Deficiencies (last 6 years)
Deficiencies (over 6 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
76% occupied
Based on a February 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 55
Capacity: 72
Deficiencies: 3
Date: Feb 12, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of medication mismanagement, failure to follow resident care plans, and failure to follow reporting requirements.
Complaint Details
The complaint investigation was substantiated for all three allegations: medication mismanagement, failure to follow resident care plans, and failure to follow reporting requirements.
Findings
The investigation substantiated all allegations. Medication mismanagement was found where a resident was not assisted with prescribed medications. Resident care plans were missing for some residents, and a fall incident was not reported to the Department as required.
Deficiencies (3)
CCR 87465(a)(4): The facility failed to assist residents with self-administered medications as needed. Resident R2 was not assisted with prescribed medication, with evidence of missed doses despite MARs indicating otherwise.
CCR 87609(b)(4)(A-C): The facility did not have written agreements with home health agencies reflecting responsibilities and care plans. Residents R3 and R4 lacked Home Health Care Plans on file.
CCR 87211(a)(1)(D): The facility failed to submit required incident reports to the licensing agency. Resident R1's fall in November 2025 was not reported as required.
Report Facts
Capacity: 72
Census: 55
Deficiencies cited: 3
Plan of Correction Due Dates: POC due dates are 02/13/2026 and 02/19/2026 for cited deficiencies
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brenda Chan | Supervisor | Supervisor overseeing the investigation |
| Vivian Villegas | Interim Administrator | Facility representative met during the investigation |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 72
Deficiencies: 0
Date: Feb 12, 2026
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that a resident sustained a fall due to licensee neglect.
Complaint Details
The complaint alleged that a resident sustained a fall due to licensee neglect. The allegation was unsubstantiated after investigation.
Findings
The investigation found no evidence to substantiate the allegation of neglect causing the resident's fall. Interviews with staff and residents did not confirm the claim, resulting in the allegation being unsubstantiated.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Vivian Villegas | Interim Administrator | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 72
Deficiencies: 1
Date: Dec 30, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit triggered by allegations including staff disclosing personal information about residents, improper incident reporting, and mishandling of residents' medications.
Complaint Details
The complaint investigation was unannounced and included allegations of staff disclosing personal information and improper incident reporting, both found unsubstantiated. The allegation of medication mishandling was substantiated with deficiencies cited and a civil penalty issued.
Findings
The investigation found the first two allegations unsubstantiated due to lack of evidence. However, the allegation of mishandling residents' medications was substantiated based on observation, record review, and interviews. Deficiencies were cited related to inaccurate medication counts and medication administration not matching MARs, posing an immediate health and safety risk.
Deficiencies (1)
CCR 87465(a)(4): The licensee failed to assist residents with self-administered medications as needed. R1’s medication count was inaccurate and medication administered did not match the MARs, posing an immediate health and safety risk.
Report Facts
Capacity: 72
Census: 57
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Britney Polman | Resident Care Director | Met with Licensing Program Analyst during investigation and named in findings |
| Jacques Leffall | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 72
Deficiencies: 1
Date: Dec 2, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2025-11-16 alleging that staff were not keeping resident information/records confidential.
Complaint Details
The complaint alleging staff were not keeping resident information confidential was substantiated based on evidence that residents were unaware their information was shared with outside Medi-Cal assisted agencies prior to enrollment.
Findings
The investigation found that residents' information was provided to outside Medi-Cal assisted agencies for referral without residents' knowledge, substantiating the allegation of confidentiality breach.
Deficiencies (1)
CCR 87506(c) requires all resident information and records to be confidential. This was not met as residents' information was shared with outside agencies without their knowledge, posing potential health, safety, or personal rights risks.
Report Facts
Capacity: 72
Census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittney Polman | Resident Care Director | Met during investigation and received report |
| Mai Yang | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 72
Deficiencies: 2
Date: Nov 25, 2025
Visit Reason
This case management visit was conducted due to issues found during a complaint investigation regarding theft of residents' money and valuables.
Complaint Details
The visit was triggered by complaint #24-AS-20250605163501 involving multiple residents having money and valuables stolen. The complaint was substantiated by observations and record reviews showing failure to safeguard valuables and report theft incidents.
Findings
The facility failed to follow regulations for safeguarding residents' valuables and did not report incidents of theft to appropriate agencies as required. Deficiencies were cited related to theft reporting and incident reporting requirements.
