Deficiencies (last 7 years)
Deficiencies (over 7 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
68% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
81% occupied
Based on a March 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 71
Capacity: 88
Deficiencies: 0
Date: Mar 12, 2026
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2025-12-22 regarding improper diapering assistance, failure to shower a resident, failure to wash resident's clothing, and failure to safeguard resident's personal items.
Complaint Details
The complaint investigation was unsubstantiated based on interviews with multiple staff members and review of Resident 1's records. Allegations included improper diapering assistance resulting in rash, failure to shower, failure to wash clothing, and failure to safeguard personal items. No preponderance of evidence was found to prove the alleged violations.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Interviews with staff and review of resident records indicated that care was provided according to residents' care plans and facility procedures, and no violations were confirmed.
Report Facts
Capacity: 88
Census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Velasquez | Business Office Director | Met with Licensing Program Analyst during investigation and exit interview |
| Tyler Branes | Administrator | Facility administrator named in report |
Inspection Report
Census: 72
Capacity: 88
Deficiencies: 1
Date: Feb 12, 2026
Visit Reason
An unannounced facility visit was conducted to perform Case Management following a self-reported incident involving medication administration.
Findings
The facility reported that Resident 1 received Ativan 0.5 mg tablets earlier than the physician’s prescribed times on two occasions. Staff acknowledged the error and updated the computer system to prevent early administration. A technical violation was reviewed during the visit.
Deficiencies (1)
Resident 1 received Ativan 0.5 mg tablets earlier than the physician’s prescribed administration times.
Report Facts
Medication administration timing error: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carmen Bodnar | Facility Nurse | Met with Licensing Program Analyst during inspection and involved in medication administration finding |
| Sarah Hurt | Licensing Program Analyst | Conducted the unannounced facility visit |
| Tyler Branes | Administrator/Director | Named as facility administrator |
Inspection Report
Annual Inspection
Census: 63
Capacity: 88
Deficiencies: 6
Date: Jul 24, 2025
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements, including review of facility conditions, resident care, and documentation.
Findings
The inspection found several deficiencies including water temperature exceeding allowed limits, medication administration errors, missing required bedroom signage and furnishings, and incomplete hospice care plans for some residents. The facility otherwise maintained clean and safe conditions with adequate emergency preparedness.
Deficiencies (6)
Water temperature in room 107 measured 123 degrees, exceeding the maximum allowed temperature.
Resident 5's medication count was off by 2 doses and Resident 3 was given an extra dose of medication on 07/16/2025.
Resident 1's bedroom did not have the required sign indicating Oxygen in use.
Several bedroom showers lacked non-slip flooring mats.
Resident 2 did not have required bedroom furnishings (dresser).
Resident 3 and Resident 4 did not have current hospice care plans.
Report Facts
Residents on hospice: 3
Medication count discrepancy: 2
Extra medication dose date: Jul 16, 2025
Water temperature: 123
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Vasquez | Administrator | Met during inspection and named in relation to medication administration deficiencies |
| Sarah Hurt | Licensing Program Analyst | Conducted the inspection |
| Brenda Chan | Licensing Program Manager | Named in report |
| Stephenie Doub | Licensing Program Manager | Named in relation to appeal rights and report |
Inspection Report
Annual Inspection
Census: 63
Capacity: 88
Deficiencies: 6
Date: Jul 24, 2025
Visit Reason
Licensing Program Analyst Sarah Hurt conducted an unannounced visit for the facility’s annual inspection to evaluate compliance with licensing requirements and review facility operations.
Findings
The inspection found the facility generally clean and in good repair with adequate food supply and safety equipment operational. However, deficiencies were noted including water temperature exceeding allowed limits, medication administration errors, missing oxygen signage, lack of non-slip mats in showers, and incomplete hospice care plans.
Deficiencies (6)
Water temperature in room 107 measured 123 degrees, exceeding the maximum allowed temperature.
Resident 5's medication count was off by 2 doses and Resident 3 was given an extra dose of medication on 07/16/2025.
Resident 1's bedroom did not have required sign indicating Oxygen in use.
Several bedroom showers lacked non-slip flooring mats.
Resident 2 did not have required bedroom furnishings (dresser).
Resident 3 and Resident 4 do not have current hospice care plans.
Report Facts
Residents on hospice: 3
Medication count discrepancy: 2
Water temperature: 123
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Vasquez | Administrator | Met during inspection and named in relation to certification and exit interview |
| Sarah Hurt | Licensing Program Analyst | Conducted the inspection and signed the report |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 88
Deficiencies: 1
Date: Apr 9, 2025
Visit Reason
The inspection was an unannounced visit to investigate a complaint alleging that staff failed to provide safe, healthful, and comfortable accommodations to residents.
