Inspection Report Summary
Most inspections at this facility were free of deficiencies, with several complaint investigations finding allegations unsubstantiated. The most recent report from April 29, 2025, had no deficiencies and found no evidence to support claims of inadequate supervision, feeding, or failure to notify responsible parties. Earlier reports identified isolated issues such as accessible toxins posing safety risks, incomplete medication records, and outdated physician visits, but these were addressed without enforcement actions or fines. A few substantiated deficiencies involved medication errors, failure to notify physicians of condition changes, and delayed medical care, some posing immediate health risks, but no license suspensions or fines were listed. The facility’s record shows improvement over time, with recent inspections showing fewer or no deficiencies compared to earlier reports.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
1.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
87% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 77
Capacity: 89
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations regarding inadequate supervision resulting in a resident pushing another resident, inadequate feeding resulting in weight loss, and failure to inform the resident's responsible party about a change in condition.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included inadequate supervision leading to a resident pushing another, inadequate feeding causing weight loss, and failure to notify the responsible party about a change in condition. Interviews and record reviews did not provide sufficient evidence to prove the allegations.
Findings
The investigation found insufficient evidence to substantiate the allegations. The incident of pushing was witnessed by a caregiver but lacked conclusive proof for further action. Weight loss was not confirmed as a concern by staff, and no evidence was found that the responsible party was not informed about changes in the resident's condition, including a reported nail fungus.
Report Facts
Weight loss: 8
Resident weight record: 177.6
Resident weight record: 182
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings. |
| Eugenia Smith | Executive Director | Met with Licensing Program Analyst during the investigation and provided information regarding allegations. |
| Jackie Jin | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation. |
| Christine Dolores Kabariti | Interviewed staff members regarding the incident between residents. |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 89
Deficiencies: 1
Date: Apr 17, 2025
Visit Reason
An unannounced complaint investigation was conducted based on allegations received on 06/23/2022 regarding toxins left accessible to residents, staff not following physician orders, insufficient staffing, and residents being left soiled.
Complaint Details
The complaint investigation was substantiated for toxins being accessible to residents. Other allegations regarding staff not following physician orders, insufficient staffing, and residents being left soiled were unsubstantiated.
Findings
The investigation substantiated the allegation that toxins and sharps were accessible to residents in 8 out of 10 apartments, posing immediate health and safety risks. The allegations that staff were not following physician orders, the facility lacked sufficient staff, and residents were left soiled were found to be unsubstantiated based on observations, interviews, and record reviews.
Deficiencies (1)
Failure to ensure disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items were in locked storage and not left unattended outside locked storage.
Report Facts
Resident apartments with accessible toxins and sharps: 8
Facility capacity: 89
Census: 80
Staff observed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Cassandra Pace | Business Office Director | Met with Licensing Program Analyst during the investigation. |
| Diana Smith | Administrator | Facility administrator named in the report. |
| Cowan April | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 89
Deficiencies: 1
Date: Apr 4, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2025-03-20 regarding staff mishandling a resident's medication and inadequate care and supervision of a resident.
Complaint Details
The complaint investigation was substantiated for the allegation that staff mishandled a resident's medication on 02/07/2025 by not recording the 6:00am dose of PRN cough medicine properly. The allegation that a resident sustained an unexplained spinal fracture and that staff did not provide adequate care and supervision was unsubstantiated due to lack of evidence.
Findings
The investigation substantiated the allegation that staff mishandled a resident's medication by failing to properly record the administration of a PRN cough medication dose, posing a potential health and safety risk. Another complaint regarding a resident sustaining an unexplained injury and inadequate supervision was unsubstantiated due to insufficient evidence.
Deficiencies (1)
Failure to ensure a record of a resident's PRN medication dose on 02/07/2025 at 6:00am was maintained, including dosage and resident's response.
Report Facts
Facility capacity: 89
Census: 78
Staff interviewed: 6
Plan of Correction due date: Apr 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eugenia Smith | Executive Director | Met with Licensing Program Analyst and named in findings review |
| Christine Kabariti | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Jackie Jin | Licensing Program Manager | Named in report as Licensing Program Manager |
| Erin Wiley | Generations Program Director | Named in findings review meeting |
Inspection Report
Complaint Investigation
Capacity: 89
Deficiencies: 0
Date: Apr 4, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2022-11-22 regarding multiple allegations about resident care and facility practices at Loma Clara Senior Living Facility.
Complaint Details
The complaint included allegations that staff did not ensure a resident's oxygen concentrator was working properly, did not keep the resident's room free of odors, improperly disposed of soiled diapers, failed to change the resident out of night clothes, did not safeguard personal belongings, and did not wash the resident's hands after meals. The investigation concluded these allegations were unsubstantiated.
