Inspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on September 12, 2025, which was clean and found the facility well maintained. However, some complaint investigations substantiated issues, primarily related to resident safety and staffing. Notably, in September 2025, the facility was cited for failing to prevent falls, delaying medical care, and not reporting incidents timely, posing immediate health risks. Earlier investigations also found deficiencies in medication management, staff mistreatment, and delayed response to call buttons, with a civil penalty assessed in March 2024 for abuse and neglect. Several other complaint investigations were unsubstantiated, and recent reports show some improvement with no deficiencies cited in the latest inspections.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Capacity: 125
Deficiencies: 0
Sep 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that facility staff failed to keep a resident hydrated, resulting in acute kidney injury.
Findings
Based on interviews, observations, and records review, the department determined that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegation was unsubstantiated.
Complaint Details
The complaint alleged that facility staff failed to keep a resident hydrated resulting in acute kidney injury. Staff interviews and records indicated the resident was regularly offered and consumed fluids, and the nurse practitioner noted no signs of dehydration. The allegation was found unsubstantiated.
Report Facts
Facility capacity: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johnathan Thomas | Executive Director | Met with during investigation and interview regarding complaint findings |
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation and telephone interview |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 125
Deficiencies: 4
Sep 25, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the facility neglected a resident resulting in fractures, failed to provide timely medical assistance after a fall, did not notify the resident’s family of condition changes, and failed to report the incident as required.
Findings
The investigation substantiated the allegations, finding that the facility failed to implement fall prevention measures, delayed medical care and notification to the resident’s responsible party, and did not report a serious incident timely. Multiple unexplained injuries occurred, and staff did not update the resident’s care plan after falls, posing immediate health and safety risks.
Complaint Details
The complaint was substantiated. Allegations included neglect causing fractures, failure to provide timely medical assistance, failure to notify family of condition changes, and failure to report incidents. Evidence from interviews, records, and outside sources confirmed these issues.
Severity Breakdown
Type A: 2
Type B: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Licensee did not put measures in place to protect one resident (R1) from falls, resulting in serious injuries. | Type A |
| Licensee failed to immediately telephone 9-1-1 for an injury posing an imminent threat to a resident. | Type A |
| Staff did not inform one resident’s doctor or responsible party when a change in condition was observed. | Type B |
| Licensee did not report a serious incident for one resident within 7 days as required. | Type B |
Report Facts
Residents in care: 100
Licensed capacity: 125
Deficiency count: 4
Plan of Correction due dates: Oct 23, 2025
Plan of Correction due dates: Sep 26, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hannah Rodgers | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Gregory Case | Executive Director | Facility administrator interviewed regarding findings and care plan issues |
| Johnathan Thomas | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 125
Deficiencies: 0
Sep 12, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not handle residents with dignity and yelled at residents.
Findings
The investigation found no preponderance of evidence to substantiate the allegations that staff handled residents roughly or yelled at them. The allegations were determined to be unsubstantiated after review of records and interviews.
Complaint Details
The complaint alleged that Staff #1 abruptly pushed Resident #1 in their wheelchair and yelled at them, and that Resident #1 had been roughly handled by an unknown staff member previously. The investigation included an unannounced visit, records review, and interviews. Resident #1 had dementia and behavioral disturbances, limiting their reliability as a historian. No evidence was found to support the allegations.
Report Facts
Capacity: 125
Census: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hannah Rodgers | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Johnathan Thomas | Executive Director | Met with the Licensing Program Analyst during the investigation and exit interview |
| Matthew Ryan | Administrator | Named as facility administrator in the report |
Inspection Report
Annual Inspection
Census: 100
Capacity: 125
Deficiencies: 0
Sep 12, 2025
Visit Reason
An unannounced continuation required annual inspection was conducted to evaluate compliance with licensing requirements and facility conditions.
Findings
The inspection found the facility to be in full compliance with no deficiencies cited. The facility was well maintained with all safety equipment in working order and proper storage of medications and food.
Report Facts
Residents present: 100
Total capacity: 125
Hospice waiver beds: 15
Bedridden residents allowed: 15
Perishable food supply: 2
Non-perishable food supply: 7
Fire extinguisher service interval: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johnathan Thomas | Executive Director | Met with during inspection and named in report narrative |
| Hannah Rodgers | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Annual Inspection
Census: 103
Capacity: 125
Deficiencies: 0
Apr 11, 2025
Visit Reason
An unannounced required annual inspection was conducted to review facility records, tour the facility, and verify compliance with licensing requirements.
