Inspection Report Summary
Most inspections and complaint investigations at this facility found no deficiencies, including the most recent report dated August 11, 2025, which was clean. Several complaint investigations were unsubstantiated, covering issues like pest control, medication management, resident dignity, and communication. However, there were a few substantiated deficiencies over time, notably a serious incident in June 2022 involving lack of supervision that led to sexual assault and serious injury, resulting in immediate health and safety risk findings. Other deficiencies included a medication error in March 2022 and a personal rights issue related to bed rails in May 2025, both isolated and addressed. The overall trend shows improvement with no deficiencies cited in recent inspections and complaint visits.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
1.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
43% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 93
Capacity: 214
Deficiencies: 0
Date: Aug 11, 2025
Visit Reason
The visit was conducted in response to an LIC624 Incident Report regarding a resident being absent without official leave (AWOL). The licensee self-reported the incident to Community Care Licensing on 08/11/2025.
Complaint Details
The visit was complaint-related due to an incident report of a resident AWOL. The incident was self-reported by the licensee. No substantiation status is stated.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst performed a facility tour, welfare check, collected records, and spoke briefly with the Executive Director. The incident may require further follow-up visits and could warrant a deficiency.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Bonn | Executive Director | Met with during the visit and involved in discussion of the incident and exit interview. |
| Marisela Garcia-Centeno | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
| Sabel Martinez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 214
Deficiencies: 0
Date: Jul 22, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that the licensee was not adequately addressing a communicable disease outbreak and that staff were not seeking medical attention for residents as necessary.
Complaint Details
The complaint alleged inadequate management of a communicable disease outbreak (specifically scabies) and failure of staff to seek medical attention for residents. The investigation included facility tour, record reviews, and interviews with residents, staff, and outside sources. The allegations were found unsubstantiated.
Findings
The investigation found no evidence to support the allegations. Resident records did not indicate any diagnosis of scabies, and staff interviews did not confirm concerns of communicable disease symptoms. Records showed appropriate communication with outside providers and adherence to treatment plans. The complaint was deemed unsubstantiated.
Report Facts
Capacity: 214
Census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Boyles | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Kim Bonn | Executive Director | Met with investigator during the visit and participated in exit interview |
| Wesley Lavender | Administrator | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Capacity: 214
Deficiencies: 0
Date: May 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-03-15 regarding staff not ensuring the facility was free from pests.
Complaint Details
The complaint alleged that staff did not ensure the facility was free from pests. The allegation was found unsubstantiated after investigation including staff and resident interviews and facility tour.
Findings
The investigation found the allegation unsubstantiated as evidence did not meet the preponderance of the evidence standard. Observations included empty pest traps, clean resident rooms, and pest control measures in place.
Report Facts
Facility capacity: 214
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Donelle Williams | Administrator | Facility Administrator involved in the investigation |
| James Ringhoff | Executive Director | Facility Executive Director involved in the investigation |
| Kristina Ryan | Licensing Program Analyst | Conducted initial virtual tour and investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 214
Deficiencies: 1
Date: May 19, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that the licensee did not allow a resident to keep their bed rails on their bed.
Complaint Details
The complaint alleged that the licensee did not allow Resident #1 to keep their bed rails on their bed. The allegation was substantiated based on interviews, observations, and records review.
Findings
The investigation substantiated that the licensee did not allow Resident #1 to keep their half-length bed rails on their hospital bed, which were the resident's personal property. This action conflicted with facility policy but was not required by regulation. The licensee failed to reasonably accommodate the resident's preference, posing a potential personal rights risk.
Deficiencies (1)
Failure to reasonably accommodate the individual need/preference of one resident regarding the use of half-length bed rails, posing a potential personal rights risk.
