Inspection Reports for
Leisure Vale Assisted Living
413 E Cypress St, Glendale, CA 91205, United States, CA, 91205
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
85% occupied
Based on a January 2026 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 169
Capacity: 199
Deficiencies: 0
Date: Jan 28, 2026
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff did not include a resident’s representative in care decisions.
Complaint Details
The complaint alleged that staff did not include the resident’s representative in care decisions. The investigation concluded the complaint was without reasonable basis and was dismissed as unfounded.
Findings
The investigation found that the allegation was unfounded as the facility was not involved in the transfer or decision-making process regarding the resident’s placement. No health or safety hazards were noted during the visit.
Report Facts
Capacity: 199
Census: 169
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Leslie Ngo-Castaneda | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Oden | Executive Director | Facility representative met during the investigation |
Inspection Report
Complaint Investigation
Census: 169
Capacity: 199
Deficiencies: 0
Date: Jan 28, 2026
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that the facility is in disrepair and did not follow fire regulations.
Complaint Details
The complaint was unsubstantiated. The elevator was out of order but the facility staff reported the issue and were working to fix it. Fire safety concerns were addressed with the local fire department.
Findings
The investigation found that the facility's only elevator was out of service, but the issue was reported timely and appropriate actions were being taken to fix it. Fire safety concerns were reported to the Los Angeles Fire Department, which responded to alleviate resident concerns. No immediate health and safety risks were observed, and the allegations were deemed unsubstantiated.
Report Facts
Elevator repair timeframe: 4
Elevator repair timeframe: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Leslie Ngo-Castaneda | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Oden | Executive Director | Met with Licensing Program Analyst and confirmed elevator issue |
Inspection Report
Complaint Investigation
Census: 169
Capacity: 199
Deficiencies: 0
Date: Jan 28, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations received on 2025-12-08 regarding timely medical care, respect towards residents, supervision at night, and rough handling of residents.
Complaint Details
The complaint included allegations that staff did not get timely medical care for a resident, staff did not treat residents with respect, lack of supervision allowed residents to enter others' bedrooms at night, and staff handled residents roughly. After investigation, all allegations were found unsubstantiated.
Findings
All allegations were investigated through interviews, observations, and document reviews. The investigation found no evidence to substantiate any of the allegations, and all were deemed unsubstantiated.
Report Facts
Residents interviewed: 17
Staff interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Leslie Ngo-Castaneda | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Oden | Executive Director | Facility administrator met during the investigation |
| Naira Margaryan | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 165
Capacity: 199
Deficiencies: 1
Date: Jan 20, 2026
Visit Reason
The inspection was a case management visit conducted in conjunction with a complaint investigation regarding multiple incidents of inappropriate behavior by a resident toward other female residents.
Complaint Details
The visit was triggered by Complaint Control #31-AS-20260115084953 concerning inappropriate behavior by resident #1 toward other female residents. The complaint was substantiated by observations and interviews.
Findings
The facility failed to report incidents of inappropriate behavior by resident #1 to Licensing as required, posing a health and safety risk to residents. A citation was issued for this failure.
Deficiencies (1)
Failure to submit incident reports involving inappropriate behavior by resident #1 to the licensing agency as required.
Report Facts
Capacity: 199
Census: 165
Plan of Correction Due Date: Feb 3, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Oden | Administrator | Named in relation to facility's failure to report incidents |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the case management visit |
| Naira Margaryan | Licensing Program Manager | Named in report header and deficiency section |
Inspection Report
Complaint Investigation
Census: 165
Capacity: 199
Deficiencies: 0
Date: Jan 20, 2026
Visit Reason
The visit was an unannounced complaint investigation to examine an allegation that facility staff failed to prevent a resident's money from being stolen.
Complaint Details
The complaint alleged that staff did not prevent a resident's money from being stolen. The allegation was unsubstantiated after interviews with the administrator, power of attorney, residents, and review of documentation.
Findings
The investigation found insufficient evidence to substantiate the allegation that facility staff were responsible for the missing money due to inconsistent reporting, lack of timely notification, and inability to determine when or where the loss occurred. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 199
Census: 165
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Oden | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the complaint investigation visit |
| Naira Margaryan | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 199
Deficiencies: 0
Date: Dec 19, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following an allegation that staff did not provide adequate supervision resulting in an altercation between residents.
Complaint Details
The complaint alleged that on 09/10/2025, Resident 1 was slapped by Resident 2 and staff did not provide adequate supervision. The investigation included interviews with staff, residents, and review of relevant reports. It was found that staff were present and intervened promptly, and no serious injury occurred. The allegation was unsubstantiated.
Findings
The investigation found that although an altercation occurred between two residents, there was staff supervision present to intervene and redirect the residents. The allegation that staff failed to prevent the altercation was deemed unsubstantiated based on interviews, documentation, and a police report.
Report Facts
Staff members during shifts: 6
Staff members during shifts: 7
Residents interviewed: 14
Total residents: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation and final report |
| Angela Smith | Administrator | Facility administrator interviewed during investigation |
| Stephanie Oden | Administrator | Met with Licensing Program Analyst during inspection visit |
| Nichelle Gillyard | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 164
Capacity: 199
Deficiencies: 0
Date: Dec 9, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2025-07-08 regarding staff behavior and care practices at Leisure Vale Assisted Living Facility.
Complaint Details
The complaint investigation was unsubstantiated based on interviews, observations, and records review. Allegations included staff yelling at residents, medication mismanagement, inadequate clothing, failure to safeguard belongings, opening mail without consent, inadequate food service, failure to follow activity schedules, and communication barriers. No credible evidence was found to support these allegations.
Findings
After interviews with residents, staff, and review of records, all allegations including staff yelling at residents, medication mismanagement, inadequate clothing, safeguarding personal belongings, mail handling, food service, activity scheduling, and communication barriers were found to be unsubstantiated. No immediate health or safety issues were observed and no citations were issued.
Report Facts
Residents interviewed: 17
Staff interviewed: 4
Facility capacity: 199
Facility census: 164
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit. |
| Angela Smith | Administrator | Facility administrator named in the report. |
| Nilda Mercado | Administrative Services Coordinator | Met with Licensing Program Analyst during the visit and provided information. |
| Stephanie Oden | Executive Director | Met with Licensing Program Analyst during the visit and provided information. |
Inspection Report
Complaint Investigation
Census: 163
Capacity: 199
Deficiencies: 1
Date: Dec 4, 2025
Visit Reason
The inspection was conducted as a Case Management Deficiencies Visit in conjunction with a complaint (31-AS-20251201143417) to investigate the failure to submit a Special Incident Report for a resident's hospitalization.
Complaint Details
The visit was triggered by complaint 31-AS-20251201143417. The complaint investigation confirmed the Executive Director did not submit the required Special Incident Report for Resident #2's hospitalization. Citation was issued.