Complaint Details
The complaint was substantiated based on interviews and observations that residents were disrupted by loud noises and staff behavior, posing a potential health, safety, or personal rights risk.
Findings
The investigation found that three out of five residents reported excessive noise in the hallway, including loud doors and staff speaking loudly. The Licensing Program Analyst observed loud door sounds and music audible in the hallway, substantiating the complaint.
Deficiencies (1)
Failure to accord residents dignity in their personal relationships due to loud sounds of doors, music, and staff speaking loudly disrupting residents.
Report Facts
Capacity: 88
Census: 35
Plan of Correction Due Date: Apr 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Marufa Tanzin | Assisted Living Director | Met with the Licensing Program Analyst during the investigation and was involved in the exit interview |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 88
Deficiencies: 1
Date: Apr 9, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff failed to provide safe, healthful, and comfortable accommodations to residents.
Complaint Details
The complaint was substantiated based on interviews and observations that residents were disrupted by loud noises and staff behavior, posing a potential health, safety, or personal rights risk.
Findings
The investigation found that three out of five residents reported excessive noise in the hallway, including loud door closings and staff speaking loudly. Observations confirmed loud noises and music audible in the hallway, substantiating the complaint.
Deficiencies (1)
Failure to accord residents dignity in their personal relationships with staff and others, evidenced by loud sounds of doors, music, and staff speaking loudly disrupting residents.
Report Facts
Capacity: 88
Census: 35
Plan of Correction Due Date: Apr 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Marufa Tanzin | Assisted Living Director | Met with the Licensing Program Analyst during the investigation and was involved in the exit interview |
| Tyler Branes | Administrator | Facility administrator named in the report |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 65
Capacity: 88
Deficiencies: 0
Date: Dec 10, 2024
Visit Reason
The visit was an unannounced Case Management visit initiated by the licensee to review an unusual incident involving a resident leaving the facility unassisted.
Findings
The Licensing Program Analyst reviewed the incident report and confirmed that the resident was able to leave the facility unassisted according to the physician's report. Facility staff will conduct two-hour safety checks and provide one-on-one supervision until reassessment. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Vasquez | Facility Administrator | Met with Licensing Program Analyst during the visit and involved in technical assistance regarding resident reassessment. |
| Sarah Hurt | Licensing Program Analyst | Conducted the unannounced Case Management visit and reviewed the unusual incident report. |
Inspection Report
Census: 65
Capacity: 88
Deficiencies: 0
Date: Dec 10, 2024
Visit Reason
The visit was an unannounced Case Management visit initiated by the licensee to review an unusual incident involving a resident leaving the facility.
Findings
The Licensing Program Analyst reviewed the incident report and found that Resident 1 left the facility but was safely returned by staff. Resident 1's physician report allows unassisted leaving. No deficiencies were cited, and technical assistance was provided regarding reassessment and safety checks.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Vasquez | Facility Administrator | Met with Licensing Program Analyst during the visit and involved in technical assistance regarding Resident 1. |
| Sarah Hurt | Licensing Program Analyst | Conducted the unannounced Case Management visit and reviewed the incident report. |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 88
Deficiencies: 1
Date: Oct 3, 2024
Visit Reason
An unannounced facility visit was conducted to open a complaint investigation regarding staff training documentation.
Complaint Details
Visit was complaint-related; no substantiation status explicitly stated.
Findings
The facility lacked proof of required medication administration training documentation for a staff member before assisting residents with self-administering medications. Technical assistance was provided to the facility staff regarding this issue.
Deficiencies (1)
Facility does not have proof of Staff 1's required medication administration training before assisting residents with self-administering medications.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Resquir | Facility staff | Met during inspection and involved in findings regarding staff training documentation. |
| Sarah Hurt | Licensing Program Analyst | Conducted the unannounced facility visit and provided technical assistance. |
| Nestor Mendez | Regional Director | Spoke by phone during the inspection to explain the purpose of the visit. |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 88
Deficiencies: 1
Date: Oct 3, 2024
Visit Reason
An unannounced facility visit was conducted to open a complaint investigation regarding staff training documentation.
Complaint Details
Complaint investigation was opened due to missing documentation of required staff training; substantiation status not stated.
Findings
The facility lacked proof of required medication administration training documentation for a staff member assisting residents with self-administering medications. Technical assistance was provided to address this issue.