Report Facts
Residents present: 93
Total licensed capacity: 214
Deficiencies cited: 1
Plan of Correction due date: May 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberly Bonn | Executive Director | Interviewed during investigation and exit interview |
| Katie Ferguson | Health Services Director | Interviewed during investigation and exit interview |
| Wesley Lavender | Administrator | Facility administrator named in report header |
Inspection Report
Annual Inspection
Census: 95
Capacity: 214
Deficiencies: 0
Date: Apr 1, 2025
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements for Laguna Estates Senior Living Facility.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies observed or cited. All safety equipment and required postings were in place, and staff and resident interviews did not raise any licensing concerns.
Report Facts
Residents present: 95
Total licensed capacity: 214
Hospice waiver residents: 25
Ambulatory residents: 23
Bedridden residents: 25
Pool fence height (feet): 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Boyles | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kim Bonn | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
Inspection Report
Annual Inspection
Census: 108
Capacity: 214
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing regulations and facility standards.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies observed or cited. All safety equipment and required postings were in place and functioning, and resident and staff records were complete and properly stored.
Report Facts
Residents present: 108
Total licensed capacity: 214
Hot water temperature: 111.9
Hot water temperature: 110.4
Hot water temperature: 114.1
Hot water temperature: 112.2
Perishable food supply: 2
Non-perishable food supply: 7
Pool fence height: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liliana Silveira | Licensing Program Analyst | Conducted the inspection and authored the report |
| Divinia Nunez | Interim Executive Director | Facility representative met during the inspection |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Wesley Lavender | Administrator/Director | Facility Administrator/Director |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 214
Deficiencies: 0
Date: Apr 23, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2020-12-30 regarding communication failures, unmet hygiene needs, property safeguarding issues, and medication mismanagement at the facility.
Complaint Details
The complaint investigation was unsubstantiated, meaning the preponderance of evidence did not support the allegations of failure to communicate health changes, unmet hygiene needs, failure to safeguard property, or medication mismanagement.
Findings
The investigation found no evidence to substantiate the allegations. Facility policies and interviews indicated proper communication with authorized representatives, adequate hygiene care despite occasional delays during the COVID-19 pandemic, no mishandling of resident property, and appropriate medication management practices.
Report Facts
Capacity: 214
Census: 108
Mental status exam score: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ramon Serrano | Licensing Program Analyst | Conducted the complaint investigation visit |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation |
| Divinia Nunez | Regional Director of Operations | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Charlie Bloom | Administrator | Facility administrator named in the report |
| Staff 1 | Interviewed regarding medication reconciliation procedures | |
| Health Services Director | Health Services Director | Interviewed regarding communication protocols with resident's responsible party |
Inspection Report
Census: 112
Capacity: 214
Deficiencies: 0
Date: Mar 22, 2024
Visit Reason
The visit was an unannounced Case Management - Incident inspection conducted in response to an LIC624A Report self-submitted by the licensee to the CCLD San Diego Regional Office.
Findings
During the visit, a facility tour and welfare check were performed, records were collected, and discussions were held with facility staff. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jonathan Thomas | Executive Director | Met with during the visit and involved in discussions regarding the inspection. |
| Mirayda Fleming | Resident Care Coordinator | Participated in discussions during the visit. |
| Liliana Silveira | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
| Jennifer Lott | Licensing Program Manager | Named in the report header. |
Inspection Report
Census: 112
Capacity: 214
Deficiencies: 0
Date: Mar 22, 2024
Visit Reason
The visit was an unannounced Case Management - Incident inspection conducted in response to an LIC624 Unusual Incident Report self-submitted by the licensee regarding a medication management issue with a resident.
Findings
During the visit, records were requested and a brief discussion about the incident took place. No deficiencies were cited during this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jonathan Thomas | Executive Director | Spoke with Licensing Program Analyst about the incident and participated in the exit interview. |
| Liliana Silveira | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 214
Deficiencies: 0
Date: Nov 7, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the licensee did not safeguard resident belongings.
Complaint Details
The complaint alleged that the licensee did not safeguard resident belongings. The investigation found no substantiation of staff theft or misplacement. The resident had not entrusted items to the facility for safekeeping, and management was unaware of the missing items. The allegation was deemed unsubstantiated.