Findings
The Executive Director did not submit the required Special Incident Report (LIC 624) for Resident #2's hospitalization on 11/23/2025 within seven days, which poses a potential health and safety risk to clients in care. A citation was issued and appeal rights were given.
Deficiencies (1)
Failure to submit Special Incident Report (LIC 624) for Resident #2's hospitalization on 11/23/25 within seven days as required by CCR 80061(b).
Report Facts
Facility Capacity: 199
Census: 163
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Smith | Administrator/Director | Named in relation to failure to submit Special Incident Report |
| Stephanie Olden | Executive Director | Met during inspection and named in deficiency finding |
| Mariana Agban | Licensing Program Analyst | Conducted the Case Management Deficiencies Visit |
| Nichelle Gillyard | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 166
Capacity: 199
Deficiencies: 0
Date: Nov 14, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that staff did not assist a resident with mobility needs in a timely manner, did not dispense medication as prescribed, and did not provide adequate fluids to the resident.
Complaint Details
The complaint investigation was unsubstantiated based on interviews, observations, and record reviews. Allegations included failure to assist resident with mobility, failure to dispense medication as prescribed, and failure to provide adequate fluids. The resident was ambulatory per physician report, medication was suspended by physician order temporarily, and no dehydration incidents were found.
Findings
After interviews with staff and residents, review of records, and physical plant tours, there was insufficient evidence to substantiate the allegations. The resident was reported to receive appropriate care, medication was withheld per physician's orders temporarily, and water was readily available with no indication of dehydration. Therefore, all allegations were unsubstantiated.
Report Facts
Residents interviewed: 17
Staff interviewed: 4
Caregivers per shift: 8
Residents per shift: 8
Medication suspension days: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Angela Smith | Administrator | Facility administrator mentioned in the report |
| Stephanie Oden | Met with during the investigation | |
| Troy Agard | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 166
Capacity: 199
Deficiencies: 0
Date: Nov 12, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation of illegal eviction at Leisure Vale Assisted Living Facility.
Complaint Details
The complaint alleged that Resident #1 was unlawfully evicted. The investigation reviewed prior complaints involving the same allegation and found that Resident #1 had relocated over three years ago and was not currently a resident. Staff and residents had no knowledge of recent evictions related to this allegation. The complaint was deemed unsubstantiated.
Findings
The investigation found the allegation of illegal eviction to be unsubstantiated. Interviews with staff and residents, review of records, and facility tours revealed no evidence of unlawful eviction. The last eviction was properly conducted in August 2025 for non-payment, and no current evictions were pending.
Report Facts
Capacity: 199
Census: 166
Number of residents interviewed: 16
Number of staff interviewed: 6
Number of prior complaints reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation |
| Angela Smith | Administrator | Facility administrator mentioned in relation to eviction allegation |
| Maria Cerventes | Business Office Manager | Interviewed during the investigation and provided information about eviction history |
| Nichelle Gillyard | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 199
Deficiencies: 0
Date: Nov 7, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation that staff left a resident soiled for an extended period of time.
Complaint Details
The complaint alleged that staff left Resident #1 waiting for pull ups for two hours and that this happened frequently. The allegation was unsubstantiated based on interviews and record review.
Findings
Based on interviews with staff and residents and review of records, there was insufficient evidence to verify the allegation. Most residents and staff stated residents are checked and changed every two hours, and no health and safety hazards were noted. The allegation was unsubstantiated.
Report Facts
Care staff providing incontinent care: 8
Incontinent residents: 57
Staff interviewed: 3
Residents interviewed: 16
Response time to calls for service: 8
Response time to calls for service: 10
Residents per caregiver: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Oden | Met with the Licensing Program Analyst during the investigation | |
| Troy Agard | Supervisor | Supervisor overseeing the investigation |
| Angela Smith | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 199
Deficiencies: 0
Date: Oct 31, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility did not ensure a sufficient amount of food to provide for the residents.
Complaint Details
The complaint alleged that Resident #1 was not provided breakfast and the facility failed to provide lunch or dinner due to supply issues. The allegation was unsubstantiated based on observations, interviews with staff and residents, and review of facility menus.
Findings
The investigation found that the facility had sufficient food stock for two days of perishable and seven days of non-perishable items. Interviews with dietary staff and residents confirmed that no meals were missed and food was sufficient. The allegation was deemed unsubstantiated.
Report Facts
Facility capacity: 199
Resident census: 167
Number of residents interviewed: 17
Food supply duration: 2
Food supply duration: 7
Food delivery frequency: 2
Culinary director tenure: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Oden | Administrator | Met with the Licensing Program Analyst during the investigation |
| Troy Agard | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 199
Deficiencies: 0
Date: Oct 16, 2025
Visit Reason
An unannounced complaint investigation was conducted to investigate allegations that staff mishandled a resident's personal belongings at Leisure Vale Assisted Living Facility.
Complaint Details
The complaint alleged that staff members went through Resident #1's room and stole belongings. Resident #1 reported missing items but could not specify what or identify any staff involved. Interviews with 17 residents and 4 staff found no evidence to support the allegation. The complaint was determined to be unsubstantiated.
Findings
The investigation found insufficient evidence to substantiate the allegation that staff stole or mishandled residents' belongings. Interviews with residents and staff did not verify the claims, and no health or safety hazards were noted during the visit.
Report Facts
Missing money amount: 400
Number of residents interviewed: 17
Number of staff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Oden | Administrator | Met with Licensing Program Analyst during investigation |
| Troy Agard | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 168
Capacity: 199
Deficiencies: 1
Date: Oct 13, 2025
Visit Reason
An unannounced Case Management - Deficiencies visit was conducted in conjunction with a complaint investigation (Complaint Control #31-AS-20251003161950) to assess facility compliance and address reported issues.
Complaint Details
The visit was conducted in conjunction with Complaint Control #31-AS-20251003161950. The complaint was substantiated by observed deficiencies.
Findings
The inspection found maintenance deficiencies including a broken window in bedroom 50 covered with a wooden board and shattered glass outside, and in bedroom 68, only one of four bathroom light bulbs was functioning, a shower head was in disrepair, and a broken bed frame was propped up with a box of cans. These issues had been reported by residents for over a year without corrective action.
Deficiencies (1)
Facility was not clean, safe, sanitary, and in good repair; broken window in room 50 and maintenance issues in room 68 posed potential health, safety, or personal rights risks.
Report Facts
Deficiencies cited: 1
Capacity: 199
Census: 168
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Oden | Administrator | Met with Licensing Program Analyst during inspection and acknowledged deficiencies |
| Evelin Rios | Licensing Program Analyst | Conducted the inspection visit and documented findings |
| Nichelle Gillyard | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 168
Capacity: 199
Deficiencies: 1
Date: Oct 13, 2025
Visit Reason
An unannounced Case Management - Deficiencies visit was conducted in conjunction with Complaint Control #31-AS-20251003161950 to investigate reported issues at the facility.