Deficiencies (2)
HSC 1569.153(i) Theft and loss program standards were not met as incidents of theft valued at $100 or more were not reported to local law enforcement within 36 hours. This poses a potential health, safety, and personal rights risk to residents.
CCR 87211(a) Reporting requirements were not met as special incident reports were not submitted to Community Care Licensing as required. This poses a potential health, safety, and personal rights risk to residents.
Report Facts
Census: 47
Total Capacity: 72
POC Due Date: Dec 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Isabel Cervantes | Generations Program Director | Met during inspection and involved in exit interview |
| Brittany Polman | Resident Care Coordinator | Involved in exit interview and plan of correction development |
| Mary Garza | Licensing Program Analyst | Conducted the inspection and signed the report |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 72
Deficiencies: 1
Date: Nov 25, 2025
Visit Reason
Unannounced complaint investigation visit triggered by allegations of financial abuse of residents.
Complaint Details
Complaint was substantiated regarding financial abuse of residents. Investigation included interviews and record reviews. Staff member S1 was terminated.
Findings
The investigation found multiple residents had money or items of value stolen. Not all incidents were reported to law enforcement or Community Care Licensing. One staff member was terminated. Deficiencies were cited related to residents' personal rights violations.
Deficiencies (1)
CCR 87468.2(a)(8) requires residents to be free from financial exploitation. Multiple residents had money or items stolen, posing a risk to their health, safety, and personal rights.
Report Facts
Capacity: 72
Census: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Garza | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Isabel Cervantes | Generations Program Director | Met with Licensing Program Analyst during investigation and exit interview |
| Brittany Polman | Resident Care Coordinator | Participated in exit interview and plan of correction development |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 72
Deficiencies: 0
Date: Nov 24, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2025-11-07 regarding staff not providing a resident with a refund.
Complaint Details
The complaint alleged staff did not provide a resident with a refund. The investigation found no sufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Findings
The investigation included interviews and record reviews which revealed no preponderance of evidence to prove the alleged violation occurred. Therefore, the allegations were unsubstantiated.
Report Facts
Monthly service fees: 1395
Monthly service fees: 1100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation |
| Brittney Polman | Resident Services Director | Met with investigator and received report copy |
Inspection Report
Census: 48
Capacity: 72
Deficiencies: 1
Date: Nov 24, 2025
Visit Reason
The visit was an unannounced Case Management deficiency inspection to address an incident where requested resident records were not provided by the due date.
Findings
The facility failed to maintain and provide requested resident records by the agreed due date, resulting in a cited deficiency under California Code of Regulations, Title 22, Division 6.
Deficiencies (1)
CCR 87506(a) Resident Records. The licensee failed to maintain a separate, complete, and current record for each resident and did not provide requested documents for resident R1 by the due date of November 14, 2025, posing a potential health and safety risk.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittney Polman | Resident Services Director | Met during inspection and named in report regarding resident record deficiency |
| Vadim Gorban | 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: 48
Capacity: 72
Deficiencies: 2
Date: Nov 20, 2025
Visit Reason
The visit was an unannounced Case Management deficiency inspection to address an incident where medications were found in a resident's room after staff had signed off that the medications were administered.
Complaint Details
The visit was complaint-related due to an incident involving medication administration errors. The complaint was substantiated by the finding that medication was not administered as recorded and the failure to report the incident timely.
Findings
The inspection found that a resident's evening medication Atorvastatin was found in the resident's room the day after staff recorded it as administered, posing an immediate health and safety risk. Additionally, a written report of the incident was not submitted to the licensing agency within seven days as required.
Deficiencies (2)
CCR 87411(d)(4) Knowledge required to safely assist with prescribed medications which are self-administered was not met. Staff recorded medication as administered when it was found in the resident's room the following day, posing an immediate health and safety risk.
CCR 87211(a)(1) A written report was not submitted to the licensing agency within seven days of the incident when the resident's medication was found after being recorded as administered, posing a potential health and safety risk.
Report Facts
Facility Capacity: 72
Resident Census: 48
Plan of Correction Due Date: Nov 21, 2025
Plan of Correction Due Date: Nov 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittney Polman | Resident Care Director | Met during inspection and involved in medication administration finding |
| Mai Yang | Licensing Program Analyst | Conducted the inspection and signed the report |
Inspection Report
Census: 48
Capacity: 72
Deficiencies: 0
Date: Nov 4, 2025
Visit Reason
The visit was an unannounced case management inspection regarding a Default Decision and Order for Staff 1, to verify that an individual without a criminal record clearance was not working at the facility.