Findings
No deficiencies were cited during the inspection. Due to time constraints, the annual inspection could not be completed and a return visit is needed.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Reika Marron | Business Office Director | Met with during inspection and exit interview. |
| Daisy Rodriguez | Memory Care Director | Met with during inspection. |
| Hannah Rodgers | Licensing Program Analyst | Conducted the inspection. |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 125
Deficiencies: 0
Jan 2, 2025
Visit Reason
The visit was conducted in response to a self-reported incident regarding a medication error for Resident #1 that occurred on 2024-12-12.
Findings
During the unannounced case management visit, a brief facility tour was conducted, records were reviewed, and staff interviewed. No deficiencies were cited during the visit.
Complaint Details
The visit was complaint-related due to a medication error incident reported by the facility. No deficiencies were cited, indicating no substantiated violations during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johnathan Thomas | Executive Director | Met with during the visit and involved in the exit interview. |
| Hannah Rodgers | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Capacity: 125
Deficiencies: 0
Nov 27, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-06-25 regarding resident hygiene, facility odor, assistance to dining hall, staff training, and staff handling of residents.
Findings
The investigation found all allegations unsubstantiated based on staff and resident interviews, observations, and records review. Staff were found to provide adequate hygiene assistance, maintain cleanliness, assist residents to the dining hall, be properly trained, and handle residents gently.
Complaint Details
The complaint included allegations that staff did not ensure residents' hygiene needs were met, the facility was malodorous, staff did not assist residents to the dining hall, untrained staff provided care and supervision, and staff handled residents roughly. All allegations were found unsubstantiated after investigation.
Report Facts
Capacity: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Fulton | Licensing Program Analyst | Conducted the complaint investigation |
| Jennifer Lott | Licensing Program Manager | Conducted the complaint investigation |
| Sonia Molina | Resident Services Director | Met with investigators and participated in interviews |
| Gregory Case | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Capacity: 125
Deficiencies: 1
Nov 22, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not respond to a resident's call button in a timely manner.
Findings
The investigation found that staff response times to call buttons exceeded 20 minutes on 76 occasions between 01/22/2024 and 02/05/2024, with some waits up to 30 minutes. The allegation was substantiated based on interviews, observations, and record reviews.
Complaint Details
The complaint alleged that staff did not respond to resident's call button in a timely manner. The allegation was substantiated based on a preponderance of evidence including interviews and record reviews.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personnel requirements not met as facility personnel were insufficient in numbers and competence to meet resident needs, evidenced by delayed call button response times. | Type B |
Report Facts
Call button response delays: 76
Resident count at risk: 96
Facility capacity: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Fulton | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jennifer Lott | Licensing Program Manager | Oversaw the complaint investigation and signed the report |
| Johnathan Thomas | Executive Director | Facility representative who participated in the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 125
Deficiencies: 0
Aug 21, 2024
Visit Reason
An unannounced complaint investigation was conducted following an allegation received on 07/09/2024 that staff did not provide adequate food service for residents.
Findings
The investigation found that staff provided adequate food service during the complaint timeframe. Observations, interviews, and records review confirmed food quality was good, staff were adequately trained, and food safety procedures were followed. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleging inadequate food service was investigated and found unsubstantiated. Resident interviews and staff records did not corroborate the allegation.
Report Facts
Capacity: 125
Census: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Case | Executive Director | Met with during investigation and named in report |
| Ryan Fulton | Licensing Program Analyst | Conducted the complaint investigation |
| Jennifer Lott | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 125
Deficiencies: 1
May 23, 2024
Visit Reason
The visit was conducted in response to a licensee self-reported medication error involving nine residents who missed their medications due to staff inability to meet the two-hour medication assistance timeframe.
Findings
The investigation found no safety concerns during the welfare check. The medication error was attributed to staff shortage. No residents experienced adverse effects. The facility implemented a plan to hire additional Med Tech staff and conducted in-service training on medication management.
