Inspection Reports for
Landmark Villa

21000 Mission Blvd, Hayward, CA 94541, CA, 94541

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Deficiencies (last 6 years)

Deficiencies (over 6 years) 2.7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

33% better than California average
California average: 4 deficiencies/year

Deficiencies per year

8 6 4 2 0
2021
2022
2023
2024
2025
2026

Occupancy

Latest occupancy rate 53% occupied

Based on a March 2026 inspection.

Occupancy rate over time

40% 60% 80% 100% Sep 2021 Jun 2022 Jan 2025 Jan 2026 Mar 2026

Inspection Report

Complaint Investigation
Census: 74 Capacity: 140 Deficiencies: 0 Date: Mar 19, 2026

Visit Reason
The inspection visit was conducted unannounced in response to an Unusual Incident Report (UIR) submitted by the facility regarding a resident found on the floor with injuries.

Complaint Details
The visit was triggered by a complaint incident involving a resident who fell and sustained injuries. The resident was diagnosed with a fracture and later passed away. No deficiencies were substantiated.
Findings
The resident was found with confusion and bruises after a fall and was diagnosed with a transverse process fracture. The resident was placed on hospice care and passed away shortly after. No deficiencies were cited during the inspection.

Report Facts
Facility capacity: 140 Resident census: 74

Employees mentioned
NameTitleContext
Geraldine TayoInterim AdministratorMet with Licensing Program Analyst during inspection and provided information about the incident

Inspection Report

Census: 78 Capacity: 140 Deficiencies: 0 Date: Feb 10, 2026

Visit Reason
An unannounced Case Management Health and Safety check was conducted to evaluate the facility's compliance with health and safety standards.

Findings
The facility was found to be clean and safe with no imminent health or safety concerns. The kitchen and food supply were adequate, and staff and resident files were properly maintained with fingerprint clearances. No deficiencies were cited during the inspection.

Report Facts
Staff observed: 9 Resident files checked: 4 Staff files checked: 4 Fingerprint clearances: 4 Refrigerator temperature: 33 Walk-in freezer temperature: -10

Employees mentioned
NameTitleContext
Geraldine TayoAdministratorMet with Licensing Program Analyst during the inspection
Jill Clancy-CzulegerLicensing Program AnalystConducted the inspection
Harpreet HumpalLicensing Program ManagerNamed in the report header

Inspection Report

Complaint Investigation
Census: 78 Capacity: 140 Deficiencies: 2 Date: Feb 2, 2026

Visit Reason
The inspection visit was an unannounced case management visit conducted as part of a complaint investigation (#15-AS-20260130110921).

Complaint Details
The visit was complaint-related under investigation number #15-AS-20260130110921.
Findings
The facility was found to have deficiencies including an inadequate supply of hygiene supplies and missing former staff personnel files, both posing potential health and safety risks to persons in care.

Deficiencies (2)
Facility did not have an adequate supply of hygiene supplies such as soap and toilet paper.
Personnel records were not maintained properly; the former staff file was missing from the facility.
Report Facts
Capacity: 140 Census: 78 Deficiencies cited: 2 Plan of Correction Due Date: Feb 11, 2026

Employees mentioned
NameTitleContext
Geraldine TayoAdministratorMet with Licensing Program Analyst during the inspection and informed about missing staff file.
Carol FowlerLicensing Program AnalystConducted the complaint investigation and inspection.
Bennett FongLicensing Program ManagerNamed as Licensing Program Manager on the report.

Inspection Report

Capacity: 140 Deficiencies: 0 Date: Jan 13, 2026

Visit Reason
The visit was an office meeting conducted virtually to discuss licensing issues including subletting of lease agreement, non-transferability of license, rescinding a letter sent to residents and families, outstanding annual fee and late charge payment, and the process for bringing in a prospective buyer as management.

Findings
The report documents discussions regarding licensing compliance issues such as withdrawal of subletting lease agreement, rescinding a letter to residents, payment of outstanding fees, and requirements for prospective management company application. No specific deficiencies were cited in this report.