Findings
The Resident Care Director confirmed that the staff member in question, Anthony Davis, is no longer employed or associated with the facility. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittaney Polman | Resident Care Director | Met during the inspection and verified staff employment status. |
| Jacques Leffall | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Mandy Rancour | Administrator | Provided information regarding staff employment status. |
Inspection Report
Census: 48
Capacity: 72
Deficiencies: 4
Date: Oct 25, 2025
Visit Reason
This case management visit was conducted to address deficiencies observed during previous complaint visits on 6/10/2025 and 10/25/2025 related to safety hazards and missing required postings.
Complaint Details
This visit was a case management follow-up to deficiencies observed during complaint investigations for complaint #24-AS-20250605163501 on 6/10/2025 and 10/25/2025.
Findings
The inspection found that a gate with a lock to the kitchenette posed a tripping hazard and restricted access to food/drink in memory care. Required postings, including the RCFE complaint poster, were not displayed. Incident reports revealed an allergic reaction and unsecured medication in residents' rooms, posing hazards to residents.
Deficiencies (4)
CCR 87468(c) Licensees did not prominently post personal rights, nondiscrimination notice, and complaint information in accessible areas of the facility. This poses a potential health, safety, or personal rights risk to residents.
CCR 87468(c)(2)(A) The RCFE complaint poster (PUB 475) was not posted in the main entryway of the facility, posing a potential health, safety, or personal rights risk to residents.
CCR 87405(d)(1) The administrator did not ensure proper care and supervision as incident reports showed a resident had an allergic reaction and another had unlocked medication accessible in their room, posing a health and personal rights risk.
CCR 87468.1(a)(3) A gate with a lock to the kitchenette prevented access to food and drink and posed a tripping hazard in memory care, risking residents' health, safety, and personal rights.
Report Facts
Plan of Correction Due Date: Nov 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Garza | Licensing Program Analyst | Conducted the case management visit and authored the report. |
| Brittany Polman | Resident Care Coordinator | Met with Licensing Program Analyst during the visit and participated in exit interview. |
| Mandy Rancour | Administrator/Director | Facility Administrator mentioned as unavailable during the visit. |
| Kimberly Reyes | Medical Technician | Met with Licensing Program Analyst at the start of the visit. |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 72
Deficiencies: 0
Date: Oct 13, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not providing adequate food service to residents in care.
Complaint Details
The complaint alleged inadequate food service to residents. The investigation found no sufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Findings
The investigation included interviews with staff, review of records, and observation of the kitchen and dining areas. The kitchen was found clean with fresh food ready to serve. The allegations were unsubstantiated due to lack of preponderance of evidence, and no deficiencies were issued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mandy Rancour | Administrator | Met with Licensing Program Analyst during complaint investigation. |
| Jacques Leffall | Licensing Program Analyst | Conducted the complaint investigation visit. |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 72
Deficiencies: 0
Date: Oct 13, 2025
Visit Reason
The visit was conducted to investigate a complaint alleging that staff spoke inappropriately to a resident and to close the complaint investigation.
Complaint Details
The complaint alleged that staff spoke inappropriately to a resident. The complaint was investigated and found to be unfounded.
Findings
The investigation found that the facility staff spoke to residents in a respectful and appropriate manner. The allegation was determined to be unfounded and the complaint was dismissed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martin Vega | Licensing Program Analyst | Conducted the complaint investigation and inspection. |
| Mandy Rancour | Administrator | Facility administrator met during the investigation. |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 72
Deficiencies: 0
Date: Oct 2, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2025-06-19 regarding food service and resident food restrictions.
Complaint Details
The complaint alleged that facility staff did not ensure resident food restrictions were followed and that food service was inadequate. The allegations were unsubstantiated after investigation.
Findings
The investigation found no preponderance of evidence to prove or disprove the allegations. The allegations were determined to be unsubstantiated and no deficiencies were issued.
Report Facts
Facility Capacity: 72
Resident Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mandy Rancour | Executive Director | Met with Licensing Program Analysts during the complaint investigation |
| Melinda Medina | Licensing Evaluator | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 72
Deficiencies: 1
Date: Sep 27, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2025-07-31 regarding alleged failure to refund a resident's preadmission fee and overcharging for services.