Complaint Details
The visit was conducted in conjunction with Complaint Control #31-AS-20251003161950. The complaint was substantiated as deficiencies were found.
Findings
The inspection found that bedroom 50 had a broken window covered with a wooden board that had been unrepaired for several months, and bedroom 68 had multiple maintenance issues including only one functioning light bulb in the bathroom, a broken shower head, and a broken bed frame propped up with a box of cans. Residents reported these issues had been communicated but not corrected for over a year.
Deficiencies (1)
Facility was not clean, safe, sanitary, and in good repair as evidenced by broken window in room 50 and maintenance issues in room 68 posing potential health, safety, or personal rights risks.
Report Facts
Deficiencies cited: 1
Capacity: 199
Census: 168
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Oden | Administrator | Met with Licensing Program Analyst during inspection and named in report |
| Evelin Rios | Licensing Program Analyst | Conducted the inspection visit and signed the report |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 170
Capacity: 199
Deficiencies: 0
Date: Sep 24, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff allowed a resident to sit in the hot sun while waiting for transportation and did not ensure the resident was cleaned properly.
Complaint Details
The complaint investigation was unsubstantiated based on interviews with staff and the resident, observations, and record reviews. No immediate health or safety concerns were observed.
Findings
The investigation found that staff provided adequate care and supervision to the resident, respecting their personal choice to sit in the sun, and there was insufficient evidence to support the allegation of improper cleaning. Both allegations were deemed unsubstantiated.
Report Facts
Facility capacity: 199
Census: 170
Number of allegations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation |
| Angela Smith | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 170
Capacity: 199
Deficiencies: 0
Date: Sep 24, 2025
Visit Reason
An unannounced complaint investigation was conducted following an allegation that staff did not seek medical attention for a resident with low blood sugar on 09/16/2025.
Complaint Details
The complaint alleged that staff did not seek medical attention for Resident #1 who had low blood sugar on 09/16/2025. After investigation, including interviews and record review, the allegation was found unsubstantiated.
Findings
The investigation found that the resident received all necessary medications and medical attention in a timely manner. Interviews and record reviews confirmed appropriate care was provided, and the allegation was deemed unsubstantiated.
Report Facts
Capacity: 199
Census: 170
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation |
| Angela Smith | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 169
Capacity: 199
Deficiencies: 0
Date: Aug 15, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff forced a resident to take a shower and assaulted the resident during the assistance.
Complaint Details
The complaint alleged that staff forced resident R1 to shower and assaulted them during the assistance. Interviews with R1 and other residents denied any assault. Records showed R1 was able to bathe themselves and had a shower schedule of two times per week. The allegation was unsubstantiated.
Findings
After interviews with residents and staff, review of records, and observation, there was no sufficient information to corroborate the allegation. The complaint was deemed unsubstantiated and no health or safety hazards were noted.
Report Facts
Resident interviews: 17
Shower frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the complaint investigation |
| Angela Smith | Administrator | Facility administrator named in report |
| Stephanie Oden | Executive Director | Met with Licensing Program Analyst during investigation |
| Naira Margaryan | Supervisor | Supervisor named in report |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 199
Deficiencies: 0
Date: Jul 30, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted to address allegations that staff were not meeting residents' personal hygiene needs at Leisure Vale Assisted Living Facility.
Complaint Details
The complaint alleged that staff were neglecting residents' personal hygiene needs, including unkempt hair and nails and untidy appearance. The complaint was found to be unsubstantiated after interviews, observations, and documentation review.
Findings
The investigation found that residents interviewed reported receiving assistance with hygiene needs, and observations showed residents were well groomed and wearing clean clothes. Staff and the administrator denied the allegations. Documentation showed refusals of hygiene assistance were properly recorded. The allegation was determined to be unsubstantiated.
Report Facts
Residents interviewed: 17
Staff interviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Spaeth | Licensing Program Analyst | Conducted the complaint investigation |
| Angela Smith | Administrator | Facility administrator met with investigator and denied allegations |
| Troy Agard | Supervisor | Supervisor named in report |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 199
Deficiencies: 0
Date: Jul 7, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff opened residents' mail and packages without their consent.
Complaint Details
The complaint alleged that staff opened residents' mail and packages without consent. The allegation was unsubstantiated after investigation.
Findings
The investigation found that mailboxes were secured with key locks and residents' mail was sorted into individual mailboxes. Staff sometimes assisted residents who lost their keys. Most residents reported no issues with mail privacy. The allegation was unsubstantiated based on observations and interviews.
Report Facts
Residents interviewed: 17
Residents confirming no issue: 15
Staff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gina Saucedo | Licensing Program Analyst | Conducted the complaint investigation. |
| Angela Smith | Administrator | Facility administrator met with the evaluator and was involved in the investigation. |
| Troy Agard | Supervisor | Supervisor named in the report. |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 199
Deficiencies: 0
Date: Jul 7, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff opened residents' mail and packages without the residents' consent.
Complaint Details
The complaint alleged that staff opened residents' mail and packages without consent. Interviews with staff and residents, as well as physical observations, did not substantiate the allegation.
Findings
The investigation found that mailboxes were secured with keys and numbered by room. Staff assist residents who need help with their keys, and residents confirmed no issues with mail being opened by staff. The allegation was unsubstantiated based on observations and interviews.
Report Facts
Staff interviewed: 4
Residents interviewed: 17
Residents confirming no issue: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gina Saucedo | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Angela Smith | Administrator | Facility administrator who met with the Licensing Program Analyst during the investigation |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 178
Capacity: 199
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
An unannounced complaint investigation was conducted to investigate the allegation that staff do not communicate with the responsible party regarding a resident's care.
Complaint Details
The complaint alleged that staff did not communicate with the responsible party regarding Resident #1's care. The allegation was unsubstantiated based on interviews and record review.
Findings
The investigation found that the facility communicated all aspects of the resident's care with the responsible party, including interviews with the administrator, staff, and resident, and review of records. The allegation was deemed unsubstantiated.
Report Facts
Capacity: 199
Census: 178
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation |
| Angela Smith | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 178
Capacity: 199
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff did not ensure the personal property of a resident was safely secured.
Complaint Details
The complaint alleged that gold coins belonging to Resident #1 were stolen by Resident #2 when hired to clean a closet. The police investigation revealed that the coins were returned to Resident #1, who later lost them again. Staff interviews and record reviews supported that the facility followed policies, and other residents did not report concerns about their belongings. The allegation was unsubstantiated.
Findings
The investigation found that although the allegation may have happened, there was not enough information to verify that the facility failed to safeguard the resident's personal belongings. The allegation was deemed unsubstantiated based on interviews, record reviews, and a police investigation.
Report Facts
Residents interviewed: 17
Facility capacity: 199
Facility census: 178
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Naira Margaryan | Licensing Program Manager | Made phone contact and spoke with Business Office Manager and facility Administrator during investigation |
| Maya Mnoyan | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 178
Capacity: 199
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that staff do not communicate with the responsible party regarding a resident's care.