Deficiencies (1)
Facility does not have proof of Staff 1's required medication administration training before assisting residents with self-administering medications.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the unannounced facility visit and provided technical assistance. |
| Heather Resquir | Facility Staff | Met with Licensing Program Analyst during the inspection and participated in exit interview. |
| Tyler Branes | Administrator/Director | Named as facility administrator/director. |
| Nestor Mendez | Regional Director | Spoke by phone with Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 88
Deficiencies: 1
Date: Sep 26, 2024
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2024-02-07 regarding multiple allegations including failure to prevent pressure injuries, unqualified staff training, medication management, and medical assessment updates.
Complaint Details
The complaint investigation was triggered by multiple allegations including failure to prevent pressure injuries, unqualified staff training, improper medication management, and failure to update medical assessment forms. One allegation was substantiated regarding delayed medical attention for a resident's skin condition; all others were unsubstantiated.
Findings
The investigation found one allegation substantiated regarding staff not seeking medical attention in a timely manner for a resident's skin condition, while all other allegations including pressure injury prevention, staff training, medication management, and medical assessment updates were unsubstantiated due to lack of sufficient evidence.
Deficiencies (1)
Failure to develop and implement a plan for incidental medical and dental care as required by CCR 87465(a).
Report Facts
Capacity: 88
Census: 62
Deficiencies cited: 1
Plan of Correction Due Date: Sep 27, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Martinez | Medication Technician | Met with during investigation and involved in findings |
| Tyler Branes | Administrator | Facility administrator named in report |
| Sarah Hurt | Licensing Program Analyst | Investigator conducting the complaint investigation |
| Nestor Mendez | Regional Director | Spoke with by phone during investigation |
Inspection Report
Annual Inspection
Census: 56
Capacity: 88
Deficiencies: 1
Date: Jun 26, 2024
Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with regulatory requirements.
Findings
The facility was generally found to be in good condition with clean and well-maintained areas, operational safety equipment, and adequate supplies. However, one deficiency was cited regarding the absence of a current hospice care plan for one resident.
Deficiencies (1)
Resident 1 does not have a current hospice care plan on file, posing a potential health, safety, or personal rights risk.
Report Facts
Residents on hospice: 5
POC Due Date: Jul 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the inspection |
| Brenda Velasquez | Business Office Manager | Met with Licensing Program Analyst during inspection and exit interview |
| Tyler Branes | Administrator/Director | Facility Administrator |
Inspection Report
Annual Inspection
Census: 56
Capacity: 88
Deficiencies: 2
Date: Jun 26, 2024
Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with regulatory requirements.
Findings
The facility was generally found to be in good condition with clean and well-maintained areas. No deficiencies were cited during the inspection except for a missing hospice care plan for one resident and several medications not logged in the medication log for another resident.
Deficiencies (2)
Resident 1 does not have a current hospice care plan on file.
Resident 2 has several medications that are not logged in the Centrally Stored Medication Log.
Report Facts
Residents on hospice: 5
Plan of Correction Due Date: Jul 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the inspection and evaluation |
| Brenda Velasquez | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Tyler Branes | Administrator/Director | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 88
Deficiencies: 3
Date: Jun 13, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations including staff not giving resident medication as prescribed, failure to follow reporting requirements, and staff undressing residents in the common area in front of visitors.
Complaint Details
The complaint investigation was triggered by allegations that staff did not give resident medication as prescribed, failed to follow reporting requirements, and undressed residents in common areas in front of visitors. All allegations were substantiated based on evidence including physician statements, record reviews, and staff interviews.
Findings
All three allegations were substantiated based on evidence including physician statements, record reviews, and staff interviews. Deficiencies were cited related to medication administration, reporting requirements, and residents' personal rights violations.
Deficiencies (3)
Facility staff did not report Resident 1's fall and transfer to hospital, which poses a potential health, safety, or personal rights risk to residents in care.
Staff 1 exposed Resident 2's skin in a facility common area in front of other residents and visitors, violating personal rights.
Resident 1 was not provided prescribed medication for more than a month, posing an immediate health, safety, or personal rights risk to residents in care.
Report Facts
Capacity: 88
Census: 56
Plan of Correction Due Date: Jun 27, 2024
Plan of Correction Due Date: Jun 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Renee Hamilton | Administrator | Facility administrator met with Licensing Program Analyst during the investigation and exit interview |
| Tyler Branes | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 88
Deficiencies: 3
Date: Jun 13, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations received on 2024-05-20 regarding medication administration, reporting requirements, and resident dignity violations.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to administer prescribed medication, failure to follow reporting requirements, and undressing residents in common areas. Evidence and interviews supported all allegations.
Findings
The investigation substantiated all three allegations: staff did not give resident medication as prescribed, failed to follow reporting requirements by not reporting a resident's fall and hospital transfer, and staff undressed a resident in a common area in front of visitors. Deficiencies were cited accordingly.
Deficiencies (3)
Facility staff did not report Resident 1's fall and transfer to hospital, which poses a potential health, safety, or personal rights risk to residents in care.