Complaint Details
The complaint investigation was substantiated regarding failure to refund a resident's preadmission fee timely. The allegation of overcharging was unsubstantiated and dismissed.
Findings
The investigation substantiated that the facility did not refund a resident's preadmission fee within the contractually required 21 business days, issuing the refund late on 2025-08-22. The allegation of overcharging a resident for services was found to be unfounded.
Deficiencies (1)
CCR 87507(g)(5)(A) Admission agreements require refund conditions to be specified. The facility did not refund a resident timely, issuing the refund on 2025-08-22 after the resident moved out on 2025-07-03, violating the 21 business day refund policy.
Report Facts
Facility Capacity: 72
Resident Census: 40
Plan of Correction Due Date: Oct 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawna Doucette | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brittany Polman | Resident Care Director | Facilitated entry and assisted during the complaint investigation |
| Mandy Rancour | Administrator | Contacted during investigation and gave permission to assist with visit |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 72
Deficiencies: 2
Date: Sep 27, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations of staff financially abusing residents and opening a resident's mail without consent.
Complaint Details
The complaint investigation was substantiated based on interviews and records review. Allegations included financial abuse by staff and unauthorized opening of resident mail.
Findings
The investigation substantiated that facility staff cashed two checks made out to a resident and deposited them into the facility account. Additionally, a staff member opened the resident's mail without permission, violating personal rights.
Deficiencies (2)
CCR 87468.2(a)(8) was not met as licensee cashed and deposited two of R1's checks into the facility bank account, posing a risk to residents' personal rights and safety.
CCR 87468.1(a)(15) was not met as licensee opened R1's mail without permission, posing a health safety and personal rights risk to residents.
Report Facts
Capacity: 72
Census: 40
Plan of Correction Due Date: Sep 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawna Doucette | Licensing Program Analyst | Conducted the complaint investigation |
| Brittany Polman | Resident Care Director | Met with the evaluator and assisted with the investigation |
| Mandy Rancour | Administrator | Contacted during the investigation and gave permission to assist with the visit |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 72
Deficiencies: 0
Date: Aug 21, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff were not allowing residents full access to the facility.
Complaint Details
The complaint alleged that staff were restricting residents' access to the facility. The allegation was investigated and found to be unfounded.
Findings
The investigation found the allegation to be unfounded after touring the facility, interviewing residents and staff, and reviewing records. Residents reported full access to common areas and restrooms, and no citations were issued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Mandy Rancour | Administrator | Met with Licensing Program Analyst during the investigation and was involved in the exit interview. |
Inspection Report
Annual Inspection
Census: 35
Capacity: 72
Deficiencies: 0
Date: Jul 9, 2025
Visit Reason
The visit was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate compliance with licensing requirements.
Findings
No deficiencies were issued during this inspection. The facility was toured and observed to be in good repair with required postings, clear pathways, and proper equipment. Some documents were requested to be submitted by a specified date.
Report Facts
Capacity: 72
Census: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mandy Rancour | Administrator | Met with Licensing Program Analyst during inspection |
| Jacques Leffall | Licensing Program Analyst | Conducted the annual inspection |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 72
Deficiencies: 1
Date: May 23, 2025
Visit Reason
The visit was an unannounced case management inspection triggered by an incident involving a resident with an infectious disease.
Complaint Details
The visit was complaint-related due to an incident involving a resident with an infectious disease. The complaint was substantiated as the facility failed to report the condition as required.
Findings
The facility failed to report a resident's contagious prohibited condition to the licensing agency and did not have a restricted health care plan for the resident. Additional deficiencies were observed beyond the original incident.
Deficiencies (1)
CCR 87211 Reporting Requirements (a) was violated because the licensee did not report a resident's contagious prohibited condition, posing a potential health, safety, or personal rights risk to residents in care.
Report Facts
Plan of Correction Due Date: May 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mandy Rancour | Administrator | Met with Licensing Program Analyst during inspection |
| Shawna Doucette | Licensing Program Analyst | Conducted the inspection and authored the report |
| Alexandria Walton | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 72
Deficiencies: 1
Date: May 23, 2025
Visit Reason
The visit was an unannounced case management inspection conducted due to an incident involving a resident on 2025-05-15.
Complaint Details
The visit was triggered by a complaint or incident involving Resident 1's medication administration on 2025-05-15. The complaint was substantiated by the finding that the resident did not swallow her medication as required.