Complaint Details
The complaint alleged that staff did not communicate with the responsible party regarding Resident #1's care. After interviews with the administrator, staff, and resident, and review of records, the allegation was found to be unsubstantiated.
Findings
The investigation found that the facility staff have communicated all aspects of the resident's care with the responsible party, and the allegation was deemed unsubstantiated.
Report Facts
Capacity: 199
Census: 178
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Smith | Administrator | Met with during the investigation and provided information regarding communication with the responsible party |
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 178
Capacity: 199
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff did not ensure the personal property of a resident was safely secured.
Complaint Details
The complaint alleged that Resident #2 stole gold coins from Resident #1 when hired to clean their closet. The police investigation concluded with the coins returned to Resident #1. Interviews and record reviews did not substantiate the facility's failure to safeguard belongings.
Findings
The investigation found that although the allegation may have occurred, there was insufficient evidence to verify that the facility failed to safeguard the resident's personal belongings. The allegation was deemed unsubstantiated.
Report Facts
Residents interviewed: 17
Facility capacity: 199
Facility census: 178
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation |
| Maya Mnoyan | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 199
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that facility staff did not seek timely medical attention for a resident in care.
Complaint Details
The complaint alleged that on 06/05/2025, facility staff sent Resident #1 to the senior program with constipation and neck pain without providing medical attention. The investigation found no evidence to support this claim, and the allegation was deemed unsubstantiated.
Findings
The investigation found that the allegation was unsubstantiated. Interviews with the Executive Director, Wellness Director, Engagement Director, and residents indicated no failure to provide timely medical attention. The resident did not report symptoms to staff on the alleged date, and prior medical issues were addressed promptly.
Report Facts
Residents interviewed: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Huma Rahimi | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Angela Smith | Executive Director | Met with the Licensing Program Analyst and provided information during the investigation. |
| Nichelle Gillyard | Supervisor | Supervisor overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 199
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that facility staff did not seek timely medical attention for a resident in care.
Complaint Details
The complaint alleged that on 06/05/2025, facility staff sent Resident #1 to the senior program with constipation and neck pain without providing medical attention. The investigation revealed that Resident #1 did not report these symptoms to staff on that date, and previous medical issues were addressed immediately. Sixteen residents interviewed expressed no concerns. The allegation was deemed unsubstantiated.
Findings
The investigation found that the allegation was unsubstantiated. Interviews with the Executive Director, Wellness Director, Engagement Director, and residents indicated that the resident did not report symptoms to staff on the alleged date, and prior medical concerns had been addressed promptly.
Report Facts
Residents interviewed: 17
Facility capacity: 199
Census: 174
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Smith | Executive Director | Met with Licensing Program Analyst during the investigation. |
| Huma Rahimi | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Nichelle Gillyard | Licensing Program Manager | Named in report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 175
Capacity: 199
Deficiencies: 1
Date: Jun 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not maintain the facility in a clean, safe, sanitary condition and did not properly manage a resident's catheter care.
Complaint Details
The complaint investigation was triggered by allegations of unsanitary facility conditions and improper catheter care management. The unsanitary condition allegation was unsubstantiated. The catheter care allegation was substantiated based on inconsistent documentation and resident refusal of assistance.
Findings
The allegation regarding unsanitary conditions was unsubstantiated after physical inspection and resident interviews. However, the allegation that staff did not properly manage Resident #2's catheter care was substantiated due to inconsistent staff notes and refusal of assistance by the resident, posing a potential risk to residents.
Deficiencies (1)
Facility staff did not properly manage resident’s catheter care, posing a potential risk to residents.
Report Facts
Capacity: 199
Census: 175
Plan of Correction Due Date: Jun 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mariana Agban | Licensing Program Analyst | Conducted the complaint investigation |
| Angela Smith | Executive Director | Facility administrator met during investigation and named in findings |
| Eva Miller | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 199
Deficiencies: 1
Date: May 30, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff failed to provide emergency medical services in a timely manner and did not respond timely to a resident's call pendant.
Complaint Details
The complaint investigation was substantiated for failure to provide timely emergency medical services to Resident #1 (R1) who was vomiting and weak on 06/21/24, with 911 not called until 11:20 p.m. The allegation regarding delayed response to call pendants was unsubstantiated.
Findings
The complaint that staff failed to provide emergency medical services in a timely manner was substantiated, with evidence showing delayed 911 call despite resident vomiting and weakness. The allegation that staff did not respond timely to the resident's call pendant was unsubstantiated based on interviews and record review.
Deficiencies (1)
Licensee did not ensure to provide immediate emergency medical assistance to resident (R1), who appeared to be weak and vomiting, posing an immediate health and safety risk.
Report Facts
Census: 173
Total Capacity: 199
Deficiency Count: 1
Response Time: 14
Vomiting incidents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Angela Smith | Administrator | Met with Licensing Program Analyst during inspection |
| Maya Mnoyan | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 199
Deficiencies: 0
Date: May 30, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint alleging that facility staff did not provide a copy of the admission agreement to a resident.
Complaint Details
The complaint alleged that facility staff did not provide a copy of the admission agreement to resident #1 (R1). The allegation was investigated through staff and resident interviews, facility tour, and records review. The complaint was found to be unsubstantiated.
Findings
The investigation found that staff did provide a copy of the admission agreement to the resident, but the resident refused to take it due to a dispute over share of cost. Interviews and records review verified that other residents received copies. The allegation was unsubstantiated with no health and safety issues noted.
Report Facts
Capacity: 199
Census: 173
Complaint control number: 31
Residents interviewed: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Maya Mnoyan | Administrator | Facility administrator met during the investigation |
| Angela Smith | Administrator | Met with during the unannounced visit |
| Rosaura Valenzuela | Licensing Program Analyst | Initiated the investigation on 08/29/2024 |
| Naira Margaryan | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 199
Deficiencies: 1
Date: May 30, 2025
Visit Reason
The visit was an unannounced complaint investigation initiated due to an allegation that facility staff did not provide a copy of the admission agreement to a resident.
Complaint Details
The complaint was unsubstantiated. The allegation was that facility staff did not provide a copy of the admission agreement to resident #1 (R1). Interviews and records review showed staff did provide the copy, but R1 refused it. Other residents confirmed receiving copies. No health and safety issues were found.
Findings
The investigation found that staff did provide a copy of the admission agreement to the resident, but the resident refused to take it due to a dispute over cost sharing. Other residents confirmed receiving their admission agreements. The allegation was determined to be unsubstantiated with no health and safety issues noted.
Deficiencies (1)
Facility staff did not provide a copy of admission agreement to resident
Report Facts
Capacity: 199
Census: 173
Residents interviewed: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Maya Mnoyan | Administrator | Facility administrator met during the investigation |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 199
Deficiencies: 1
Date: May 30, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff failed to provide emergency medical services in a timely manner and did not respond promptly to a resident's call pendant.