Complaint Details
The visit was complaint-related due to a licensee self-reported medication error. The incident was substantiated with one deficiency cited.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee did not ensure that 9 of 24 residents were assisted as needed with self-administration of prescription medications on 05/10/24, posing a potential health risk. | Type B |
Report Facts
Residents missed medications: 9
Deficiencies cited: 1
Residents affected: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Case | Executive Director | Interviewed regarding the medication error incident and involved in plan of correction |
| Joanne Gomez | Regional Clinical Specialist | Interviewed regarding the medication error incident |
| Liliana Silveira | Licensing Program Analyst | Conducted the inspection visit |
| Jennifer Lott | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 125
Deficiencies: 0
Mar 27, 2024
Visit Reason
The visit was conducted in response to an LIC624 Incident Report submitted by the Licensee regarding a medication incident involving Resident #1.
Findings
During the visit, the Licensing Program Analyst performed a facility tour and welfare check on the resident involved, interviewed relevant parties, and reviewed medical records. No deficiencies were observed or cited during the visit.
Complaint Details
The visit was complaint-related, triggered by a medication incident reported in an LIC624 Incident Report received on 02/09/2024. The resident was found alert, safe, and feeling well. No deficiencies were cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Case | Executive Director | Met with during the visit and involved in the exit interview. |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management – Incident visit. |
| Lizzette Tellez | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 125
Deficiencies: 2
Mar 27, 2024
Visit Reason
The visit was an unannounced Case Management - Incident inspection conducted in response to two LIC624 Incident Reports submitted by the Licensee regarding allegations of staff mistreatment of residents.
Findings
The investigation found that Staff #1 mistreated three residents by handling one roughly during personal care, giving another a cold shower, and neglecting a third resident. The staff member was suspended and subsequently terminated. Two deficiencies were cited, including a repeat violation, and a civil penalty was assessed.
Complaint Details
The visit was complaint-related based on allegations of mistreatment by Staff #1 involving Residents #1, #2, and #3. The allegations were substantiated by staff interviews and records. Staff #1 was suspended and later terminated for patient abuse/neglect. Licensee failed to report one incident involving Resident #3 as required.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee’s staff (S1) did not ensure that 3 of 87 residents (R1, R2, and R3) were free from neglect, punishment, and/or mental/physical abuse, posing an immediate health and personal rights risk. | Type A |
| Licensee did not submit a written report to the licensing agency and responsible persons within seven days for an incident threatening the welfare, safety, or health of Resident #3. | Type B |
Report Facts
Deficiencies cited: 2
Civil penalty amount: 250
Residents involved: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Case | Executive Director | Met with Licensing Program Analyst during the visit and participated in exit interview. |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit and investigation. |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Annual Inspection
Census: 86
Capacity: 125
Deficiencies: 0
Mar 19, 2024
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing regulations for the facility.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies cited. All required safety equipment, furnishings, and documentation were present and in order.
Report Facts
Licensed capacity: 125
Current census: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Case | Executive Director | Met with Licensing Program Analysts during inspection and participated in exit interview |
| Nacole Patterson | Licensing Program Analyst | Conducted the inspection |
| Ryan Fulton | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 125
Deficiencies: 3
Jan 24, 2024
Visit Reason
The visit was conducted in response to an incident report regarding Resident #1 eloping from the facility without staff supervision on 2024-01-13.
Findings
The investigation found that staff allowed Resident #1 to leave unescorted due to lack of training and understanding of the resident's cognitive limitations. The facility failed to notify the responsible person and licensing agency within the required timeframe and did not have a written Absentee Notification Plan as required by regulations.
Complaint Details
The visit was complaint-related due to an incident where Resident #1 eloped from the facility unsupervised. The complaint was substantiated by findings of staff error, delayed notification to responsible parties, and missing required policies.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility personnel (S1) was not competent to provide the services necessary to meet the safety needs of Resident #1, posing a potential safety risk. | Type B |
| Licensee did not develop a written Absentee Notification Plan for missing residents, posing a potential safety risk to all 96 residents. | Type B |
| Licensee failed to submit a written incident report to the licensing agency and the resident's responsible person within seven days of the incident. | Type B |
Report Facts
Residents present during inspection: 96
Total licensed capacity: 125
Deficiencies cited: 3
Plan of Correction due date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Becca Black | Interim Executive Director | Met during inspection and participated in exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted inspection and authored report |
| Juliana Barfield | Licensing Program Analyst | Conducted inspection |
| Daryl Ann C Robinson | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 125
Deficiencies: 0
Jun 27, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation received on 2023-05-15 that the Licensee did not follow Covid-19 protocols.