Findings
The facility failed to ensure that Resident 1 swallowed her administered morning medication, which was later found by staff in the afternoon. This posed an immediate health, safety, and personal rights risk.
Deficiencies (1)
CCR 87465(a)(4) requires the licensee to assist residents with self-administered medications as needed. The licensee did not ensure Resident 1 swallowed administered morning medication, which was later found in the afternoon, posing an immediate health and safety risk.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mandy Rancour | Administrator | Met with Licensing Program Analyst during inspection and involved in medication administration discussion |
| Shawna Doucette | Licensing Program Analyst | Conducted the inspection and authored the report |
| Alexandria Walton | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 72
Deficiencies: 1
Date: Dec 5, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-12-02 regarding facility conditions.
Complaint Details
The complaint investigation was substantiated. The facility kitchen sink disposal was found to be in disrepair and not functioning for a month, causing water to clog the sink.
Findings
The facility kitchen sink disposal had not been operating for a month, causing water to build up in the sink. The allegation was substantiated based on observations and staff interviews.
Deficiencies (1)
CCR 87555(b)(29) requires all food service equipment to be kept clean and maintained in good repair. The facility kitchen sink disposal was not operating, causing water buildup in the sink.
Report Facts
Facility Capacity: 72
Resident Census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Meshell Ramos | Executive Director | Interviewed during investigation and agreed to plan of correction |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 72
Deficiencies: 1
Date: Aug 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-03-25 regarding unsafe transfers, inappropriate staff behavior, and rough handling of residents.
Complaint Details
The complaint investigation was substantiated for allegations of unsafe transfers causing injuries and inappropriate staff conduct including rude speech and rough handling. Allegations of untimely assistance were unsubstantiated.
Findings
The investigation substantiated that residents sustained injuries due to staff not following care plans for two-person assists and that staff spoke rudely, handled residents roughly, and intimidated residents when they complained. Another set of allegations about untimely assistance was found unsubstantiated.
Deficiencies (1)
CCR 87468.1 Personal Rights of Residents in All Facilities: Staff spoke rudely to residents and were rough when providing care. Residents requiring additional support were intimidated or punished.
Report Facts
Facility Capacity: 72
Resident Census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katrina Sinift | Administrator | Met with Licensing Program Analyst during complaint investigation and exit interview |
| Kamaldeep Kaur | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
Inspection Report
Complaint Investigation
Capacity: 72
Deficiencies: 0
Date: Aug 7, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-03-26 regarding resident care issues at Prestige Assisted Living at Visalia.
Complaint Details
The complaint involved allegations that staff allowed residents to be left in soiled clothing for extended periods, did not address incontinence and healthcare needs, did not keep residents' rooms free from malodors, and did not timely empty catheter bags. The investigation concluded these allegations were unsubstantiated.
Findings
The investigation found the allegations unsubstantiated based on staff interviews and record reviews. There was no preponderance of evidence to prove the alleged violations occurred.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Katrina Sinift | Administrator | Facility administrator met with the evaluator during the investigation. |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 72
Deficiencies: 3
Date: Jul 30, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations including resident injuries due to lack of staff care and supervision, non-adherence to the resident's Admission Agreement, and inadequate staff training.
Complaint Details
The complaint investigation was substantiated. The resident sustained injuries due to lack of staff care and supervision. Staff failed to follow the resident’s care plan, resulting in multiple fractures after a fall. Staff admitted to non-compliance with the care plan. The allegations were found substantiated based on interviews and record reviews.
Findings
The investigation substantiated that a resident sustained multiple fractures after staff failed to follow the resident's care plan, specifically regarding two-person transfers. Staff admitted to non-compliance with the care plan, posing immediate health and safety risks. Additional civil penalties are pending review.
Deficiencies (3)
CCR 87411(a) Personnel Requirements – Facility personnel were insufficient in number and competence to meet resident needs, evidenced by failure to follow the resident's care plan resulting in multiple fractures and a fall.
CCR 87411(d)(3) Personnel Requirements – Staff lacked necessary skill and knowledge, including communication and training on two-person transfers, posing immediate health and safety risks.
CCR 87507(f) Admission Agreements – The licensee failed to comply with terms of the admission agreement by not adhering to the resident’s care plan for two-person transfers, posing a potential health and safety risk.