Findings
The investigation included interviews, records review, and a facility tour. The allegation was found unsubstantiated as there was no evidence of staff stealing or misplacing resident belongings, and the resident did not disclose missing items to management.
Report Facts
Capacity: 214
Census: 106
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Mirayda Fleming | Resident Care Coordinator | Met with the Licensing Program Analyst during the investigation and participated in the exit interview |
| Wesley Lavender | Administrator | Facility administrator named in the report |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 214
Deficiencies: 0
Date: Sep 14, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff did not administer medications as prescribed and did not treat residents with dignity.
Complaint Details
The complaint alleged that staff failed to administer medications as prescribed and did not treat residents with dignity. After investigation, including interviews with staff, residents, and review of medication records, the allegations were found unsubstantiated.
Findings
The investigation included interviews, records review, and observations. It was found that medication administration was consistent with prescribed orders and staff treated residents respectfully. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 214
Census: 110
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the complaint investigation |
| Wesley Lavender | Executive Director | Facility Executive Director present during investigation |
| Sue Alvarez | Assistant Health Services Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 214
Deficiencies: 1
Date: Sep 8, 2023
Visit Reason
An unannounced case management visit was conducted to follow up on a Death Report related to a resident's fall and subsequent death.
Complaint Details
The visit was triggered by a complaint related to a Death Report (LIC624A) following a resident's fall and injury. The complaint was substantiated by the finding that the facility failed to submit the required incident report.
Findings
The facility did not submit an Incident Report for the resident's fall on 08/23/2023, which poses a potential safety risk to all residents. No immediate health or safety concerns were observed during the visit.
Deficiencies (1)
Failure to submit an incident report to the Department regarding Resident 1's fall on 08/23/2023.
Report Facts
Residents in care: 109
Total licensed capacity: 214
Deficiency count: 1
Plan of Correction due date: Sep 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wesley Lavender | Executive Director | Interviewed during the visit and named in relation to the deficiency. |
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report. |
| Lizzette Tellez | Licensing Program Manager | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 214
Deficiencies: 1
Date: Sep 7, 2023
Visit Reason
The visit was conducted in response to an LIC624 Incident Report self-submitted by the licensee regarding a medication incident involving Resident #1.
Complaint Details
The visit was complaint-related, triggered by a medication incident report (LIC624) involving Resident #1. No deficiency was substantiated for the incident.
Findings
No deficiency was cited for the medication incident or observed during the site visit. One Technical Violation was issued related to reporting requirements, and Technical Assistance was provided regarding medication cart procedures.
Deficiencies (1)
Technical Violation regarding reporting requirements
Report Facts
Census: 109
Total Capacity: 214
Technical Violations Issued: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management – Incident visit |
| Sulema Alvarez | Assistant Health Services Director | Met with Licensing Program Analyst during the visit and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 214
Deficiencies: 0
Date: Feb 28, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility did not provide hot water.
Complaint Details
The complaint alleged that the facility did not provide hot water. The investigation was unsubstantiated, meaning there was insufficient evidence to prove the violation occurred.
Findings
The investigation found that on 01/25/2023, hot water was not working in building B due to a broken water pump which was replaced on 01/27/2023. Interim showers were provided to residents during the outage. The allegation was determined to be unsubstantiated due to lack of corroborating evidence.
Report Facts
Capacity: 214
Census: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wesley Lavender | Executive Director | Met with Licensing Program Analyst during complaint investigation and named in findings |
| Liliana Silveira | Licensing Program Analyst | Conducted complaint investigation visit and authored report |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 214
Deficiencies: 0
Date: Dec 21, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that the licensee did not keep the facility free from rodents and did not maintain the facility in good repair.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to keep the facility free from rodents and failure to maintain the facility in good repair. Evidence showed pest control measures were taken and the memory care keypad issue was being managed.