Findings
Based on interviews, record reviews, observations, and photographs, the allegations were found to be unsubstantiated. The investigation found no preponderance of evidence to prove the alleged violations occurred, and no deficiencies were cited.
Report Facts
Facility capacity: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Kabariti | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jackie Jin | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Eugenia Smith | Executive Director | Met with Licensing Program Analyst during the investigation |
| Erin Wiley | Generations Program Director | Received a copy of the report |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 89
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that a facility staff physically abused a resident by picking him/her up, carrying him/her, and putting him/her down causing shoulder and hip pain.
Complaint Details
The complaint alleged physical abuse by a tall male caregiver towards a resident (R1). The investigation included interviews and record reviews. The resident denied any staff abuse and stated only female caregivers provide care. Staff confirmed male caregivers do not provide care to the resident. The allegation was determined to be unfounded.
Findings
Based on interviews with staff, a witness, and the resident, as well as record review and observation, the allegation was found to be unfounded. No evidence supported that staff physically abused the resident, and no deficiencies were cited.
Report Facts
Facility capacity: 89
Census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Kabariti | Licensing Program Analyst | Conducted the complaint investigation |
| Cassandra Pace | Business Office Director | Met with the investigator and reviewed the report |
| Jackie Jin | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Erin Wiley | Generations Program Director | Reviewed the report with Business Office Director |
Inspection Report
Annual Inspection
Census: 74
Capacity: 89
Deficiencies: 1
Date: Feb 13, 2025
Visit Reason
The inspection was an unannounced annual required 1-year inspection conducted by the Licensing Program Analyst to evaluate compliance with regulations at Loma Clara Senior Living Facility.
Findings
The facility was generally compliant with regulations including fire safety, food storage, and staff training. However, a deficiency was cited due to two residents in the memory care unit having outdated physician reports, which posed a potential health and safety risk. The facility took corrective action by following up with physicians and implementing a plan to ensure annual routine visits.
Deficiencies (1)
Failure to ensure all residents receive an annual routine visit with a licensed medical professional as required, evidenced by 2 residents in Generation's medical assessments being outdated from 2022 and 2023.
Report Facts
Staff training hours: 20
Fire extinguisher last service date: Jan 9, 2025
Fire drill last date: Jan 30, 2025
Plan of Correction Due Date: Feb 20, 2025
Resident files reviewed: 4
Resident medications reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eugenia Smith | Executive Director | Met with Licensing Program Analyst during inspection and discussed findings |
| Christine Kabariti | Licensing Program Analyst | Conducted the inspection and authored the report |
| Jackie Jin | Licensing Program Manager | Named as supervisor and licensing program manager on the report |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 89
Deficiencies: 0
Date: Sep 5, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations received on 2024-08-26 regarding staff behavior towards a resident.
Complaint Details
The complaint alleged that staff yelled at a resident and mishandled a resident in a wheelchair. The investigation determined these allegations were false and without reasonable basis.
Findings
The investigation found the allegations to be unfounded based on staff interviews, record reviews, and observations. No deficiencies were cited under California Code of Regulations, Title 22.
Report Facts
Capacity: 89
Census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eugenia Smith | Executive Director | Met with Licensing Program Analysts during the investigation and reviewed the report |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation |
| Marcella Tarin | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Sarah Yip | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 89
Deficiencies: 0
Date: Sep 5, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that a resident was not allowed to have phone calls or visitors.
Complaint Details
The complaint alleged that facility staff did not allow resident R1 to have phone calls and visitors. Interviews with staff and the resident indicated that R1 has a cell phone and visits are allowed based on the resident's choice and screening process. The resident preferred not to see a particular visitor and staff intervened with consent. The allegations were determined to be false and without reasonable basis.
Findings
The investigation found the allegations to be unfounded based on staff and resident interviews and record reviews. No deficiencies were cited.
Report Facts
Complaint Control Number: 26
Capacity: 89
Census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Eugenia Smith | Executive Director | Met with Licensing Program Analysts during the investigation and report review |
Inspection Report
Annual Inspection
Census: 76
Capacity: 89
Deficiencies: 1
Date: Feb 16, 2024
Visit Reason
The inspection was an unannounced required 1-year annual inspection of the Loma Clara Senior Living Facility conducted by the Licensing Program Analyst.
Findings
The facility was generally compliant with regulations including resident file documentation, medication storage, and environmental safety. However, a deficiency was cited related to medication administration where one resident was not provided the correct dosage for four medications, posing an immediate health and safety risk.