Report Facts
Capacity: 140

Employees mentioned
NameTitleContext
Jeremy FongLicensing Program ManagerAttended the virtual meeting and discussed licensing issues
Alicia DelmundoLicensing Program AnalystAttended the virtual meeting and discussed licensing issues
Prema ThekkekLicensee/Corporate OfficerAttended the virtual meeting and discussed licensing issues including fee payment
Diane PedersonExecutive DirectorAttended the virtual meeting and discussed licensing issues

Inspection Report

Census: 78 Capacity: 140 Deficiencies: 0 Date: Jan 6, 2026

Visit Reason
The visit occurred for case management and other reasons, including discussion of a notification to residents and family members regarding a change of ownership and the submission process for a new license application.

Findings
The Licensing Program Analyst discussed with the Executive Director the notification of change of ownership and referred to relevant regulations and codes. No deficiencies or violations were cited in this report.

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorDiscussed notification of change of ownership and licensing process.
Alicia DelmundoLicensing Program AnalystConducted the visit and discussed licensing requirements with the Executive Director.
Bennett FongLicensing Program ManagerNamed as Licensing Program Manager on the report.

Inspection Report

Annual Inspection
Census: 74 Capacity: 140 Deficiencies: 0 Date: Sep 11, 2025

Visit Reason
The inspection was an unannounced annual required inspection conducted by Licensing Program Analyst Delmundo to evaluate compliance with licensing requirements.

Findings
The facility was toured and inspected including common areas and resident apartments. Food supplies and safety equipment were found in compliance. Records for disaster drills and medication management were reviewed. No deficiencies were cited during this inspection.

Report Facts
Food supply duration: 2 Food supply duration: 7 Resident apartments inspected: 8 Staff files reviewed: 5 Resident files reviewed: 5 Residents interviewed: 4 Hot water temperature: 110.6 Facility capacity: 140 Current census: 74 Liability insurance coverage: 3000000

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with Licensing Program Analyst during inspection and involved in facility tour
Alicia DelmundoLicensing Program AnalystConducted the inspection and signed the report
Bennett FongLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Annual Inspection
Census: 74 Capacity: 140 Deficiencies: 0 Date: Sep 11, 2025

Visit Reason
The visit was an unannounced annual required inspection conducted by the Licensing Program Analyst to evaluate compliance with licensing requirements.

Findings
The inspection found the facility to be in compliance with all applicable regulations, with no deficiencies cited. The facility's environment, safety equipment, medication management, and disaster preparedness were all reviewed and found satisfactory.

Report Facts
Food supply duration: 2 Food supply duration: 7 Disaster drill frequency: 4 Hot water temperature: 110.6 Liability insurance coverage: 3000000

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with Licensing Program Analyst during inspection
Alicia DelmundoLicensing Program AnalystConducted the inspection
Bennett FongLicensing Program ManagerNamed in report header and signature section

Inspection Report

Complaint Investigation
Census: 72 Capacity: 140 Deficiencies: 0 Date: May 14, 2025

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2022-02-03 regarding resident care concerns at Landmark Villa.

Complaint Details
The complaint involved five allegations: 1) Resident sustained pressure injuries while in care; 2) Resident's diapering needs not met; 3) Resident's hygiene needs not met; 4) Staff does not assist resident when requested; 5) Staff does not treat resident with dignity and respect. The investigation found no preponderance of evidence to substantiate these allegations.
Findings
The investigation reviewed multiple allegations including pressure injuries, unmet diapering and hygiene needs, lack of staff assistance, and disrespectful treatment. Based on interviews, observations, and records review, there was insufficient evidence to substantiate any of the allegations, and all five allegations were closed as unsubstantiated.

Report Facts
Capacity: 140 Census: 72

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with Licensing Program Analyst during investigation
Alicia DelmundoLicensing Program AnalystConducted the complaint investigation

Inspection Report

Complaint Investigation
Census: 72 Capacity: 140 Deficiencies: 0 Date: May 14, 2025

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2022-02-03 regarding allegations of pressure injuries, unmet diapering and hygiene needs, lack of staff assistance, and disrespectful treatment of a resident (R1).

Complaint Details
The complaint involved five allegations: 1) Resident (R1) sustained pressure injuries while in care; 2) Resident's diapering needs are not being met; 3) Resident's hygiene needs are not being met; 4) Staff does not assist resident when requested; 5) Staff does not treat resident with dignity and respect. The investigation concluded all allegations were unsubstantiated due to lack of evidence and inability to obtain information from some involved parties.
Findings
After interviews with staff, residents, and family members, review of resident and home health records, and observations, the investigation found insufficient evidence to substantiate any of the five allegations. The allegations were closed as unsubstantiated.