Staff 1 exposed Resident 2's skin in a facility common area in front of other residents and visitors, violating personal rights.
Resident 1 was not provided prescribed medication for more than a month, posing an immediate health, safety, or personal rights risk to residents in care.
Report Facts
Capacity: 88
Census: 56
Plan of Correction Due Date: Jun 14, 2024
Plan of Correction Due Date: Jun 27, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Renee Hamilton | Administrator | Facility administrator met with evaluator and was involved in the investigation |
| Tyler Branes | Administrator | Named as facility administrator in report header |
| Brenda Chan | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 88
Deficiencies: 2
Date: Apr 10, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not distribute residents' medications as prescribed and did not report incidents to appropriate parties.
Complaint Details
The complaint was substantiated based on evidence that staff failed to administer medications as prescribed and failed to report incidents to appropriate parties.
Findings
The investigation substantiated that Resident 1 was not given medication on 04/07/2024 and 04/08/2024 despite medication being available, and the facility failed to notify State Licensing or Resident 1's Responsible Parties of the missed medications.
Deficiencies (2)
Resident 1 was not given medication on 04/07/2024 and 04/08/2024, posing an immediate health, safety, or personal rights risk to residents in care.
The facility did not report Resident 1's missed medications to State Licensing or Resident 1's Responsible party, posing a potential health, safety, or personal rights risk to residents in care.
Report Facts
Census: 57
Total Capacity: 88
Deficiencies cited: 2
Plan of Correction Due Dates: Type A deficiency POC due 04/11/2024; Type B deficiency POC due 04/24/2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Barnes | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 88
Deficiencies: 2
Date: Apr 10, 2024
Visit Reason
An unannounced complaint investigation was conducted based on allegations that staff did not distribute residents' medications as prescribed and did not report incidents to appropriate parties.
Complaint Details
The complaint investigation was substantiated based on evidence that staff did not distribute medications as prescribed and failed to report incidents to appropriate parties.
Findings
The investigation substantiated that Resident 1 was not given medication on 04/07/2024 and 04/08/2024 despite medication being available, and the facility failed to notify State Licensing or Resident 1's Responsible Parties of the missed medications.
Deficiencies (2)
Failure to assist residents with self-administered medications as needed, evidenced by Resident 1 not receiving medication on 04/07/2024 and 04/08/2024.
Failure to report incidents to the licensing agency and responsible parties within required timeframes, specifically not reporting Resident 1's missed medications.
Report Facts
Capacity: 88
Census: 57
Plan of Correction Due Date: Apr 11, 2024
Plan of Correction Due Date: Apr 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Barnes | Administrator | Met during investigation and named in findings related to medication administration and reporting |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 88
Deficiencies: 2
Date: Oct 11, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-09-21 regarding resident injuries and staff neglect at Madonna Gardens facility.
Complaint Details
The complaint investigation was triggered by allegations that residents sustained multiple injuries due to staff neglect and that staff did not prevent inappropriate behaviors from residents. The first allegation was unsubstantiated, while the second was substantiated based on evidence reviewed.
Findings
The investigation found one allegation unsubstantiated regarding residents sustaining multiple injuries due to staff neglect, with no evidence supporting neglect. Another allegation that staff did not prevent inappropriate behaviors from residents was substantiated based on care notes and interviews.
Deficiencies (2)
Residents sustained multiple injuries due to staff neglect
Staff did not prevent inappropriate behaviors from residents
Report Facts
Capacity: 88
Census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Barnes | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 88
Deficiencies: 2
Date: Oct 11, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 06/02/2023 regarding staff mismanaging resident medications, failure to prevent altercations between residents, and failure to inform residents' authorized persons of incidents occurring between residents.
Complaint Details
The complaint investigation was based on allegations that staff were mismanaging resident medications, failing to prevent altercations between residents, and not informing residents' authorized persons of incidents. The medication mismanagement allegation was unsubstantiated. The allegations regarding altercations and failure to inform authorized persons were substantiated.
Findings
The allegation of medication mismanagement was found to be unsubstantiated after review of medication logs and physician orders. However, allegations that staff did not prevent altercations between residents and did not inform residents' authorized persons of incidents were substantiated based on care notes and interviews. Deficiencies related to personal rights violations were cited.
Deficiencies (2)
Resident 1 has been in several altercations with other facility residents which poses an immediate, health, safety, or personal rights risk to residents in care.
The facility did not document Responsible parties for several residents being notified after physical altercations involving Resident 1.