Deficiencies (1)
Resident (R1) was not provided with the correct dosage for 4 medications, which contained extra dosages in the bubble packs posing an immediate health, safety or personal rights risk.
Report Facts
Deficiency count: 1
Plan of Correction Due Date: Feb 17, 2024
Resident files reviewed: 8
Staff files reviewed: 5
Staff training hours: 20
Emergency drills: 4
Hot water temperature: 110
Refrigerator temperature: 36
Freezer temperature: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eugenia Smith | Executive Director | Met with Licensing Program Analyst during inspection and reviewed report findings. |
| Christine Dolores | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Sarah Yip | Licensing Program Manager | Supervisor of the inspection. |
| Julie Mayder | Named in review of the deficiency report with Executive Director and others. | |
| Maria Martinez | Named in review of the deficiency report with Executive Director and others. | |
| Cassandra Pace | Named in review of the deficiency report with Executive Director and others. | |
| Rubin Aguila | Named in review of the deficiency report with Executive Director and others. | |
| Anissa Padilla | Named in review of the deficiency report with Executive Director and others. | |
| Rebecca DiRubio | Named in review of the deficiency report with Executive Director and others. |
Inspection Report
Census: 72
Capacity: 89
Deficiencies: 0
Date: Dec 27, 2023
Visit Reason
The visit was an unannounced case management - other visit to advise the facility of Title 22 regulations regarding Restricted Health Condition for Indwelling Urinary Catheters and the exception request process.
Findings
No deficiencies were cited. The Licensing Program Analyst advised the facility on Title 22 regulations and exception request procedures for residents with indwelling urinary catheters. An advisory note was provided.
Report Facts
Residents with indwelling urinary catheters: 1
Residents with temporary urinary catheter: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Mayder | Senior Resident Care Director | Met with Licensing Program Analyst during visit |
| Christine Dolores | Licensing Program Analyst | Conducted the unannounced case management visit and provided regulatory guidance |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 89
Deficiencies: 1
Date: Jul 14, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 08/30/2022 regarding failure to seek timely medical care for a resident, questionable death, and understaffing at the facility.
Complaint Details
The complaint investigation was substantiated for failure to seek timely medical care for resident R1. The allegation was supported by evidence including medical records, observations, and staff interviews. The allegations of questionable death and understaffing were unsubstantiated.
Findings
The investigation substantiated the allegation that staff did not provide timely medical treatment to resident R1, posing an immediate health and safety risk. The resident tested positive for COVID-19, showed progressive weakness, and was eventually hospitalized and placed under hospice care before passing away. The allegations of questionable death and understaffing were found to be unsubstantiated based on record review and interviews.
Deficiencies (1)
The licensee did not immediately telephone 9-1-1 when an injury or other circumstance resulted in an imminent threat to a resident’s health, including an apparent life-threatening medical crisis.
Report Facts
Capacity: 89
Census: 60
Deficiency count: 1
Plan of Correction Due Date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Becca Black | Interim Executive Director | Met with Licensing Program Analyst during investigation and report review |
| Diana Smith | Administrator | Facility administrator named in report header |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 89
Deficiencies: 0
Date: Jul 14, 2023
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 2023-01-23 regarding the facility's failure to provide proper notice to a resident's representative within 2 business days of a rate increase after initially providing services.
Complaint Details
The complaint alleged that the licensee did not provide proper notice to the resident's representative within 2 business days of the rate increase after initially providing services. The allegation was found unsubstantiated based on interviews, record review, and observation.
Findings
The investigation found the allegation unsubstantiated after review of records, interviews, and observations. The resident sustained an unwitnessed fall, and although a one-to-one companion was required and endorsed, the resident was not billed for this service due to departure from the facility. No deficiencies were cited.
Report Facts
Facility capacity: 89
Census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Becca Black | Interim Executive Director | Met with Licensing Program Analyst during investigation and reviewed report |
| Jairus Cabuena | Administrator | Facility administrator named in report header |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 89
Deficiencies: 1
Date: Jul 14, 2023
Visit Reason
The visit was conducted as a case management - deficiencies visit due to violations observed during a complaint investigation related to a resident testing positive for COVID-19 and lack of physician notification.
Complaint Details
Complaint control number 26-AS-20220830100730. The complaint involved a resident testing positive for COVID-19 and the facility's failure to notify the resident's physician of condition changes. The deficiency was substantiated.
Findings
The facility failed to notify the resident's physician of changes in condition from 07/11/2022 to 07/17/2022 while the resident was diagnosed with COVID-19, posing an immediate health, safety, and personal rights risk.