Report Facts
Facility capacity: 140 Census: 72 Complaint received date: Feb 3, 2022

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with Licensing Program Analyst during investigation
Alicia DelmundoLicensing Program AnalystConducted the complaint investigation
Bennett FongLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Census: 72 Capacity: 140 Deficiencies: 0 Date: May 14, 2025

Visit Reason
The visit was an unannounced case management incident inspection to continue obtaining additional information from a prior visit started on January 23, 2025.

Findings
No deficiencies were cited during this inspection. Interviews were conducted and an exit interview was held with the Executive Director.

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with Licensing Program Analyst during the inspection.

Inspection Report

Census: 72 Capacity: 140 Deficiencies: 0 Date: May 14, 2025

Visit Reason
The visit was an unannounced case management incident inspection to continue obtaining additional information from a prior visit started on January 23, 2025.

Findings
No deficiencies were cited during this inspection. Interviews were conducted with the Executive Director, and an exit interview was completed with a copy of the report provided.

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with during the inspection and involved in interviews.

Inspection Report

Complaint Investigation
Census: 75 Capacity: 140 Deficiencies: 0 Date: Jan 23, 2025

Visit Reason
The inspection visit was conducted in response to an Unusual Incident Report submitted by the facility regarding alleged rough physical and verbal handling of a resident by a caregiver.

Complaint Details
The complaint involved staff (S2) witnessing caregiver (S1) physically and verbally handling resident (R1) roughly. The caregiver was removed from schedule and terminated following investigation. The resident's daughter, Ombudsman, and Community Care Licensing were notified.
Findings
The investigation included review of resident and staff records and interviews; the caregiver involved was removed from the schedule and terminated. No deficiencies were cited during this visit.

Report Facts
Capacity: 140 Census: 75

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with Licensing Program Analyst during inspection and involved in notification and investigation
Geraldine TayoResident Care DirectorMet with Licensing Program Analyst during inspection

Inspection Report

Complaint Investigation
Census: 75 Capacity: 140 Deficiencies: 0 Date: Jan 23, 2025

Visit Reason
The inspection visit occurred in response to an Unusual Incident Report submitted by the facility regarding alleged rough physical and verbal handling of a resident by a caregiver.

Complaint Details
The complaint involved an allegation that on 1/19/25, staff witnessed a caregiver physically and verbally handling a resident roughly. The caregiver was removed from schedule, the resident's family and Ombudsman were notified, and an investigation was conducted resulting in termination of the caregiver.
Findings
The investigation included review of resident and staff records and interviews. No deficiencies were cited during this unannounced visit, and the caregiver involved was removed from schedule and terminated.

Report Facts
Capacity: 140 Census: 75

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with Licensing Program Analyst during inspection
Geraldine TayoResident Care DirectorMet with Licensing Program Analyst during inspection

Inspection Report

Annual Inspection
Census: 70 Capacity: 140 Deficiencies: 0 Date: Sep 5, 2024

Visit Reason
The visit was an unannounced annual required inspection conducted by the Licensing Program Analyst to evaluate compliance with licensing regulations.

Findings
The inspection included a tour of the facility, review of food safety, medication storage, fire safety equipment, and staff and resident files. No deficiencies were cited during the inspection.

Report Facts
Food supply perishables duration: 2 Food supply non-perishables duration: 7 Residents apartments inspected: 12 Hot water temperature: 113.6 Fire extinguisher service date: Jan 11, 2024 Disaster drill last conducted: Jun 11, 2024 Staff files reviewed: 5 Resident files reviewed: 5 Liability insurance coverage: 3000000

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with Licensing Program Analyst during inspection
Geraldine TayoResident Services DirectorMet with Licensing Program Analyst during inspection
Alicia DelmundoLicensing Program AnalystConducted the inspection
Bennett FongSupervisorSupervisor overseeing the inspection

Inspection Report

Annual Inspection
Census: 70 Capacity: 140 Deficiencies: 0 Date: Sep 5, 2024

Visit Reason
The inspection was an unannounced annual required inspection conducted by the Licensing Program Analyst to assess compliance with regulatory standards.

Findings
The facility was toured and inspected including common areas, resident apartments, and safety equipment. Food supplies, medication storage, and disaster preparedness were reviewed. No deficiencies were cited during the inspection.