Complaint Details
The complaint investigation was initiated due to allegations that staff failed to provide emergency medical services timely and did not respond promptly to a resident's call pendant. The emergency medical services allegation was substantiated; the call pendant response allegation was unsubstantiated. The resident involved (R1) had been vomiting since 7:00 p.m. on 06/21/24, but 911 was not called until 11:00 p.m. R1 passed away on 06/22/24.
Findings
The complaint that staff failed to provide timely emergency medical services was substantiated, with evidence showing delayed 911 call for a resident who was vomiting and weak. The allegation regarding delayed response to call pendants was unsubstantiated, with staff response times within 14 minutes and no resident concerns noted.
Deficiencies (1)
Licensee did not ensure to provide immediate emergency medical assistance to resident (R1), who appeared to be weak and vomiting, posing an immediate health and safety risk.
Report Facts
Resident census: 173
Total capacity: 199
Deficiency count: 1
Staff response time: 14
Vomiting incidents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation report |
| Maya Mnoyan | Administrator | Facility administrator named in the report |
| Angela Smith | Administrator | Met with Licensing Program Analyst during the inspection visit |
| Rosaura Valenzuela | Licensing Program Analyst | Initiated the investigation on 07/10/2024 |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 199
Deficiencies: 0
Date: May 12, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff did not respond timely to a resident's emergency alerts, did not provide required medical attention to a resident, and did not properly maintain a resident's room.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to respond timely to emergency alerts, failure to provide medical attention, and failure to maintain a resident's room. Interviews with residents and staff, as well as record reviews, did not support these allegations.
Findings
Based on interviews with residents and staff, record reviews, and observations, there was insufficient evidence to verify any of the allegations. The complaint was determined to be unsubstantiated, and no health or safety hazards were noted during the visit.
Report Facts
Residents interviewed: 11
Staff interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Smith | Executive Director | Met with Licensing Program Analyst during the complaint investigation and named in the report |
| Angelica Segovia | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Troy Agard | Licensing Program Manager | Assisted in investigation by conducting physical plant tour and interviews |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 199
Deficiencies: 0
Date: May 12, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-04-14 regarding staff response to emergency alerts, provision of medical attention, and room maintenance at the facility.
Complaint Details
The complaint included three allegations: 1) staff did not respond timely to a resident's emergency alerts, 2) staff did not provide required medical attention to a resident, and 3) staff did not properly maintain a resident's room. All allegations were found to be unsubstantiated based on interviews and record reviews.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with residents and staff, as well as record reviews, indicated that staff responded to emergency alerts, provided medical attention when needed, and maintained residents' rooms properly. No health and safety hazards were noted during the visit.
Report Facts
Residents interviewed: 11
Staff interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Smith | Executive Director | Met with Licensing Program Analyst during the investigation and named in the report |
| Angelica Segovia | Licensing Program Analyst | Conducted the complaint investigation visit |
| Troy Agard | Licensing Program Manager | Assisted in investigation and named in the report |
Inspection Report
Annual Inspection
Census: 169
Capacity: 199
Deficiencies: 0
Date: Apr 16, 2025
Visit Reason
The inspection was a required one-year unannounced visit to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be in compliance with health and safety standards, including adequate fire safety measures, proper food storage, clean and well-maintained living areas, and medication securely stored. No health and safety hazards were noted during the visit.
Report Facts
Fire extinguisher last inspection date: Oct 21, 2024
Hot water temperature: 117.8
Perishable food stock: 2
Non-perishable food stock: 7
Facility capacity: 199
Current census: 169
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Smith | Executive Director | Met with Licensing Program Analyst during inspection |
| Abeye Duguma | Licensing Program Analyst | Conducted the inspection and authored the report |
| Naira Margaryan | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 169
Capacity: 199
Deficiencies: 0
Date: Apr 16, 2025
Visit Reason
The inspection was a required unannounced one-year visit to evaluate compliance with licensing requirements at the assisted living facility.
Findings
The facility was found to be generally compliant with no health and safety hazards noted. The physical plant was toured, medication was inaccessible to residents, first aid kits were complete, and environmental conditions such as temperature and cleanliness were adequate.
Report Facts
Licensed capacity: 199
Current census: 169
Non-ambulatory capacity: 100
Bedridden capacity: 30
Hospice waiver capacity: 30
Food stock duration (perishable): 2
Food stock duration (non-perishable): 7
Hot water temperature: 117.8
Fire extinguisher last inspection date: Oct 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Smith | Executive Director | Met with Licensing Program Analyst during inspection |
| Abeye Duguma | Licensing Program Analyst | Conducted the inspection and authored the report |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 172
Capacity: 199
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that the facility elevator was in disrepair and not working, potentially affecting residents using wheelchairs on the third floor.
Complaint Details
The complaint alleged that the facility elevator was in disrepair and not working, affecting residents who use wheelchairs on the third floor. The allegation was unsubstantiated based on observations and interviews.
Findings
The Licensing Program Analyst observed the elevator to be working during a physical tour, interviewed 17 residents and 3 staff who confirmed the elevator was operational, and noted that residents on the second and third floors did not use wheelchairs. The allegation was found to be unsubstantiated.
Report Facts
Number of resident interviews: 17
Number of staff interviews: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gina Saucedo | Licensing Program Analyst | Conducted the complaint investigation and physical tour |
| Angela Smith | Administrator | Facility administrator met with the evaluator and was involved in the investigation |
| Troy Agard | Supervisor | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 172
Capacity: 199
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation regarding an allegation that the facility elevator was in disrepair and not working, affecting residents who use wheelchairs on the third floor.
Complaint Details
The complaint alleged that the facility elevator was in disrepair and not working, impacting residents using wheelchairs on the third floor. The investigation found the elevator operational and the allegation unsubstantiated.
Findings
The Licensing Program Analyst observed the elevator to be working, conducted 17 interviews with residents and 3 with staff, all confirming the elevator was operational and that residents on the second and third floors did not use wheelchairs. The allegation was found to be unsubstantiated, no citations were issued.
Report Facts
Number of resident interviews: 17
Number of staff interviews: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gina Saucedo | Licensing Program Analyst | Conducted the complaint investigation and physical tour |
| Angela Smith | Administrator | Met with Licensing Program Analyst during the investigation |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 199
Deficiencies: 0
Date: Mar 5, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff did not follow up with a resident's medical coverage.
Complaint Details
The complaint alleged that staff did not follow up with Resident #1's HMO insurance coverage. Interviews with residents and staff revealed the resident had an expired HMO card, causing a rejected appointment, which was rescheduled and resolved. The allegation was unsubstantiated.
Findings
The investigation found that the resident's issue was a misunderstanding and was resolved immediately. Staff assist residents with medical appointments and insurance management, and no health or safety hazards were noted. The allegation was unsubstantiated.