Deficiencies (1)
Failure to inform resident (R1)'s physician of any changes of condition while being diagnosed with COVID-19.
Report Facts
Capacity: 89
Census: 60
Deficiencies cited: 1
Plan of Correction Due Date: Jul 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Becca Black | Interim Executive Director | Met with Licensing Program Analyst during visit and discussed findings |
| Maria Martinez | Generations Program Director | Reviewed report with Licensing Program Analyst |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Sarah Yip | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 89
Deficiencies: 0
Date: Apr 6, 2023
Visit Reason
The visit was an unannounced case management incident inspection triggered by an incident report and death report received for a resident who choked on food and subsequently expired at the facility.
Complaint Details
The visit was based on an incident report and death report for resident R1 who choked on food on 03/29/2023 and expired at the facility. The facility is pending the coroner's report and will forward it once obtained.
Findings
The Licensing Program Analyst conducted an unannounced visit, reviewed records, and interviewed the Executive Director. The resident was given a regular diet and had no history of choking. No deficiencies were cited per California Code of Regulations, Title 22.
Report Facts
Census: 63
Total Capacity: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jett Cabuena | Executive Director | Interviewed during the inspection and confirmed incident details |
| Christine Dolores | Licensing Program Analyst | Conducted the unannounced case management incident visit |
Inspection Report
Capacity: 89
Deficiencies: 0
Date: Feb 10, 2023
Visit Reason
The visit was a case management - other unannounced visit to follow-up on a self-reported SOC-341 regarding inappropriate behavior by staff with resident(s) in care.
Findings
During the visit, the Licensing Program Analyst toured the memory care section and interviewed four staff members. No deficiencies were cited per California Code of Regulations, Title 22.
Report Facts
Staff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jairus Cabuena | Executive Director | Met with Licensing Program Analyst during the visit and named in the report |
Inspection Report
Annual Inspection
Census: 66
Capacity: 89
Deficiencies: 0
Date: Feb 10, 2023
Visit Reason
The inspection was an unannounced annual inspection focusing on infection control at the Loma Clara Senior Living Facility.
Findings
The facility was found to be in compliance with no deficiencies cited. Infection control measures were observed, including staff wearing face coverings, symptom screening, availability of PPE, and COVID-19 related signage throughout the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jairus Cabuena | Executive Director | Met with Licensing Program Analyst during the inspection and reviewed the report. |
| Christine Dolores | Licensing Program Analyst | Conducted the annual inspection focusing on infection control. |
| Sarah Yip | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 89
Deficiencies: 0
Date: Feb 1, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not follow a resident's care plan and that a resident received a fracture due to staff negligence.
Complaint Details
The complaint was received on 08/29/2022 and involved allegations that staff failed to follow the resident's care plan and that the resident sustained a fracture due to staff negligence. The investigation concluded the allegations were unsubstantiated due to insufficient evidence.
Findings
The investigation found that the allegations were unsubstantiated based on interviews and record reviews. The resident's signed service agreement indicated a one-person assist for bathing, and staff believed showers and transport were one-person assists. No deficiencies were cited.
Report Facts
Complaint control number: 26-AS-20220829084324
Capacity: 89
Census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jairus Cabuena | Executive Director | Met with Licensing Program Analyst during investigation |
| Sarah Yip | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 89
Deficiencies: 2
Date: Feb 1, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2023-01-23 regarding facility safety concerns including unsecured toxins and obstructed stairwells.
Complaint Details
The complaint investigation was substantiated based on observations and record review. The allegations included unsecured toxins and obstructed stairwells, both posing immediate risks to residents.
Findings
The investigation substantiated that toxins were accessible in resident apartments and one of two stairwells was obstructed by large items. Both issues posed immediate health, safety, and personal rights risks. The facility corrected the deficiencies during the visit and developed a plan of correction.
Deficiencies (2)
Facility stairwells were not free of obstruction, with large items blocking passageways.
Toxins were accessible to residents with dementia, posing a danger.
Report Facts
Facility capacity: 89
Resident apartments toured: 10
Stairwells inspected: 2
Staff interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jairus Cabuena | Executive Director | Facility administrator involved in the investigation and plan of correction |
| Maria Martinez | Memory Care Director | Met with Licensing Program Analyst during investigation and toured memory care section |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 89
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-05-11 regarding staff mismanagement of medications, rough handling of residents, failure to follow prescribed diet plans, and theft of residents' personal belongings.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff mismanaging medications, rough handling of residents, failure to follow diet plans, and theft of personal belongings. Interviews with staff and residents, document reviews, and observations did not support these allegations.