Report Facts
Capacity: 88
Census: 56
Deficiency Type A due date: Oct 12, 2023
Deficiency Type B due date: Oct 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Tyler Barnes | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 88
Deficiencies: 2
Date: Oct 11, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that residents sustained multiple injuries due to staff neglect and that staff did not prevent inappropriate behaviors from residents.
Complaint Details
The complaint investigation was triggered by allegations of resident injuries due to staff neglect and failure to prevent inappropriate resident behaviors. The first allegation was unsubstantiated, while the second was substantiated.
Findings
The allegation that residents sustained multiple injuries due to staff neglect was found to be unsubstantiated based on review of records and interviews. The allegation that staff did not prevent inappropriate behaviors from residents was substantiated based on care notes and interviews documenting aggressive behaviors by a resident.
Deficiencies (2)
Residents sustained multiple injuries due to staff neglect
Staff did not prevent inappropriate behaviors from residents
Report Facts
Capacity: 88
Census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Barnes | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brenda Chan | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 88
Deficiencies: 2
Date: Oct 11, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including staff mismanaging resident medications, failure to prevent altercations between residents, and failure to inform residents' authorized persons of incidents occurring between residents.
Complaint Details
The complaint investigation was initiated based on allegations received on 2023-06-02 regarding medication mismanagement and failure to prevent and report resident altercations. The medication mismanagement allegation was unsubstantiated, while the allegations related to altercations and failure to notify authorized persons were substantiated.
Findings
The allegation of medication mismanagement was found to be unsubstantiated after review of medication logs and physician orders. However, allegations that staff did not prevent altercations between residents and did not inform residents' authorized persons of incidents were substantiated based on care notes and interviews. Deficiencies related to residents' personal rights were cited.
Deficiencies (2)
Failure to accord dignity in personal relationships as evidenced by Resident 1's several altercations posing immediate health, safety, or personal rights risk to residents in care.
Failure to regularly inform residents' representatives of activities related to care or services, including ongoing evaluations, as evidenced by lack of documentation of notification to responsible parties after physical altercations involving Resident 1.
Report Facts
Capacity: 88
Census: 56
Plan of Correction Due Date: Oct 12, 2023
Plan of Correction Due Date: Oct 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Tyler Barnes | Administrator | Facility administrator met with Licensing Program Analyst during investigation and exit interview |
| Brenda Chan | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Annual Inspection
Census: 48
Capacity: 88
Deficiencies: 0
Date: May 11, 2023
Visit Reason
Licensing Program Analyst Sarah Hurt conducted an unannounced visit for the facility’s annual inspection as required for the 1-year licensing period.
Findings
The inspection found the facility to be in good condition with clean and well-maintained bedrooms, adequate food supply, operational safety equipment, and locked medication and toxin storage. No deficiencies were observed or cited during the inspection.
Report Facts
Residents on hospice: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the annual inspection visit |
| Tyler Barnes | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Census: 48
Capacity: 88
Deficiencies: 0
Date: May 11, 2023
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate the facility's compliance with regulatory requirements.
Findings
The facility was found to be in good condition with no deficiencies observed or cited. The inspection included review of the interior and exterior, resident and staff records, and safety equipment checks.
Report Facts
Residents on hospice: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Barnes | Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Sarah Hurt | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 48
Capacity: 88
Deficiencies: 1
Date: May 5, 2023
Visit Reason
The visit was an unannounced Case Management inspection to evaluate compliance and identify deficiencies at the facility.
Findings
The inspection found that all outer doors to resident bedrooms in the Memory Care area were locked, preventing emergency personnel from easily entering rooms, which poses an immediate health, safety, or personal rights risk to residents. One deficiency was cited related to noncompliance with Title 22 Regulations regarding fire clearance for residents with dementia.
Deficiencies (1)
Facility doors to Memory Care resident bedrooms were locked, preventing emergency personnel from easily entering rooms, violating nonambulatory fire clearance requirements for residents with dementia.
Report Facts
Capacity: 88
Census: 48
Plan of Correction Due Date: May 6, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Barnes | Administrator | Met with Licensing Program Analyst during inspection and named in deficiency finding |
| Sarah Hurt | Licensing Program Analyst | Conducted the unannounced Case Management visit and authored the report |
| Brenda Chan | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Census: 48
Capacity: 88
Deficiencies: 1
Date: May 5, 2023
Visit Reason
Unannounced Case Management visit to evaluate deficiencies at the facility.
Findings
The Licensing Program Analyst observed that all outer doors to resident bedrooms in the Memory Care area were locked, preventing emergency personnel from easily entering rooms, which poses an immediate health, safety, or personal rights risk to residents.
Deficiencies (1)
All Memory Care facility doors were locked preventing emergency personnel services from easily entering rooms, posing an immediate health, safety, or personal rights risk to residents.