Findings
The investigation found that a rodent issue was addressed by the facility with professional pest control services and that the memory care keypad was not working but was being actively monitored and repaired. The allegations were found to be unsubstantiated based on observations, records review, and interviews.
Report Facts
Capacity: 214
Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wesley Lavender | Executive Director | Met with Licensing Program Analyst during complaint investigation and discussed complaint elements |
| Ramon Serrano | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 101
Capacity: 214
Deficiencies: 0
Date: Jun 29, 2022
Visit Reason
An unannounced Case Management Visit was conducted to deliver additional documents and discuss the purpose of the visit with the Executive Director.
Findings
No deficiencies were cited or observed during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wesley Lavender | Executive Director | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
| Ramon Serrano | Licensing Program Analyst | Conducted the unannounced Case Management Visit. |
| Denise Powell | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 214
Deficiencies: 2
Date: Jun 28, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of neglect/lack of supervision resulting in serious bodily injury and sexual abuse of a resident by an unknown perpetrator.
Complaint Details
The complaint investigation was substantiated. Allegations included neglect/lack of supervision resulting in serious bodily injury and sexual abuse of a resident by an unknown perpetrator. Evidence showed the resident was sexually assaulted and suffered a fall causing a subdural hematoma. The facility failed to implement adequate supervision and safety measures.
Findings
The investigation substantiated the allegations that lack of supervision and safety protocols resulted in the attempted rape of a resident (R1) and that the resident suffered a fall resulting in serious bodily injury. The facility failed to update the resident's appraisal to note significant changes and did not provide safe, healthful, and comfortable accommodations, posing immediate health and safety risks.
Deficiencies (2)
The pre-admission appraisal was not updated to note significant changes and keep the appraisal accurate for 1 of 100 persons in care (R1), posing an immediate health and safety risk.
The facility did not accord safe, healthful, and comfortable accommodations for 1 of 100 persons in care (R1), posing an immediate health and safety risk.
Report Facts
Capacity: 214
Census: 100
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ramon Serrano | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Denise Powell | Licensing Program Manager | Named in report as Licensing Program Manager |
| Wesley Lavender | Facility representative met during investigation and exit interview | |
| Charlie Bloom | Administrator | Facility Administrator named in report |
Inspection Report
Census: 97
Capacity: 214
Deficiencies: 0
Date: May 24, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on two self-reported incidents involving residents leaving the facility grounds and swallowing difficulties.
Findings
No immediate health and safety concerns were noted during the facility tour and health and safety check, and no deficiencies were cited at this time.
Report Facts
Capacity: 214
Census: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Divinia Nunez | Executive Director | Interviewed during the visit and exit interview conducted |
| Stefanie Ancheta | Health Services Director | Interviewed during the visit |
| Liliana Silveira | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Annual Inspection
Census: 91
Capacity: 214
Deficiencies: 0
Date: Apr 14, 2022
Visit Reason
An unannounced annual required inspection was conducted to verify compliance with statutes, regulations, and other requirements relevant to protecting the health of residents and staff, including infection control practices.
Findings
The facility was found to be in compliance with infection control practices as outlined in its COVID-19 Mitigation Plan Report (LIC808). No deficiencies were observed during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donelle Williams | Executive Director | Met with Licensing Program Analyst during the inspection and involved in review of infection control practices. |
| Esther Miller | Licensing Program Analyst | Conducted the unannounced annual required inspection. |
| Denise Powell | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Capacity: 214
Deficiencies: 0
Date: Mar 22, 2022
Visit Reason
The visit was a Case Management inspection to review the newly constructed memory care building approved for bedridden and non-ambulatory residents and to assess submitted documentation for approval of eight bedridden rooms and other rooms for non-ambulatory use.
Findings
All required documentation was submitted and reviewed, the Carlsbad Fire Department conducted a Fire Clearance inspection, and no issues or deficiencies were observed during the inspection. The portion of the application process is complete and will be forwarded for final management review and approval.
