islas | Business Office Manager | Met with during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 66
Deficiencies: 1
Feb 6, 2023
Visit Reason
Unannounced visit to investigate a complaint received on 10/26/2022 alleging that a resident sustained a fracture while in care.
Findings
The complaint was substantiated based on observations, interviews, and record reviews. It was found that a night shift caregiver was not paying attention and moved the resident's legs incorrectly, causing injury, and failed to report the incident to a supervisor. Deficiencies were issued per Title 22, California Code of Regulations.
Complaint Details
Complaint alleging that a resident sustained a fracture while in care was substantiated. The investigation found that the night shift caregiver moved the resident's legs incorrectly and failed to report the injury.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not comply with CCR 87464(f)(1) Basic Services requiring care and supervision; resident sustained a fracture while in care and staff failed to report it. | Type A |
Report Facts
Capacity: 66
Census: 56
Deficiencies cited: 1
Plan of Correction due date: Feb 20, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sarah John | Facility Administrator / Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Luz Adams | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 66
Deficiencies: 0
Oct 28, 2022
Visit Reason
An unannounced visit was conducted to perform a case management and health and safety check in conjunction with complaint number 22-AS-20221026170408.
Findings
The facility was found to be in good repair with no immediate threats to resident health and safety. Fire and safety equipment were operational and recent fire inspections were passed. No citations were issued during this visit.
Complaint Details
Visit was conducted in response to complaint 22-AS-20221026170408. No immediate threats or citations were found.
Report Facts
Residents on hospice: 8
Water temperature: 109.3
Fire alarm inspection date: Oct 22, 2022
Fire sprinkler inspection date: Oct 24, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah John | Executive Director | Met with Licensing Program Analyst during the inspection and participated in exit interview |
| Celine De Perio | Licensing Program Analyst | Conducted the unannounced inspection visit and authored the report |
Inspection Report
Annual Inspection
Census: 54
Capacity: 66
Deficiencies: 0
Aug 17, 2022
Visit Reason
The inspection was an unannounced Required 1 Year inspection conducted to evaluate the facility's compliance with regulatory standards.
Findings
The facility was found to be clean and sanitary with all required elements present. No deficiencies were cited during the inspection. COVID-19 precautions and emergency preparedness measures were observed and found adequate.
Report Facts
Residents receiving Hospice services: 11
Hot water temperature: 113.1
Fire drill date: Aug 2, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah John | Executive Director | Facility representative who greeted the Licensing Program Analyst and accompanied the tour |
| Shobhana Frank | Licensing Program Analyst | Conducted the inspection visit |
| Armando J Lucero | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 50
Capacity: 66
Deficiencies: 0
Oct 1, 2021
Visit Reason
The inspection was an unannounced Required 1 Year inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean and sanitary with all required elements present, including COVID-19 precautions, emergency supplies, and updated resident files. No deficiencies were cited during the inspection.
Report Facts
Residents receiving Hospice services: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zehra Syed | Executive Director | Met with Licensing Program Analyst during inspection and involved in facility tour |
| Shobhana Frank | Licensing Program Analyst | Conducted the unannounced Required 1 Year inspection |
| Marina Stanic | Licensing Program Manager | Named in report header |
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