Report Facts
Residents interviewed: 3
Staff interviewed: 2
Days rescheduled appointment: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Smith | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Abeye Duguma | Licensing Program Analyst | Conducted complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 199
Deficiencies: 0
Date: Mar 5, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff did not follow up with a resident's medical coverage.
Complaint Details
The complaint alleged that staff did not follow up with Resident #1's HMO insurance coverage. Interviews with residents and staff revealed the resident had an expired HMO card but was rescheduled and received treatment. The allegation was unsubstantiated due to insufficient evidence.
Findings
The investigation found that the resident's issue with medical coverage was a mix-up that was resolved immediately, and the resident received needed care. Staff assist residents with appointments and insurance management, and no health or safety hazards were noted. The allegation was unsubstantiated.
Report Facts
Capacity: 199
Census: 173
Complaint Control Number: 31
Number of residents interviewed: 3
Number of staff interviewed: 2
Days rescheduled after error: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Smith | Executive Director | Met with Licensing Program Analyst during investigation |
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 199
Deficiencies: 1
Date: Oct 25, 2024
Visit Reason
An unannounced Case Management visit was conducted to address an incident of alleged financial abuse by Staff #1 involving multiple residents, which occurred on 2024-10-17.
Complaint Details
The visit was complaint-related due to allegations of financial abuse by Staff #1 involving six residents, with three police reports filed. The facility did not submit an incident report for the 2024-09-25 incident until 2024-10-24. Four of six alleged victims confirmed abuse during interviews. The investigation is ongoing and dollar amounts involved are unknown.
Findings
The investigation confirmed financial abuse involving six residents, with three filing police reports. The facility failed to submit a timely incident report for a related 2024-09-25 incident. Four of six alleged victims confirmed some form of financial abuse during interviews. No other health or safety hazards were noted.
Deficiencies (1)
Failure to submit an incident report within 24 hours as required by CCR 87211(a)(2) related to financial abuse incidents.
Report Facts
Residents involved in alleged abuse: 6
Police reports filed: 3
Residents interviewed: 4
Plan of Correction due date: Oct 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Smith | Executive Director | Met with Licensing Program Analyst during visit and provided statements regarding the incident |
| Abeye Duguma | Licensing Program Analyst | Conducted the unannounced Case Management visit and authored the report |
| Naira Margaryan | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 199
Deficiencies: 1
Date: Oct 25, 2024
Visit Reason
An unannounced Case Management visit was conducted to address an incident of alleged financial abuse by Staff #1 involving multiple residents, with police reports filed by some residents.
Complaint Details
The visit was complaint-related due to allegations of financial abuse by Staff #1 involving six residents, with three residents filing police reports. Four of six alleged victims were interviewed and confirmed some form of financial abuse. The investigation is ongoing with unknown dollar amounts involved.
Findings
The investigation confirmed financial abuse involving six residents, with four interviewed victims confirming abuse. The facility failed to submit an incident report timely for the 09/25/2024 incident. No other health and safety hazards were noted during the visit.
Deficiencies (1)
Failure to submit an incident report within 24 hours as required for occurrences threatening the welfare of residents; incident report was submitted late on 10/24/2024.
Report Facts
Number of residents involved in alleged abuse: 6
Number of residents who filed police reports: 3
Number of residents interviewed: 4
Plan of Correction due date: Oct 26, 2024
Census: 158
Total capacity: 199
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Smith | Executive Director | Met with Licensing Program Analyst and provided statements regarding the incident |
| Abeye Duguma | Licensing Program Analyst | Conducted the unannounced Case Management visit and investigation |
| Naira Margaryan | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Capacity: 199
Deficiencies: 0
Date: Sep 5, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not provide adequate supervision resulting in a resident eloping from the facility.
Complaint Details
The complaint alleged inadequate supervision leading to a resident eloping. The allegation was unsubstantiated based on interviews and record review.
Findings
The investigation found insufficient evidence to verify the allegation. Resident #1 was determined to be independent and not at risk for wandering or elopement. No health and safety hazards were noted during the visit, and the allegation was unsubstantiated.
Report Facts
Facility capacity: 199
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brandy Rangel | Assistant Administrator | Met with Licensing Program Analyst during the visit |
| Maya Mnoyan | Administrator | Named as facility administrator |
| Naira Margaryan | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 199
Deficiencies: 0
Date: Sep 5, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not provide adequate supervision, resulting in a resident eloping from the facility.
Complaint Details
The allegation that staff did not provide adequate supervision resulting in resident eloping was investigated and found to be unsubstantiated.
Findings
The investigation found that Resident #1 was independent and authorized to leave the facility unassisted. Staff interviews and record reviews indicated the incident was isolated, and there was insufficient evidence to substantiate the allegation. No health and safety hazards were noted during the visit.
Report Facts
Capacity: 199
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Maya Mnoyan | Administrator | Facility administrator named in the report |
| Brandy Rangel | Assistant Administrator | Met with Licensing Program Analyst during the visit |
| Naira Margaryan | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Census: 156
Capacity: 199
Deficiencies: 0
Date: Aug 29, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff did not provide a copy of the admission agreement to a resident.
Complaint Details
The allegation that facility staff did not provide a copy of the admission agreement to a resident was unsubstantiated based on staff interviews and records review.
Findings
The investigation found that staff did provide a copy of the admission agreement to the resident, and records confirmed this. There was insufficient information to support the allegation, and no health or safety issues were noted at the time of the visit.
Report Facts
Capacity: 199
Census: 156
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brandy Rangel | Assistant Administrator | Met with the Licensing Program Analyst during the investigation |
| Maya Mnoyan | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 156
Capacity: 199
Deficiencies: 0
Date: Aug 29, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff did not provide a copy of the admission agreement to a resident.
Complaint Details
The complaint alleged that facility staff did not provide a copy of the admission agreement to a resident. The allegation was unsubstantiated based on staff interviews and record reviews.
Findings
The investigation found that staff did provide a copy of the admission agreement to the resident, and records confirmed this. The allegation was determined to be unsubstantiated with no health or safety issues noted during the visit.
Report Facts
Capacity: 199
Census: 156
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brandy Rangel | Assistant Administrator | Met with Licensing Program Analyst during the investigation |
| Maya Mnoyan | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 199
Deficiencies: 0
Date: Jul 10, 2024
Visit Reason
An unannounced complaint investigation was conducted due to allegations that facility staff did not respond in a timely manner to a resident's call pendant and failed to provide emergency medical services in a timely manner.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included delayed response to a resident's call pendant and failure to provide timely emergency medical services. Interviews and records did not support these claims.
Findings
Based on interviews and records review, there was insufficient information to support the allegations. The resident was monitored frequently, and emergency services were called appropriately when the resident showed signs of distress. Both allegations were unsubstantiated.
Report Facts
Capacity: 199
Census: 154
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandy Rangel | Assistant Administrator | Met with Licensing Program Analyst during the investigation |
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 199
Deficiencies: 0
Date: Jul 10, 2024
Visit Reason
An unannounced complaint investigation was conducted due to allegations that facility staff did not respond in a timely manner to a resident's call pendant and failed to provide emergency medical services promptly.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included delayed staff response to a resident's call pendant and failure to provide timely emergency medical services. Interviews and record reviews did not support these allegations.