Findings
The investigation included facility tours, record reviews, staff and resident interviews, and direct observations. No evidence was found to substantiate the allegation; staff and residents confirmed adherence to Covid-19 protocols, and records showed proper infection control measures and communication with public health authorities.
Complaint Details
The complaint alleged that the Licensee did not follow Covid-19 protocols. The investigation found the allegation to be unsubstantiated based on interviews, observations, and records review.
Report Facts
Capacity: 125
Census: 92
Estimated Days of Completion: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Launa Moore | Executive Director | Facility representative interviewed during the investigation |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 125
Deficiencies: 0
Jun 27, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that the facility did not include its license number in a local newspaper advertisement during January 2023.
Findings
The investigation found that all online and print advertisements during January 2023 included the facility's license number. The allegation was determined to be unfounded and dismissed.
Complaint Details
The complaint alleged that the license number was not included in an advertisement as required. The allegation was found to be unfounded based on review of outside source records showing all advertisements included the license number.
Report Facts
Capacity: 125
Census: 92
Number of online advertisements reviewed: 6
Number of print advertisements reviewed: 8
Estimated Days of Completion: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Launa Moore | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 125
Deficiencies: 0
Nov 18, 2022
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding an allegation that the licensee was not providing hygiene supplies to residents in care.
Findings
The investigation found that a resident with dementia used excessive toilet paper to wipe surfaces, which led to a shortage of toilet paper in a shared bathroom. However, there was no evidence that the facility failed to provide toilet paper to meet resident care needs. The allegation was unsubstantiated due to lack of corroborating evidence.
Complaint Details
The complaint alleged that the licensee was not providing hygiene supplies, specifically that staff were not stocking a bathroom with toilet paper, causing residents to use a towel instead. The allegation was unsubstantiated after investigation.
Report Facts
Capacity: 125
Census: 81
Estimated Days of Completion: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Segura | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Launa Moore | Senior Executive Director | Facility representative met during investigation and exit interview |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 62
Capacity: 125
Deficiencies: 0
Apr 15, 2022
Visit Reason
An unannounced Required 1-Year Visit was conducted to evaluate the facility's compliance with licensing requirements, including infection control measures.
Findings
No deficiencies were cited or observed during the inspection. The Licensing Program Analyst provided technical assistance and evaluated the facility's infection control mitigation plan.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Launa Moore | Executive Director | Met with Licensing Program Analyst during the inspection and participated in the exit interview. |
| Ramon Serrano | Licensing Program Analyst | Conducted the unannounced Required 1-Year Visit and evaluation. |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Original Licensing
Capacity: 125
Deficiencies: 0
Mar 30, 2021
Visit Reason
The inspection was a pre-licensing visit conducted virtually via FaceTime to ensure the facility complies with California Code of Regulations, Title 22, Division 6, prior to licensing.
Findings
The facility was found to be clean, in good repair, with no pathway obstructions. Resident bedrooms, bathrooms, kitchen, and common areas were inspected and found compliant. All required postings were present, and no firearms or ammunition were on the premises.
Report Facts
Licensed capacity: 125
Bedridden residents allowed: 15
Census: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Launa Cornell | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Eva Torres | Licensing Program Analyst | Conducted the virtual pre-licensing inspection |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Original Licensing
Capacity: 125
Deficiencies: 0
Feb 10, 2021
Visit Reason
Initial licensing evaluation for a new Residential Care Facility for the Elderly with dementia care and delayed egress, with new construction expected to be completed by March 2021.
Findings
The applicant and administrator participated in a Component II call with the licensing analyst, confirming understanding of Title 22 requirements including facility operation, staff qualifications, program policies, and application document review. The Component II was successfully completed with no deficiencies noted.
Report Facts
Capacity: 125
Census: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Launa Cornell | Administrator | Facility administrator who participated in the Component II call and licensing evaluation |
| Jude De La Concepcion | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Bethany Hunter | Licensing Program Analyst | Conducted Component II call and signed the report |
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