Report Facts
Capacity: 72
Census: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katrina Sinift | Administrator | Named in relation to findings and interviews during the complaint investigation |
| Gary Allinger | Regional Director | Named in relation to findings and interviews during the complaint investigation |
Inspection Report
Census: 32
Capacity: 72
Deficiencies: 1
Date: Jul 30, 2024
Visit Reason
The visit was a Case Management - Deficiencies inspection to evaluate compliance following a medication error incident.
Findings
A medication error occurred involving missed medication or missed dosage by a new med-tech staff member. Deficiencies were cited related to failure to assist residents with self-administered medications as required by California Code of Regulations, Title 22, Division 6.
Deficiencies (1)
CCR 87465(a)(4) Incidental Medical and Dental Care. The licensee failed to assist residents with self-administered medications as needed, evidenced by missed medication or missed dosage by staff.
Report Facts
Capacity: 72
Census: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katrina Sinift | Administrator | Named in relation to medication error and interviews |
| Gary Allinger | Regional Director | Present during inspection and interviews |
Inspection Report
Annual Inspection
Census: 31
Capacity: 72
Deficiencies: 4
Date: Jul 16, 2024
Visit Reason
The visit was an unannounced annual inspection conducted to evaluate compliance with licensing requirements at Prestige Assisted Living at Visalia.
Findings
The inspection found deficiencies related to unsafe storage of sharps and chemicals in resident rooms, insufficient nonperishable food supplies, incomplete documentation of residents' responses to PRN medications, and inaccurate or missing information in residents' physician reports. The facility was otherwise observed to be clean, safe, and properly equipped.
Deficiencies (4)
CCR 87309(a) Storage Space: Sharps and chemicals were found in 3 out of 6 resident rooms, posing immediate health and safety risks.
CCR 87555(b)(26) General Food Service Requirements: Nonperishable food supplies did not meet the required 7-day minimum, posing immediate health and safety risks.
CCR 87465(c)(3) Incidental Medical and Dental Care Services: Resident response to PRN medication was not documented for 1 out of 3 residents reviewed.
CCR 87458(b)(1) Medical Assessment: 3 out of 5 residents' physician reports were inaccurate or incomplete, including missing diagnoses and ambulatory status.
Report Facts
Deficiencies cited: 4
POC Due Date: Jul 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katrina Sinift | Administrator | Met with Licensing Program Analysts during inspection and named in plans of correction. |
| Kamaldeep Kaur | Licensing Evaluator | Conducted the inspection and signed the report. |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 72
Deficiencies: 0
Date: Jun 27, 2024
Visit Reason
This was an unannounced complaint investigation visit triggered by a complaint received on 2024-03-21 regarding allegations of inadequate resident care.
Complaint Details
The complaint involved allegations that staff did not ensure resident access to call button and did not provide adequate food service. The investigation concluded these allegations were unsubstantiated.
Findings
The investigation found that the resident had access to a call button and pendant, though it was undetermined if the resident could utilize them due to physical capacity. The resident was provided meals in their room with staff assistance and was new to the facility, not yet adjusted to the meal schedule. The allegations were unsubstantiated due to lack of preponderance of evidence.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Herrera | LVN | Met with Licensing Program Analyst during investigation and discussed allegations. |
| Katrina Sinift | Administrator | Named as facility administrator; was not available during findings delivery. |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 72
Deficiencies: 0
Date: Jun 27, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2024-03-11 alleging that staff did not treat residents with dignity or respect.
Complaint Details
The complaint alleging staff did not treat residents with dignity or respect was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The investigation found no evidence to substantiate the allegation that staff did not treat residents with dignity or respect. The allegations were determined to be unsubstantiated based on records review and staff interviews.
Report Facts
Capacity: 72
Census: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Herrera | LVN | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 72
Deficiencies: 1
Date: Mar 13, 2024
Visit Reason
The visit was an unannounced complaint inspection combined with case management to investigate a complaint and assess compliance.
Complaint Details
The inspection was triggered by a complaint. The deficiency cited was substantiated based on observation during the visit.
Findings
The inspection found that the maintenance room was unlocked and contained hazardous items such as Clorox Bleach Cleaner, Bleach Wipes, sharp tools, and aerosol cans, posing an immediate health and safety risk to persons in care.
Deficiencies (1)
CCR 87309(a) requires disinfectants, cleaning solutions, poisons, firearms, and other dangerous items to be stored where inaccessible to clients. The licensee did not comply as the unlocked maintenance room contained hazardous items posing an immediate health and safety risk.