Report Facts
Capacity: 88
Census: 48
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Barnes | Administrator | Met during inspection and cited in findings |
| Sarah Hurt | Licensing Program Analyst | Conducted the inspection and cited deficiency |
| Brenda Chan | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 88
Deficiencies: 0
Date: Feb 6, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints alleging staff caused a resident to fall multiple times while in care, staff are not properly trained, and staff are not following a resident's medication orders.
Complaint Details
The complaint investigation addressed three main allegations: 1) Staff caused a resident to fall multiple times while in care, which was unsubstantiated; 2) Staff are not properly trained, which was unsubstantiated; 3) Staff are not following a resident's medication orders, which was unfounded.
Findings
All allegations were investigated and found to be unsubstantiated or unfounded. There was no preponderance of evidence to prove the alleged violations occurred, and no deficiencies were cited per Title 22 Regulations.
Report Facts
Facility capacity: 88
Census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Barnes | Administrator / Executive Director | Met with Licensing Program Analyst during the complaint investigation and provided statements regarding allegations |
| Sarah Hurt | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 88
Deficiencies: 0
Date: Feb 6, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations including staff causing a resident to fall multiple times, improper staff training, and failure to follow a resident's medication orders.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Sarah Hurt. Allegations included staff causing a resident to fall multiple times, staff not properly trained, and staff not following a resident's medication orders. Each allegation was found to be unsubstantiated or unfounded after review of incident reports, physician's orders, and interviews with the resident's Power of Attorney and facility staff.
Findings
All allegations were investigated and found to be unsubstantiated or unfounded based on facility records, interviews, and documentation reviewed. No deficiencies were cited per Title 22 Regulations.
Report Facts
Capacity: 88
Census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Barnes | Administrator / Executive Director | Met with Licensing Program Analyst during the complaint investigation and provided statements regarding allegations |
| Sarah Hurt | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 88
Deficiencies: 0
Date: Jan 30, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff do not prevent residents from engaging in inappropriate interactions.
Complaint Details
The complaint allegation was that staff do not prevent residents from engaging in inappropriate interactions. The allegation was found to be unsubstantiated based on interviews and record reviews.
Findings
The investigation found that staff are preventing residents from engaging in inappropriate interactions. Interviews with staff, residents, and the Executive Director indicated no violations of residents' personal rights. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 88
Census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Barnes | Executive Director | Met during the investigation and provided statements regarding the allegation |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 88
Deficiencies: 0
Date: Jan 30, 2023
Visit Reason
An unannounced complaint investigation was conducted based on a complaint received on 01/25/2023 regarding allegations that residents were being put to bed too early and eating dinner too early.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included residents being put to bed too early and eating dinner too early. Interviews with staff and observations did not support these allegations.
Findings
The investigation found both allegations to be unsubstantiated based on interviews with facility staff and observations. Residents were not put to bed at a specific early time and were allowed to stay awake as late as they wished. Dinner was served at 5 p.m. with appropriate meal timing policies in place. No deficiencies were cited.
Report Facts
Complaint Control Number: 24-AS-20230125133711
Facility Capacity: 88
Census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Barnes | Executive Director | Met with Licensing Program Analyst during complaint investigation and exit interview |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 88
Deficiencies: 0
Date: Jan 30, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff do not prevent residents from engaging in inappropriate interactions.
Complaint Details
The complaint alleged that staff do not prevent residents from engaging in inappropriate interactions. The allegation was unsubstantiated based on interviews and record reviews.
Findings
The investigation found that staff are preventing residents from engaging in inappropriate interactions. Interviews with staff, residents, and records showed no evidence of unwanted interactions violating residents' personal rights. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 88
Census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Barnes | Executive Director | Met during the investigation and provided information regarding the allegation |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 88
Deficiencies: 0
Date: Jan 30, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that residents were being put to bed too early and eating dinner too early.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included residents being put to bed too early and eating dinner too early, both found unsupported by evidence.
Findings
The investigation found both allegations to be unsubstantiated based on interviews with facility staff and observations. Residents were not put to bed at a specific early time and were allowed to stay awake as late as they wished. Dinner was served at 5 p.m. with breakfast between 7 a.m. and 8 a.m., consistent with facility policy.
Report Facts
Capacity: 88
Census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation |
| Tyler Barnes | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 88
Deficiencies: 1
Date: May 9, 2022
Visit Reason
The visit was conducted to address an incident reported to the department where resident R1 went AWOL during an activity on 04/26/22 and was found by facility neighbors shortly after.
Complaint Details
The visit was complaint-related due to an incident where resident R1 went AWOL during an activity on 04/26/22. The deficiency was substantiated and cited.