Report Facts
Food supply perishables duration: 2 Food supply non-perishables duration: 7 Residents apartments inspected: 12 Hot water temperature: 113.6 Fire extinguisher service date: Jan 11, 2024 Disaster drill last conducted: Jun 11, 2024 Staff files reviewed: 5 Resident files reviewed: 5 Liability insurance coverage: 3000000

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with LPA during inspection and submitted updated Infection Control Plan
Geraldine TayoResident Services DirectorMet with LPA during inspection
Alicia DelmundoLicensing Program AnalystConducted the inspection
Bennett FongLicensing Program ManagerNamed in report header and signature section

Inspection Report

Annual Inspection
Census: 80 Capacity: 140 Deficiencies: 1 Date: Sep 28, 2023

Visit Reason
The inspection was an unannounced annual required inspection conducted by the Licensing Program Analyst to evaluate compliance with regulatory requirements.

Findings
The facility was toured and inspected including common areas, resident rooms, and staff files. A deficiency was cited for failure to submit an updated Infection Control Plan prior to the visit, and an unlocked chest rub was observed in a resident's room posing an immediate health and safety risk. The facility submitted updated documents during the visit and discussed plans of correction with the Executive Director.

Deficiencies (1)
Unlocked chest rub in resident's room posing an immediate health and safety risk to persons in care.
Report Facts
Capacity: 140 Census: 80 Plan of Correction Due Date: Sep 29, 2023 Food supply duration: 2 Food supply duration: 7 Staff files reviewed: 5 Resident files reviewed: 5 Resident rooms inspected: 8 Staff interviewed: 2 Residents interviewed: 2 Fire extinguisher service date: Dec 28, 2022 Hot water temperature: 113.6

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with Licensing Program Analyst during inspection and discussed findings
Geraldine TayoResident Services DirectorMet with Licensing Program Analyst during inspection
Bennett FongLicensing Program ManagerSupervisor overseeing the inspection
Alicia DelmundoLicensing Program AnalystConducted the inspection and authored the report

Inspection Report

Annual Inspection
Census: 80 Capacity: 140 Deficiencies: 1 Date: Sep 28, 2023

Visit Reason
The Licensing Program Analyst conducted an unannounced annual required inspection to evaluate compliance with regulatory standards and facility operations.

Findings
The facility was generally compliant with regulations, including proper food storage, medication management, and safety equipment maintenance. However, a deficiency was cited for an unlocked chest rub in a resident's room, posing an immediate health and safety risk.

Deficiencies (1)
Unlocked chest rub in resident's room posing immediate health and safety risks to persons in care.
Report Facts
Capacity: 140 Census: 80 Plan of Correction Due Date: Sep 29, 2023 Liability Insurance: 3000000

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with Licensing Program Analyst during inspection and discussed deficiency and plan of correction
Geraldine TayoResident Services DirectorMet with Licensing Program Analyst during inspection
Alicia DelmundoLicensing EvaluatorConducted the inspection and authored the report
Bennett FongSupervisorSupervisor overseeing the inspection

Inspection Report

Complaint Investigation
Census: 71 Capacity: 140 Deficiencies: 2 Date: Jun 1, 2022

Visit Reason
The visit was an unannounced case management inspection conducted during the course of investigation for a complaint (#15-AS-20200710153037).

Complaint Details
The visit was conducted as part of an investigation for complaint #15-AS-20200710153037. The complaint was substantiated by the observed deficiencies.
Findings
Deficiencies were found related to failure to update a resident's Appraisal/Needs and Services Plan after changes in condition and failure to retain medication and destruction records as required by regulations.

Deficiencies (2)
Facility staff did not update resident’s (R1) Appraisal/Needs and Services Plan after each change in condition/hospital visit.
Facility did not retain original medication and destruction records for resident R1 for at least three years following termination of service.
Report Facts
Capacity: 140 Census: 71 Plan of Correction Due Date: Jun 15, 2022

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with Licensing Program Analyst during inspection and provided information regarding deficiencies.
Alicia DelmundoLicensing Program AnalystConducted the unannounced case management visit and documented findings.
Bennett FongSupervisorSupervisor overseeing the licensing evaluation.

Inspection Report

Complaint Investigation
Census: 71 Capacity: 140 Deficiencies: 0 Date: Jun 1, 2022

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2020-07-10 regarding neglect and improper care of a resident (R1) at Landmark Villa facility.