Findings
Based on interviews and records review, there was insufficient information to support the allegations. The resident was monitored frequently, and emergency services were called appropriately when the resident showed signs of distress. No health and safety issues were noted at the time of the visit.
Report Facts
Capacity: 199
Census: 154
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation |
| Brandy Rangel | Assistant Administrator | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 199
Deficiencies: 0
Date: Jun 28, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff mismanaged a resident's medication and did not meet the resident's medical needs.
Complaint Details
The complaint involved allegations of medication mismanagement and failure to meet medical needs. After interviews and record reviews, the allegations were found unsubstantiated.
Findings
The investigation found that the facility followed all physician orders and properly assisted the resident with medication and medical appointments. Both allegations were deemed unsubstantiated. No immediate health and safety risks were observed during the visit.
Report Facts
Facility capacity: 199
Resident census: 143
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation |
| Maya Mnoyan | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 199
Deficiencies: 1
Date: Jun 28, 2024
Visit Reason
An unannounced complaint investigation was conducted to investigate allegations that staff did not prevent an altercation between residents at the facility.
Complaint Details
The complaint alleged that staff did not prevent an altercation between residents. The allegation was substantiated based on interviews with residents and staff, and record review. The facility did not update service plans to address behavioral issues and failed to intervene timely during the altercation.
Findings
The investigation substantiated that staff did not intervene in time to prevent a physical altercation between Resident #1 and Resident #2. Interviews and record reviews revealed that service plans were not updated to address the residents' behavioral issues, and staff training was scheduled to address these concerns. No immediate health and safety risks were observed during the visit.
Deficiencies (1)
Failure to accord residents safe, healthful, and comfortable accommodations as evidenced by staff not intervening to prevent altercations between residents.
Report Facts
Residents involved in altercation: 2
Residents interviewed: 3
Staff interviewed: 4
Deficiency count: 1
Facility capacity: 199
Facility census: 143
Plan of Correction due date: Jul 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation |
| Maya Mnoyan | Administrator | Facility administrator named in report |
| Naira Margaryan | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 199
Deficiencies: 0
Date: Jun 28, 2024
Visit Reason
An unannounced complaint investigation was conducted to investigate allegations that staff mismanaged a resident's medication and did not meet the resident's medical needs.
Complaint Details
The complaint involved allegations of medication mismanagement and failure to meet medical needs. After interviews and record reviews, both allegations were found unsubstantiated.
Findings
The investigation found that the facility followed all physician orders and properly assisted the resident with their medication and medical needs. Both allegations were deemed unsubstantiated. No immediate health and safety risks were observed during the visit.
Report Facts
Facility capacity: 199
Resident census: 143
Medication dosage change: 1000
Medication dosage change: 800
Lab appointment dates: Jun 18, 2024
Lab appointment dates: Jun 21, 2024
Lab results received date: Jun 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Maya Mnoyan | Administrator | Facility administrator mentioned in relation to investigation |
| Brandy Rangel | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 199
Deficiencies: 1
Date: Jun 28, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff did not prevent an altercation between residents.
Complaint Details
The complaint alleged that staff did not prevent an altercation between residents. The allegation was substantiated based on interviews and record review. Staff failed to intervene in time to prevent the altercation between Resident #1 and Resident #2. The facility has agreed to update service plans and schedule staff training.
Findings
The investigation found that staff did not intervene in time to prevent a physical altercation between Resident #1 and Resident #2. The allegation was substantiated, and a deficiency was cited related to personal rights of residents.
Deficiencies (1)
Failure to ensure residents were accorded safe, healthful and comfortable accommodations as staff did not intervene to prevent an altercation between residents.
Report Facts
Residents involved in altercation: 2
Residents interviewed: 3
Staff interviewed: 4
Deficiency count: 1
Facility census: 143
Facility capacity: 199
Plan of Correction due date: Jul 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 199
Deficiencies: 0
Date: Jun 12, 2024
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that staff did not safeguard residents' belongings.
Complaint Details
The complaint alleging staff did not safeguard residents' belongings was investigated and found to be unsubstantiated.
Findings
The investigation found that Resident #1 left the facility on the same day of arrival without signing the admissions agreement and their belongings were placed in facility storage. There was insufficient information to support the allegation, and it was unsubstantiated.
Report Facts
Capacity: 199
Census: 151
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation visit |
| Nilda Mercado | Business Office Manager | Met with the evaluator during the investigation |
| Maya Mnoyan | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 199
Deficiencies: 0
Date: Jun 12, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not safeguard residents' belongings.
Complaint Details
The complaint alleging staff did not safeguard residents' belongings was unsubstantiated.
Findings
The investigation found insufficient information to support the allegation. Resident #1 left the facility before completing admission and their belongings were placed in facility storage. No health and safety issues were noted.
Report Facts
Capacity: 199
Census: 151
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation visit |
| Nilda Mercado | Business Office Manager | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Capacity: 199
Deficiencies: 0
Date: May 29, 2024
Visit Reason
An unannounced complaint investigation was conducted following an allegation that staff did not provide a safe environment for a resident.
Complaint Details
The complaint alleged that staff did not provide a safe environment for a resident. The allegation was unsubstantiated after investigation.
Findings
The investigation found that Resident #1 had been out of the community since 05/06/2024 due to being a danger to others, and staff were not aware of any threats or assaults against the resident. Based on interviews and record reviews, there was insufficient information to support the allegation, which was determined to be unsubstantiated.
Report Facts
Facility capacity: 199
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation |
| Brandy Rangel | Assistant Administrator | Met with Licensing Program Analyst during investigation |
| Maya Mnoyan | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 199
Deficiencies: 0
Date: May 29, 2024
Visit Reason
An unannounced complaint investigation visit was conducted due to allegations of lack of supervision resulting in resident assaults and staff not providing a safe environment for residents.
Complaint Details
The complaint involved allegations of lack of supervision leading to resident assaults and unsafe environment claims. The allegations were found to be unsubstantiated based on interviews and record reviews.
Findings
The investigation found insufficient evidence to substantiate the allegations. One resident was hospitalized after an altercation, but staff responded appropriately and residents reported feeling safe. No health and safety issues were noted at the time of the visit.
Report Facts
Capacity: 199
Census: 154
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandy Rangel | Assistant Administrator | Met with Licensing Program Analyst during the investigation |
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation visit |
| Naira Margaryan | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 199
Deficiencies: 0
Date: May 29, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff does not provide a safe environment for residents.
Complaint Details
The allegation that staff does not provide a safe environment for a resident was unsubstantiated after investigation. Resident #1 was out of the community due to being a danger to others and placed on a 5150 hold. Staff reported no knowledge of any threats or assaults against the resident.