Findings
A deficiency was cited for failure to provide care and supervision when R1 left the facility unsupervised, posing immediate health and safety risks. Staff had been retrained prior to the visit and the plan of correction was cleared during the visit.
Deficiencies (1)
Failure to provide care and supervision when resident left the facility unsupervised, posing immediate health and safety risks.
Report Facts
Capacity: 88
Census: 41
Plan of Correction Due Date: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mai Yang | Licensing Program Analyst | Conducted the case management visit and cited the deficiency |
| Melinda Hoffmann | Supervisor | Supervisor overseeing the licensing evaluation |
| Renee Hamilton | Administrator | Facility administrator met with LPA during the visit |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 88
Deficiencies: 1
Date: May 9, 2022
Visit Reason
The visit was conducted to address an incident reported to the department where resident R1 went AWOL during an activity on 04/26/22 and was found by facility neighbors.
Complaint Details
The visit was complaint-related due to an incident where resident R1 went AWOL during an activity and was found outside the facility by neighbors. A deficiency was cited based on this incident.
Findings
A deficiency was cited for failure to provide care and supervision when resident R1 left the facility unsupervised, posing immediate health and safety risks to persons in care.
Deficiencies (1)
Failure to provide care and supervision when resident R1 left the facility unsupervised on 04/26/22 at 10:40 a.m. and was located at 10:45 a.m. by a facility neighbor, posing immediate health and safety risks.
Report Facts
Capacity: 88
Census: 41
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mai Yang | Licensing Program Analyst | Conducted the case management visit and cited the deficiency |
| Melinda Hoffmann | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
| Renee Hamilton | Administrator | Facility administrator met during the visit and was provided the report |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 88
Deficiencies: 2
Date: Apr 23, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff were not trained to administer medications and that staff gave a resident the wrong medication.
Complaint Details
The complaint was substantiated based on evidence that staff were not trained to administer medications and that a resident was given the wrong medication. The facility took steps to notify the physician and family and monitored the resident with no adverse reactions.
Findings
The investigation substantiated that a Medtech was not properly trained or shadowed prior to administering medications, and a resident was given the wrong medication on 09/17/2021. The facility notified the resident's physician and family, monitored the resident with no adverse reactions, and provided an incident report. Deficiencies related to personnel training and medication management were cited.
Deficiencies (2)
Medtech 1 was not properly trained or provided shadowing prior to administering medication, violating personnel training requirements.
The licensee did not provide resident R1 with required refrigerated medication timely and gave four wrong medications on 09/17/2021, posing an immediate risk to residents.
Report Facts
Capacity: 88
Census: 41
Medication error date: Sep 17, 2021
Incident report date: Oct 1, 2021
Plan of Correction due date: Apr 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the complaint investigation |
| Stephenie Doub | Licensing Program Manager | Named in report as Licensing Program Manager |
| Patricia King | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 88
Deficiencies: 2
Date: Apr 23, 2022
Visit Reason
This was an unannounced complaint investigation visit triggered by complaints received on 2021-09-24 regarding staff not trained to administer medications and staff giving a resident the wrong medication.
Complaint Details
The complaint investigation was substantiated. Allegations included staff not trained to administer medications and staff giving a resident the wrong medication. The facility notified the primary care physician and family, monitored the resident with no adverse reactions, and provided an incident report. The investigation found training deficiencies and medication errors.
Findings
The investigation substantiated that a Medtech was not properly trained or shadowed before administering medications, resulting in medication errors on multiple dates. Additionally, a resident was given the wrong medication on 2021-09-17, but no adverse reactions occurred. Deficiencies related to personnel training and medication management were cited.
Deficiencies (2)
Medtech 1 was not properly trained or provided shadowing prior to administering medication, violating personnel training requirements.
The licensee did not provide a resident with required refrigerated medication timely and gave four wrong medications on 9/17/2021, posing an immediate risk to residents.
Report Facts
Capacity: 88
Census: 41
Plan of Correction Due Date: Apr 25, 2022
Medication error date: Sep 17, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Evaluator | Conducted the complaint investigation |
| Stephenie Doub | Supervisor | Named in relation to findings and report supervision |
Inspection Report
Routine
Census: 46
Capacity: 88
Deficiencies: 0
Date: Nov 18, 2021
Visit Reason
The visit was a Case Management - COVID-19 unannounced tele-visit conducted to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility.
Findings
No deficiencies were cited during the visit. Recommendations were made to improve COVID-19 prevention measures, including use of PPE and placement of trash cans.
