Most inspections in recent years found no deficiencies, with the latest report from December 20, 2024, showing full compliance and a well-maintained, safe environment. Earlier complaint investigations were mostly unsubstantiated, including one in November 2023 regarding building entrance safety. However, a substantiated complaint in October 2021 found staff neglect that led to a resident’s fall and minor injury, along with a deficiency in staffing levels for dementia care. In September 2021, the facility was cited for employee theft and financial exploitation of residents dating back to 2018, with corrective actions taken. Since then, inspections have shown improvement, with no further serious issues or enforcement actions noted.
An unannounced continuation required annual inspection was conducted to evaluate compliance with licensing requirements and facility conditions.
Findings
The facility was found to be in compliance with all licensing requirements. No deficiencies were cited. The facility was clean, safe, and well-maintained with all required equipment and documentation in order.
An unannounced required annual inspection was conducted to review the facility's compliance with licensing requirements.
Findings
The Licensing Program Analyst toured the facility, reviewed records, and observed residents. No deficiencies were cited during this visit, but the inspection could not be completed due to time constraints and a return visit is needed.
Employees Mentioned
Name
Title
Context
Scottie Geno
Executive Director
Met with during the inspection and participated in the exit interview.
Hannah Rodgers
Licensing Program Analyst
Conducted the unannounced required annual inspection.
An unannounced required one-year inspection was conducted to evaluate compliance with licensing regulations for the facility.
Findings
The inspection found the facility to be in compliance with regulations including proper functioning of fire and emergency systems, sanitary conditions, adequate staffing, proper medication storage, and sufficient food supplies. No significant licensing concerns were identified during staff and client interviews.
An unannounced complaint investigation visit was conducted in response to an allegation received on 10/17/2023 that the licensee did not maintain building entrances in good repair.
Findings
The investigation found that one entrance outside a resident's patio was not an approved entrance/exit and had safety concerns, but the resident was instructed not to use it. Another pathway alleged to be a tripping hazard was found to be in good repair with no safety hazards. The allegation was unsubstantiated based on interviews, observations, and records review.
Complaint Details
The complaint alleged that the licensee did not maintain building entrances in good repair. The allegation was found to be unsubstantiated after investigation.
Report Facts
Capacity: 130Census: 112Complaint received date: Oct 17, 2023Investigation visit date: Nov 8, 2023
Employees Mentioned
Name
Title
Context
Nacole Patterson
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Santos Arroyo
Environmental Services Director
Met with the Licensing Program Analyst during the investigation and exit interview
The inspection was an unannounced Required 1-Year Visit to evaluate the facility's compliance with licensing requirements and infection control practices.
Findings
The facility was found to be in compliance with infection control practices, including COVID-19 mitigation measures, and no deficiencies were observed during the visit.
Employees Mentioned
Name
Title
Context
Laura West
Executive Director
Conducted the facility tour and participated in the exit interview.
Scottie Geno
Business Manager
Greeted the Licensing Program Analyst and discussed the purpose of the visit.
Sabel Martinez
Licensing Program Analyst
Conducted the unannounced Required 1-Year Visit and evaluation.
An unannounced complaint investigation visit was conducted to investigate allegations of staff neglect resulting in a minor injury from a fall and other related complaints regarding resident care.
Findings
The investigation substantiated that facility staff neglected to respond to a private caregiver's multiple requests for assistance, resulting in a resident's fall and minor injury. Other allegations including rough handling, leaving the resident soiled, failure to meet needs, and failure to safeguard belongings were found to be unsubstantiated.
Complaint Details
The complaint investigation was substantiated regarding staff neglect to respond to Resident 1's private caregiver's calls for assistance, resulting in a fall and minor injury. Other allegations such as rough handling, leaving the resident soiled, failure to meet needs, and failure to safeguard belongings were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Care of Persons with Dementia - There is an inadequate number of direct care staff to support resident's physical, social, emotional, safety and health care needs as identified in their current appraisal.
Type A
Report Facts
Census: 113Total Capacity: 130Residents affected: 1Deficiency Type: 1Plan of Correction Due Date: Oct 2, 2021
An unannounced Case Management Inspection was conducted to follow-up on previous incidents of theft and fraudulent financial activities involving residents, initially reported in 2018.
Findings
The investigation confirmed that an employee (S1) engaged in fraudulent and theft activities against the financial welfare of four residents during their employment from May to July 2018. A citation was issued and a Plan of Correction was developed with the Executive Director.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Engaged in conduct inimical to the financial welfare of residents, posing an immediate financial risk to four of the 97 residents at the facility.
Type B
Report Facts
Residents present during inspection: 112Total licensed capacity: 130Financial loss amount: 2300Financial loss amount: 1000Financial loss amount: 950Number of residents affected by financial misconduct: 4Plan of Correction due date: Oct 14, 2021
Employees Mentioned
Name
Title
Context
Laura West
Executive Director
Met with Licensing Program Analysts during inspection and involved in Plan of Correction development
Scottie Geno
Business Manager
Met with Licensing Program Analysts during inspection
Simon Jacob
Licensing Program Manager
Supervisor overseeing the inspection
Laarni Santiago
Licensing Program Analyst
Conducted the inspection and authored the report
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