Report Facts
Deficiency Type Count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katrina Sinift | Administrator | Met with Licensing Program Analyst during inspection and discussed plan of corrections. |
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint inspection and case management visit. |
Inspection Report
Annual Inspection
Census: 39
Capacity: 72
Deficiencies: 2
Date: Sep 5, 2023
Visit Reason
The visit was an unannounced Annual Inspection conducted by Licensing Program Analysts to assess compliance with regulatory requirements at the assisted living facility.
Findings
The inspection found the facility generally clean and well-maintained with proper safety equipment and resident care. However, deficiencies were cited related to food service equipment cleanliness and medication administration documentation.
Deficiencies (2)
CCR 87555(b)(29) General Food Service Requirements: The ice machine had brown buildup underneath the door lift area, posing an immediate health and safety risk.
CCR 87465(a)(4) Incidental Medical and Dental Care Services: Medication audit revealed missed dosages for two residents and a missing pill for another, with incomplete documentation.
Report Facts
Deficiencies cited: 2
Medication audit: 4
Missed dosages: 2
Missing pills: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Trina Sinfit | Executive Director | Met with Licensing Program Analysts during inspection |
| Crystal Gonzales | Administrator | Named in plan of correction and exit interview |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 72
Deficiencies: 1
Date: Mar 1, 2023
Visit Reason
Unannounced complaint investigation visit triggered by an allegation of an uncleared adult present at the facility.
Complaint Details
The complaint was substantiated based on evidence that Staff 1 worked without a cleared criminal background check, violating licensing requirements.
Findings
The investigation found that Staff 1 was hired and worked at the facility without a cleared criminal background check and was subsequently terminated. The allegation was substantiated and a civil penalty was assessed.
Deficiencies (1)
CCR 87355(a) requires a criminal record review for all specified individuals. Staff 1's background clearance was pending while working at the facility, posing an immediate risk to residents. The facility terminated Staff 1 on 1/26/2023 and completed the plan of correction prior to the visit.
Report Facts
Capacity: 72
Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Crystal Gonzales | Administrator | Facility administrator involved in the investigation |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 72
Deficiencies: 1
Date: Aug 24, 2022
Visit Reason
The visit was conducted to address an incident on 06/01/22 where a staff member removed a resident's lotions and after shave without permission.
Complaint Details
The visit was complaint-related, investigating an incident where Staff 1 removed resident 1's lotions and after shave without permission. The deficiency was substantiated and cited.
Findings
A deficiency was cited for violating residents' personal rights as staff removed resident items without permission, posing a potential health, safety, or personal rights risk.
Deficiencies (1)
CCR 87468.1(a)(1) requires residents to be accorded dignity in personal relationships. Staff removed resident items without permission, violating this right and posing a potential risk.
Report Facts
Census: 43
Total Capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Crystal Gonzales | Administrator | Met during inspection and involved in plan of correction development |
| Mai Yang | Licensing Program Analyst | Conducted the inspection and cited deficiency |
Inspection Report
Annual Inspection
Census: 43
Capacity: 72
Deficiencies: 1
Date: Aug 24, 2022
Visit Reason
The visit was an unannounced Annual Inspection focused on Infection Control conducted by the Licensing Program Analyst.
Findings
The facility was generally compliant with infection control practices, including use of facial coverings, visitor screening, and social distancing. However, a deficiency was cited for unsafe storage of cleaning chemicals accessible to residents.
Deficiencies (1)
CCR 87309(a) requires disinfectants and cleaning solutions to be stored where inaccessible to clients. Cleaning chemicals were observed unlocked and accessible to residents in the activity room and on the dining counter, posing an immediate health and safety risk.
Report Facts
Residents present in dining room: 18
PPE supplies observed: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Crystal Gonzales | Administrator | Met with Licensing Program Analyst during inspection and involved in Plan of Correction |
| Mai Yang | Licensing Program Analyst | Conducted the inspection |
| Melinda Hoffmann | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 43
Capacity: 72
Deficiencies: 0
Date: Aug 27, 2021
Visit Reason
Licensing Program Analyst conducted an Annual Required Infection Control Inspection as part of the required 1-year unannounced visit.
Findings
The facility was found to be clean with no fire clearance issues, adequate infection control measures including mask use and social distancing, and sufficient supplies. No deficiencies were observed during the inspection.
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