Findings
Based on interviews, record reviews, and observations conducted between 2022-08-08 and 2022-12-01, the Department determined that the allegations were unsubstantiated with no preponderance of evidence to prove violations occurred. No deficiencies were cited.
Report Facts
Staff interviewed: 5
Residents interviewed: 5
Facility capacity: 89
Facility census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jett Cabuena | Executive Director | Met with Licensing Program Analyst during the investigation |
| Sarah Yip | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 89
Deficiencies: 0
Date: Jul 1, 2022
Visit Reason
An unannounced initial complaint investigation was conducted by the Licensing Program Analyst at the facility.
Complaint Details
The visit was triggered by an initial complaint investigation. A technical violation was issued but no deficiencies were cited.
Findings
A technical violation was observed regarding the absence of 'No Smoking - Oxygen in use' signs in two resident rooms requiring oxygen. The facility staff corrected the violation during the visit. No deficiencies were cited.
Report Facts
Resident rooms without oxygen signs: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Mayder | Resident Care Director | Met with Licensing Program Analyst during complaint visit. |
| Christine Dolores | Licensing Program Analyst | Conducted the unannounced complaint investigation and case management visit. |
| Jackie Jin | Licensing Program Manager | Named in report header. |
Inspection Report
Annual Inspection
Census: 69
Capacity: 89
Deficiencies: 0
Date: Feb 23, 2022
Visit Reason
An unannounced annual required inspection was conducted to focus on infection control at the facility.
Findings
The inspection found that the facility had appropriate infection control measures in place, including signage, symptom screening, PPE supplies, social distancing, and sanitation practices. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Smith | Administrator | Met with Licensing Program Analyst during inspection and reviewed report findings. |
| Christine Dolores | Licensing Program Analyst | Conducted the unannounced annual inspection focusing on infection control. |
| Jackie Jin | Licensing Program Manager | Named in report header as Licensing Program Manager. |
Inspection Report
Routine
Census: 59
Capacity: 89
Deficiencies: 0
Date: Dec 31, 2021
Visit Reason
The visit was a scheduled technical assistance visit conducted to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility.
Findings
The Licensing Program Analyst conducted a Facetime tour of the facility and made several COVID-19 related recommendations. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Bruhn | Executive Director | Met with Licensing Program Analyst during the visit. |
| Christine Dolores | Licensing Program Analyst | Conducted the scheduled technical assistance visit. |
| Jackie Jin | Licensing Program Manager | Participated in the facility tour and report review. |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 89
Deficiencies: 0
Date: Oct 29, 2021
Visit Reason
An unannounced complaint investigation was conducted following allegations that a resident sustained multiple fractures while in care and that staff failed to seek medical attention for the resident in a timely manner.
Complaint Details
The complaint involved allegations that a resident sustained multiple fractures and that staff failed to seek timely medical attention after a fall in May 2021. The investigation included interviews with staff, the resident's responsible party, and review of medical records. The findings were unsubstantiated due to insufficient evidence to prove the allegations.
Findings
The investigation found that the resident had multiple fractures and a neurocognitive disorder with a history of falls. Staff encouraged use of a walker and monitored the resident, but the resident often refused assistance. The allegation that staff failed to seek timely medical attention was unsubstantiated as the resident's health care agent delayed hospital transfer and staff assessments were documented.
Report Facts
Facility capacity: 89
Resident census: 63
Complaint control number: 26-AS-20210511092104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jennifer Bruhn | Executive Director | Met with Licensing Program Analyst during investigation |
| Jolie C. Higgins | Administrator | Facility administrator interviewed regarding resident condition |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 89
Deficiencies: 0
Date: Jul 16, 2021
Visit Reason
An unannounced case management visit was conducted to discuss an incident report submitted regarding a resident who was reported to be held against his will and made sexual advancements to staff.
Complaint Details
The visit was triggered by a complaint alleging that Resident R1 was being held against his will and made sexual advancements to staff. The complaint was investigated through interviews and review of documentation, and the incident was denied by staff and resident.
Findings
Interviews with facility staff and the resident denied the incident occurred. A plan of action was created involving communication with family and the resident's physician, a psychological evaluation suggestion, and adjustments to medication administration procedures. No deficiencies were cited during the visit.
Report Facts
Capacity: 89
Census: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolie C. Higgins | Administrator | Facility administrator listed in the report |
| Sarah Serpa | Generation Program Director | Met with Licensing Program Analyst and Manager during the visit and reviewed the report |
| Christine Dolores | Licensing Program Analyst | Conducted the unannounced case management visit |
| Jackie Jin | Licensing Program Manager | Conducted the unannounced case management visit |
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