Most inspections found no deficiencies, with the facility generally clean, in good repair, and compliant with regulations. The most recent report from March 25, 2025, cited one deficiency for not conducting emergency drills quarterly as required, which poses a potential health and safety risk. Earlier deficiencies included a shortfall in maintaining a seven-day supply of non-perishable food in July 2022, but these issues were isolated and minor. Several complaint investigations were not applicable as no complaints were noted. The facility appears to have maintained or improved compliance over time, with the latest inspection showing only a single, relatively minor deficiency.
The Licensing Program Analyst conducted an unannounced visit to perform a required annual inspection of the facility.
Findings
The facility was found to be clean, in good repair, and compliant with most regulations. One deficiency was cited related to emergency drills not being conducted quarterly as required, posing a potential health and safety risk.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Facility did not conduct emergency drills quarterly as required; only one drill conducted yearly.
Type B
Report Facts
Capacity: 6Census: 6Deficiencies cited: 1Fire extinguisher service date: Jul 26, 2024Last fire drill date: Feb 20, 2025Administrator certification expiration: Dec 2, 2025Plan of Correction due date: Apr 4, 2025
Employees Mentioned
Name
Title
Context
Loren McElvain
Administrator
Met with Licensing Program Analyst during inspection
The inspection was an unannounced required 1-year visit to evaluate the facility's compliance with licensing regulations.
Findings
No deficiencies were observed during the visit as needed repairs were already in process. The facility had minor physical issues such as a broken fence and missing kitchen drawers, with repairs expected to be completed by 4/23/2024. Documentation was mostly complete except for one resident's missing last page of a physician's report, which the administrator is addressing.
An unannounced visit was conducted by Licensing Program Analyst Janira Arreola to perform a health and safety check and to gather documentation concerning a resident death.
Findings
The facility was toured including resident rooms and supplies. A deficiency was noted for not maintaining a 7-day supply of non-perishable food at the time of the visit.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Non-perishable food supply at the facility did not meet the required one week supply.
Type A
Report Facts
Capacity: 6Census: 4Deficiencies cited: 1
Employees Mentioned
Name
Title
Context
Janira Arreola
Licensing Program Analyst
Conducted the unannounced visit and inspection
Joel Esquivel
Licensing Program Manager
Supervisor overseeing the inspection
Loren McElvain
Licensee / Administrator
Facility licensee met during the inspection and informed of findings
An unannounced annual inspection was conducted with an emphasis on infection control to evaluate the facility's compliance with Community Care Licensing guidelines.
Findings
The inspection found no deficiencies. The facility demonstrated adequate infection control measures, including sufficient hand hygiene supplies, cleaning provisions, and a designated infection control lead person responsible for COVID-19 related protocols.
Employees Mentioned
Name
Title
Context
Jerry McElvain
Staff
Met with Licensing Program Analysts during the inspection and participated in the exit interview.
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