Complaint Details
The complaint involved three main allegations: 1) Resident (R1) sustained multiple falls resulting in injuries; 2) Resident (R1) was not provided medical attention in a timely manner; 3) Staff failed to respond to resident's pull cord in a timely manner. After investigation including interviews and record reviews, all allegations were closed as unsubstantiated or unfounded.
Findings
The investigation found insufficient evidence to substantiate the allegations of neglect, lack of timely medical attention, and failure to respond to resident pull cords. The complaint was closed as unsubstantiated. Additionally, an allegation regarding improper medication administration was found to be unfounded.

Report Facts
Facility capacity: 140 Census: 71

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with Licensing Program Analyst during investigation and exit interview
Alicia DelmundoLicensing Program AnalystConducted the complaint investigation
Bennett FongSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 71 Capacity: 140 Deficiencies: 0 Date: Jun 1, 2022

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2020-07-10 regarding neglect and improper care of resident R1, including multiple falls, delayed medical attention, and failure to respond to pull cord calls.

Complaint Details
The complaint involved three allegations: 1) Resident R1 sustained multiple falls resulting in injuries; 2) Resident R1 was not provided medical attention in a timely manner; 3) Staff failed to respond to resident R1's pull cord in a timely manner. All allegations were closed as unsubstantiated or unfounded after review of medical records, interviews, and facility documentation.
Findings
The investigation found insufficient evidence to substantiate the allegations of neglect or improper care. The resident's multiple falls, medical attention, and staff response to pull cords were reviewed and determined to be adequately managed. The medication administration allegation was also found unfounded.

Report Facts
Complaint Control Number: 15-AS-20200710153037 Number of allegations: 4

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with Licensing Program Analyst during investigation and exit interview
Alicia DelmundoLicensing Program AnalystConducted the complaint investigation
Bennett FongLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Complaint Investigation
Census: 71 Capacity: 140 Deficiencies: 2 Date: Jun 1, 2022

Visit Reason
The visit was an unannounced case management inspection conducted during the course of investigation for complaint #15-AS-20200710153037.

Complaint Details
The visit was conducted as part of an investigation for complaint #15-AS-20200710153037.
Findings
Deficiencies were found related to failure to update a resident's Appraisal/Needs and Services Plan after changes in condition and failure to retain medication records for the required minimum of three years, posing potential health and personal rights risks to the resident.

Deficiencies (2)
Failure to update resident R1's Appraisal/Needs and Services Plan after each change in condition, posing potential health risks.
Failure to retain original medication records for resident R1 for at least three years, posing potential health and personal rights risks.
Report Facts
Capacity: 140 Census: 71 Plan of Correction Due Date: Jun 15, 2022

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with Licensing Program Analyst during inspection and provided information regarding deficiencies

Inspection Report

Census: 71 Capacity: 140 Deficiencies: 0 Date: Jun 1, 2022

Visit Reason
The visit was conducted to deliver the findings for a complaint #15-AS-20200710153037 and to receive the facility's completed Infection Control Plan due for submission in June.

Complaint Details
The visit was related to complaint #15-AS-20200710153037; no substantiation status is stated.
Findings
The Executive Director informed the Licensing Program Analyst that the facility's Infection Control Plan was completed and provided a copy on the day of the visit. An exit interview was conducted and a copy of the report was provided.

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorInformed Licensing Program Analyst about completion of Infection Control Plan during complaint findings delivery.

Inspection Report

Census: 71 Capacity: 140 Deficiencies: 0 Date: Jun 1, 2022

Visit Reason
The visit was conducted to deliver the findings for a complaint #15-AS-20200710153037 and to receive the facility's completed Infection Control Plan due for submission in June.

Complaint Details
The visit was related to complaint #15-AS-20200710153037; no substantiation status is stated.
Findings
The Executive Director informed the Licensing Program Analyst that the facility's Infection Control Plan was completed and provided a copy on the day of the visit. An exit interview was conducted and a copy of the report was provided.

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorInformed Licensing Program Analyst of completed Infection Control Plan and was met during the visit.
Alicia DelmundoLicensing Program AnalystReceived the Infection Control Plan and conducted the visit.
Bennett FongSupervisorNamed as supervisor on the report.

Inspection Report

Complaint Investigation
Census: 74 Capacity: 140 Deficiencies: 0 Date: Feb 7, 2022

Visit Reason
The inspection was conducted as a result of a complaint received by the Department (Control # 15-AS-20220203093410) to perform a health and safety inspection.