Report Facts
Capacity: 214
Census: 0
Number of bedridden rooms requested: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donelle Williams | Executive Director | Met during the inspection and participated in the exit interview |
| Ramon Serrano | Licensing Program Analyst | Conducted the Case Management visit |
| Denise Powell | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 214
Deficiencies: 1
Date: Mar 9, 2022
Visit Reason
An unannounced complaint investigation was conducted following an allegation that staff administered incorrect medication to a resident.
Complaint Details
The complaint was substantiated. Staff administered incorrect medication to a resident, leading to the resident being found on the floor and transported to the hospital. The LVN self-reported the incident and was terminated after investigation.
Findings
The investigation substantiated that a Licensed Vocational Nurse administered incorrect medication to one resident, which posed a potential health and safety risk. The resident was found on the floor and transported to the hospital for evaluation. The LVN was removed from medication duties and subsequently terminated after an internal investigation.
Deficiencies (1)
Facility personnel did not ensure Resident #1 received the correct medication, posing a potential health and safety risk.
Report Facts
Census: 81
Total Capacity: 214
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donelle Williams | Administrator | Met with Licensing Program Analyst during investigation and involved in exit interview |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| John Rante | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 214
Deficiencies: 0
Date: Oct 13, 2021
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that the facility did not have hot water.
Complaint Details
The complaint was unsubstantiated because the preponderance of the evidence standard was not met and the facility addressed the maintenance issue promptly.
Findings
The investigation found that there was no hot water in Building B from December 15 through 18, 2020, but the issue was immediately repaired and no further problems were reported. There were no health or safety concerns related to the outage, and the complaint was unsubstantiated.
Report Facts
Capacity: 214
Census: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alexandre Vo | Licensing Program Analyst | Conducted the complaint investigation |
| Donelle Williams | Executive Director | Met with Licensing Program Analyst during investigation |
| Stephanie Ancheta | Resident Services Director | Met with Licensing Program Analyst during investigation |
| James Ringhoff | Interim Administrator | Notified Licensing Program Analyst of maintenance issues during the outage |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 214
Deficiencies: 0
Date: Jul 7, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 12/20/2019 alleging that facility staff failed to seek medical care for a resident, failed to treat residents with dignity, failed to provide incontinence care, and that the licensee failed to meet residents' needs.
Complaint Details
The complaint alleged failure to seek medical care, failure to treat residents with dignity, failure to provide incontinence care, and failure to meet residents' needs. The investigation found no evidence supporting these allegations, and they were determined to be unsubstantiated.
Findings
The investigation included interviews with staff, the Administrator, outside sources, and a review of facility and outside records. The allegations were found to be unsubstantiated as there was no preponderance of evidence to prove that the alleged deficiencies occurred.
Report Facts
Facility capacity: 214
Census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Hamer | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Donelle Williams | Administrator | Met with Licensing Program Analyst during the investigation and received findings |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 214
Deficiencies: 0
Date: Mar 15, 2021
Visit Reason
The inspection was an unannounced case management virtual visit triggered by a self-reported incident where a resident left the facility without authorization and was returned by law enforcement.
Complaint Details
The visit was complaint-related due to a self-reported incident involving Resident 1 leaving the facility without authorization (AWOL) on March 11, 2021, and being returned by law enforcement. No deficiencies were found.
Findings
The Licensing Program Analyst conducted a health and safety check and reviewed facility records and staff interviews. No deficiencies were cited during this visit.
Report Facts
Capacity: 214
Census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donelle Williams | Administrator | Met with Licensing Program Analyst during the visit and involved in exit interview |
| James Ringhoff | Assistant Administrator | Met with Licensing Program Analyst during the visit and involved in exit interview |
| Kristina Ryan | Licensing Program Analyst | Conducted the unannounced case management virtual visit |
| Simon Jacob | Licensing Program Manager | Named in the report as Licensing Program Manager |
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