Findings
The investigation found insufficient information to support the allegation. Interviews and record reviews confirmed that the alleged resident was not present at the facility during the visit and staff were not aware of any threats or assaults. No health and safety issues were noted at the time of the visit.
Report Facts
Facility capacity: 199
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brandy Rangel | Assistant Administrator | Met with Licensing Program Analyst during the visit |
| Maya Mnoyan | Administrator | Facility administrator named in report header |
| Naira Margaryan | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 199
Deficiencies: 0
Date: May 29, 2024
Visit Reason
An unannounced complaint investigation visit was conducted due to allegations of lack of supervision resulting in resident assaults and staff not providing a safe environment for residents.
Complaint Details
The complaint involved allegations of lack of supervision leading to resident assaults and unsafe environment. The allegations were found to be unsubstantiated based on interviews and records review.
Findings
The investigation found insufficient evidence to substantiate the allegations. One resident was hospitalized after an altercation, but staff intervened promptly and residents reported feeling safe. No health and safety issues were noted at the time of the visit.
Report Facts
Capacity: 199
Census: 154
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brandy Rangel | Assistant Administrator | Met with Licensing Program Analyst during the visit |
| Maya Mnoyan | Administrator | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Census: 199
Capacity: 199
Deficiencies: 0
Date: May 21, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the licensee does not allow a resident to have a cat.
Complaint Details
The complaint alleged that the licensee does not allow Resident #1 to have a cat. The investigation found that the resident's medical doctor stated the resident was not capable of caring for service animals, and staff had explained this to the resident and case manager. The allegation was unsubstantiated.
Findings
Based on staff interviews and facility records review, there was insufficient information to support the allegation. The complaint was determined to be unsubstantiated with no health and safety issues noted at the time of the visit.
Report Facts
Capacity: 199
Census: 199
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandy Rangel | Assistant Administrator | Met with Licensing Program Analyst during the complaint investigation |
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
Inspection Report
Complaint Investigation
Capacity: 199
Deficiencies: 0
Date: May 21, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the licensee does not allow a resident to have a cat.
Complaint Details
The complaint alleged that the licensee does not allow a resident to have a cat. The allegation was found to be unsubstantiated based on staff interviews and record review.
Findings
The investigation found that the resident's medical doctor stated the resident is not capable of caring for service animals, and staff explained this to the resident and their case manager. Facility records confirmed this information. The allegation was unsubstantiated.
Report Facts
Facility capacity: 199
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brandy Rangel | Assistant Administrator | Met with the Licensing Program Analyst during the investigation |
| Maya Mnoyan | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 149
Capacity: 199
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that, because of lack of supervision, a resident was able to leave the facility unassisted.
Complaint Details
The complaint alleged that Resident #1 was able to leave the facility unassisted due to lack of supervision. The investigation found that Resident #1 arrived on 04/16/2024 and left the facility the same day without signing the admissions agreement and has not returned. The facility is not locked down and Resident #1 is ambulatory. The allegation was unsubstantiated.
Findings
Based on interviews and records review, the allegation was found to be unsubstantiated. No health and safety issues were noted at the time of the visit.
Report Facts
Facility capacity: 199
Resident census: 149
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandy Rangel | Assistant Administrator | Met with Licensing Program Analyst during the investigation |
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation visit |
| Naira Margaryan | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 149
Capacity: 199
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that a resident was able to leave the facility unassisted because of lack of supervision.
Complaint Details
The complaint alleged lack of supervision allowing a resident to leave unassisted. The allegation was found unsubstantiated based on interviews and records review.
Findings
The investigation found that Resident #1 left the facility unassisted before completing admission paperwork. Records and staff interviews confirmed the resident is ambulatory and the facility is not locked down. The allegation was unsubstantiated with no health or safety issues noted at the time of the visit.
Report Facts
Capacity: 199
Census: 149
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brandy Rangel | Assistant Administrator | Met with Licensing Program Analyst during investigation |
| Aaron Khodorkovsky | Administrator | Facility administrator named in report header |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Original Licensing
Census: 143
Capacity: 199
Deficiencies: 0
Date: Feb 22, 2024
Visit Reason
The visit was an unannounced pre-licensing inspection conducted to evaluate the facility's readiness for licensing and compliance with regulatory standards.
Findings
The facility was found to be clean, well-maintained, and properly equipped with no deficiencies noted. Areas inspected included the kitchen, bedrooms, bathrooms, medication storage, common areas, and surroundings.
Report Facts
Facility capacity: 199
Resident census: 143
Facility temperature range: 72
Facility temperature range: 76
Hot water temperature: 119.9
Fire extinguisher last serviced date: Nov 19, 2023
Bedrooms inspected: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Khodorkovsky | Administrator | Met with Licensing Program Analysts during inspection |
| Rosaura Valenzuela | Licensing Evaluator | Conducted the facility evaluation |
| Naira Margaryan | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Original Licensing
Census: 143
Capacity: 199
Deficiencies: 0
Date: Feb 22, 2024
Visit Reason
The visit was an announced Pre-Licensing inspection conducted to evaluate the facility for licensing approval.
Findings
The facility was toured and inspected including the kitchen, bedrooms, bathrooms, medication room, common areas, and surroundings. No deficiencies were found and the facility met all requirements for pre-licensing.
Report Facts
Facility capacity: 199
Census: 143
Hot water temperature: 119.9
Fire extinguisher last serviced date: Nov 19, 2023
Inspection start time: 1030
Inspection end time: 1639
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Khodorkovsky | Administrator | Met with Licensing Program Analysts during inspection |
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the inspection and signed the report |
| Abeye Duguma | Licensing Program Analyst | Conducted the inspection |
| Naira Margaryan | Licensing Program Manager | Named in report header |
Inspection Report
Original Licensing
Census: 126
Capacity: 199
Deficiencies: 0
Date: Nov 30, 2023
Visit Reason
The visit was conducted as a Component II evaluation for a Change in Ownership (CHOW) application for the Residential Care Facility for Elderly (RCFE).
Findings
The Component II completion was successful, confirming that the Applicant and Administrator understand community care facility licensing laws and regulations. The evaluation covered facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and pre-licensing readiness.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Khodorkovsky | Administrator | Administrator participating in Component II evaluation and interview. |
| Steven Atlas | Applicant | Applicant participating in Component II evaluation and interview. |
Inspection Report
Original Licensing
Census: 126
Capacity: 199
Deficiencies: 0
Date: Nov 30, 2023
Visit Reason
The visit was conducted as a Component II evaluation for a Change in Ownership (CHOW) application for a Residential Care Facility for Elderly (RCFE).
Findings
The Component II evaluation was completed successfully, confirming that the Applicant and Administrator understand the community care facility licensing laws and regulations, including facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints and reporting, and pre-licensing readiness.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Khodorkovsky | Administrator | Administrator participating in Component II evaluation |
| Steven Atlas | Applicant | Applicant participating in Component II evaluation |
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