Complaint Details
Inspection was complaint-related based on a complaint received (Control # 15-AS-20220203093410). No deficiencies were cited, indicating no substantiated violations.
Findings
The Licensing Program Analyst inspected common areas and selected apartments, noting minor observations such as hand washing posters missing in kitchenettes and no trash bin with pedal-operated lid outside the isolation room. No deficiencies were cited during this visit.

Report Facts
Facility Capacity: 140 Census: 74

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with Licensing Program Analyst during inspection
Alicia DelmundoLicensing Program AnalystConducted the health and safety inspection
Bennett FongLicensing Program ManagerNamed in report header

Inspection Report

Complaint Investigation
Census: 74 Capacity: 140 Deficiencies: 0 Date: Feb 7, 2022

Visit Reason
The inspection was conducted as a result of a complaint received by the Department (Control # 15-AS-20220203093410) to perform a health and safety inspection.

Complaint Details
Inspection was triggered by a complaint (Control # 15-AS-20220203093410). No deficiencies were cited, indicating no substantiated violations.
Findings
The Licensing Program Analyst inspected common areas and five apartments, noting hand washing posters in apartments but not in kitchenettes, and the absence of a trash bin with a pedal-operated lid outside the isolation room. No deficiencies were cited during this visit.

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with Licensing Program Analyst during inspection and informed of purpose of visit.

Inspection Report

Complaint Investigation
Census: 75 Capacity: 140 Deficiencies: 2 Date: Oct 13, 2021

Visit Reason
The inspection visit was conducted as a case management investigation of a complaint regarding the care of a resident with dementia, specifically concerning missing medical assessments and lack of a Dementia Care Plan.

Complaint Details
The visit was triggered by a complaint (Control # 15-AS-20190926095603) concerning the care of a resident with dementia. The complaint was investigated and deficiencies were substantiated related to missing medical assessments and lack of Dementia Care Plan.
Findings
The facility was found deficient for not having medical assessments for the resident with dementia for 2018 and 2019, and for not having or submitting a Dementia Care Plan as required by regulations. These deficiencies posed potential health and safety risks to residents.

Deficiencies (2)
Resident with dementia did not have medical assessments for 2018 and 2019 as required.
Facility does not have a Dementia Care Plan nor submitted an addendum to the Plan of Operation for residents with dementia.
Report Facts
Deficiencies cited: 2 Plan of Correction Due Date: Oct 27, 2021 Capacity: 140 Census: 75

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorDiscussed deficiencies and plan of correction during the visit
Alicia DelmundoLicensing Program AnalystConducted the complaint investigation and authored the report
Bennett FongSupervisorSupervisor overseeing the licensing evaluation

Inspection Report

Complaint Investigation
Census: 75 Capacity: 140 Deficiencies: 2 Date: Oct 13, 2021

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of lack of care or supervision resulting in a resident's (R1) AWOL and a fall causing serious bodily injuries.

Complaint Details
The complaint was substantiated based on evidence including resident and medical records, staff interviews, and police reports. Resident R1 with dementia was found down in the community with serious injuries after leaving the facility unnoticed. A $500 civil penalty was assessed.
Findings
The investigation substantiated the allegations that resident R1, who has dementia, was able to leave the facility unnoticed and was found with multiple fractures from a fall. The facility failed to implement adequate safety measures to prevent wandering and ensure resident safety.

Deficiencies (2)
Failure to implement safety measures to address behaviors such as wandering, aggressive behavior, and ingestion of toxic materials, resulting in resident R1 being able to AWOL and sustain injuries.
Failure to provide care, supervision, and services that meet individual needs with sufficient, qualified, and competent staff, resulting in resident R1's AWOL and fall with injuries.
Report Facts
Civil penalty amount: 500 Capacity: 140 Census: 75

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with Licensing Program Analyst and discussed findings and plan of correction.
Alicia DelmundoLicensing Program AnalystConducted the complaint investigation and delivered findings.
Bennett FongSupervisorSupervisor overseeing the licensing evaluation.

Inspection Report

Complaint Investigation
Census: 75 Capacity: 140 Deficiencies: 2 Date: Oct 13, 2021

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that lack of care or supervision resulted in a resident's (R1) AWOL and fall causing serious bodily injuries.