Report Facts
COVID-19 positive residents: 11
COVID-19 positive staff: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted tele-visit and evaluation |
| Sarah Yip | Licensing Program Manager | Conducted tele-visit |
| Lori Kopplinger | Nurse | Conducted tele-visit and provided recommendations |
| Patricia King | Administrator | Facility Administrator met during tele-visit and reported COVID-19 cases |
Inspection Report
Routine
Census: 46
Capacity: 88
Deficiencies: 0
Date: Nov 18, 2021
Visit Reason
The visit was a Case Management - COVID-19 tele-visit conducted to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility.
Findings
No deficiencies were cited during the visit. Recommendations were made to improve COVID-19 safety measures, including use of PPE and placement of trash cans.
Report Facts
COVID-19 positive residents: 11
COVID-19 positive staff: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia King | Administrator | Met with Licensing Program Analyst and Nurse during tele-visit |
| David Marrufo | Licensing Program Analyst | Conducted tele-visit and provided technical assistance |
| Sarah Yip | Licensing Program Manager | Participated in tele-visit |
| Lori Kopplinger | Nurse | Provided recommendations during tele-visit |
Inspection Report
Routine
Census: 48
Capacity: 88
Deficiencies: 0
Date: Jul 20, 2021
Visit Reason
An unannounced infection control site visit was conducted as a required 1-year inspection.
Findings
The facility was observed to be sanitary with COVID-19 mitigation measures in place, including PPE supply, temperature screening, and social distancing. No deficiencies were cited, but an advisory note was issued.
Report Facts
Restrooms inspected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Enery Garcia | Memory Care Director Assistant | Met with Licensing Program Analyst during infection control site visit |
| Yatfai Eric Ng | Licensing Program Analyst | Conducted the unannounced infection control site visit |
Inspection Report
Annual Inspection
Census: 48
Capacity: 88
Deficiencies: 0
Date: Jul 20, 2021
Visit Reason
An unannounced infection control site visit was conducted as part of the required 1-year inspection.
Findings
The facility was observed to be in sanitary condition with COVID-19 mitigation measures in place, including PPE supply and social distancing. No deficiencies were cited, but an advisory note was issued.
Report Facts
Restrooms inspected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Enery Garcia | Memory Care Director Assistant | Met with Licensing Program Analyst during infection control site visit |
| Yatfai Eric Ng | Licensing Program Analyst | Conducted the unannounced infection control site visit |
| Sarah Yip | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 88
Deficiencies: 0
Date: Mar 25, 2021
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the Facility Administrator does not meet administrator certification requirements.
Complaint Details
The complaint alleged that the Facility Administrator did not meet administrator certification requirements. The allegation was found to be unfounded based on interviews, records review, and observations.
Findings
The investigation found the allegation to be unfounded after reviewing records and interviewing the Executive Director, who had completed recertification requirements and submitted renewal documents on time. The Department confirmed the application was received and in process.
Report Facts
Continuing education hours: 80
Facility capacity: 88
Facility census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia King | Executive Director | Interviewed regarding administrator certification and recertification status |
| Gladys Kuizon | Licensing Program Analyst | Conducted the complaint investigation tele-visit |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 44
Capacity: 88
Deficiencies: 0
Date: Nov 6, 2020
Visit Reason
The visit was a Case Management - Other type conducted via tele-inspection due to COVID-19 preventive measures, focusing on COVID-19 case management and facility compliance with related guidelines.
Findings
No deficiencies were cited during the tele-visit. Observations included COVID-19 posters, screening stations, staff wearing face shields and masks, and recommendations for infection control practices were provided.
Report Facts
Residents tested: 25
Staff tested: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patty King | Executive Director | Met during tele-inspection and provided information about testing and facility operations |
| Jeriah Arreola | Resident Care Manager | Present during tele-inspection |
| Rebekah Bird Wohlgemuth | Health Facilities Evaluator Nurse | Present during tele-inspection and provided recommendations |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 88
Deficiencies: 0
Date: Nov 2, 2020
Visit Reason
The visit was conducted to obtain additional information on an incident report received regarding an alleged abuse towards a resident by a staff member.
Complaint Details
The complaint involved an alleged abuse incident reported on 10/26/2020. The staff member was interviewed and denied the allegation. The staff member was taken off work on 10/19/2020 and returned on 10/23/2020. The allegation was not substantiated.
Findings
The Executive Director reported that the staff member denied the allegation and was temporarily removed from work during the investigation. No deficiencies were cited during this tele-inspection visit.
Report Facts
Date of incident report: Oct 26, 2020
Date staff taken off work: Oct 19, 2020
Date staff returned to work: Oct 23, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patty King | Executive Director | Interviewed during the investigation and exit interview |
| Brenda Velazquez | Business Office Manager | Present during the interview |
| Grace Davis | Licensing Program Analyst | Conducted the unannounced case management tele-inspection |
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