Complaint Details
The complaint investigation was substantiated. Resident R1 with dementia was found down in the community with serious injuries after leaving the facility unnoticed. The allegations met the preponderance of evidence standard. A $500 civil penalty was assessed.
Findings
The investigation substantiated the allegations that resident R1, who has dementia, was able to leave the facility unnoticed and was found injured in the community. Deficiencies were cited related to safety measures for persons with dementia and personal rights, and a $500 civil penalty was assessed.

Deficiencies (2)
Failure to implement safety measures to address behaviors such as wandering, aggressive behavior, and ingestion of toxic materials, resulting in resident R1 with dementia leaving the facility unnoticed.
Failure to provide care, supervision, and services that meet individual needs, resulting in resident R1's AWOL and fall causing injuries.
Report Facts
Civil penalty amount: 500 Capacity: 140 Census: 75 Plan of Correction Due Date: Oct 14, 2021

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet with Licensing Program Analyst and discussed deficiencies and civil penalty
Alicia DelmundoLicensing Program AnalystConducted complaint investigation and authored report
Bennett FongLicensing Program ManagerOversaw complaint investigation process

Inspection Report

Complaint Investigation
Census: 75 Capacity: 140 Deficiencies: 2 Date: Oct 13, 2021

Visit Reason
The visit was conducted as part of an investigation of a complaint (Control # 15-AS-20190926095603) regarding the care of a resident with dementia and review of facility records.

Complaint Details
Investigation of complaint Control # 15-AS-20190926095603 regarding care of a resident with dementia. Deficiencies were substantiated related to missing medical assessments and lack of Dementia Care Plan.
Findings
The facility failed to provide medical assessments for the resident with dementia for 2018 and 2019 and did not have or submit a Dementia Care Plan as required by regulations. These deficiencies posed potential health and safety risks to the resident.

Deficiencies (2)
Resident with dementia did not have medical assessments for 2018 and 2019 as required.
Facility did not have a Dementia Care Plan nor submitted an addendum to the Plan of Operation for residents with dementia.
Report Facts
Deficiencies cited: 2 Plan of Correction Due Date: Oct 27, 2021

Employees mentioned
NameTitleContext
Diane PedersonExecutive DirectorMet during visit and discussed deficiencies and plan of correction.
Alicia DelmundoLicensing Program AnalystConducted investigation and authored report.
Bennett FongLicensing Program ManagerSupervisor named in report.

Inspection Report

Annual Inspection
Census: 72 Capacity: 140 Deficiencies: 0 Date: Sep 22, 2021

Visit Reason
The visit was a required unannounced 1-year annual infection control inspection conducted to evaluate compliance with COVID-19 infection control practices and overall facility safety.

Findings
The facility was found to be in compliance with infection control protocols, including proper PPE use, symptom screening, and social distancing. No deficiencies were cited during the visit. Emergency plans, medication storage, and safety equipment were properly maintained.

Report Facts
Staff wearing face masks: 16 Residents eating lunch: 14 Apartments in facility: 97 Percent staff and residents fully vaccinated: 95 Days of nonperishable food supply: 7 Days of perishable food supply: 2 Facility room temperature: 73 Certified administrator onsite hours per week: 20

Employees mentioned
NameTitleContext
Daisy PanlilioLicensing Program AnalystConducted the infection control annual inspection
Diane PedersonAdministratorFacility administrator met with Licensing Program Analyst during inspection
Bennett FongSupervisorSupervisor overseeing the licensing evaluation

Inspection Report

Annual Inspection
Census: 72 Capacity: 140 Deficiencies: 0 Date: Sep 22, 2021

Visit Reason
The inspection was an infection control annual inspection conducted to evaluate the facility's compliance with COVID-19 infection control practices and other regulatory requirements.

Findings
The facility was found to be in compliance with infection control protocols, including proper use of PPE, symptom screening, social distancing, and emergency preparedness. No deficiencies were cited during this visit.

Report Facts
Staff wearing face masks: 16 Residents eating lunch: 14 Vaccination rate: 95 Emergency food supplies: 7 Emergency food supplies: 2 Administrator onsite hours: 20 Facility room temperature: 73

Employees mentioned
NameTitleContext
Daisy PanlilioLicensing Program AnalystConducted the infection control annual inspection
Diane PedersonAdministratorFacility administrator met with Licensing Program Analyst during inspection
Bennett FongLicensing Program ManagerNamed as Licensing Program Manager on the report

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