Inspection Report Summary
Most inspections found deficiencies related primarily to unsafe storage of medications and hazardous items, missing or outdated resident care plans, and some environmental safety issues. The facility received an immediate civil penalty for fire clearance violations in September 2024, which was the most serious enforcement action noted. Several complaint investigations were unsubstantiated or not applicable, and some follow-up visits found no deficiencies, indicating partial improvement. The most recent report from September 17, 2025, identified multiple safety risks including lack of carbon monoxide detectors and unsecured medications, showing that some issues persist. Overall, the facility’s record shows ongoing challenges with safety and documentation, with no clear pattern of consistent improvement.
Deficiencies per Year
16
12
8
4
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 9
Sep 17, 2025
Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.
Findings
The facility was found to have multiple deficiencies including lack of carbon monoxide detector, unsafe storage of hazardous items and medications, unclean bathrooms, broken patio furniture, missing staff training records, and incomplete personnel files. Several immediate and potential safety risks to residents were identified.
Severity Breakdown
Type A: 4
Type B: 5
Deficiencies (9)
| Description | Severity |
|---|---|
| No carbon monoxide detector in the facility posing an immediate health and safety risk. | Type A |
| Unsafe storage of lysol wipes, disinfectant spray, and Tide Pods accessible to residents posing immediate safety risk. | Type A |
| Both residents' bathrooms uncleaned, strong urine odor in R5's room, and broken patio furniture posing potential safety and personal rights risk. | Type B |
| Staff S3 and S4 did not have required training within the last year posing potential safety risk. | Type B |
| Half bed rail used for R1 without a doctor's order posing potential safety risk. | Type B |
| No first aid kit observed posing potential safety risk. | Type B |
| Unlocked medications in residents' rooms posing immediate safety risk. | Type A |
| Missing personnel file for staff S4 posing potential safety risk. | Type B |
| Failure to report an incident involving resident R3 to licensing posing potential safety risk. | Type B |
Report Facts
Residents' records reviewed: 6
Staff records reviewed: 3
Medication samples reviewed: 4
Facility capacity: 6
Facility census: 6
POC due dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Sunderraj | Administrator | Authorized staff to sign report and named in plans of correction |
| Satvinder Kaur | Direct Care Staff | Met with Licensing Program Analyst during inspection |
| Patricia Manalo | Licensing Program Analyst | Conducted the inspection and signed the report |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Follow-Up
Census: 5
Capacity: 6
Deficiencies: 0
Jan 16, 2025
Visit Reason
An unannounced Case Management visit was conducted to follow up on deficiencies observed during the annual inspection on 09/19/2024, specifically regarding failure to provide doctor's orders for the use of half rails for residents R2, R3, and R4.
Findings
During the visit, the Administrator stated that residents R2, R3, and R4 no longer needed the half rails and had removed them. No deficiencies were cited during this visit.
Report Facts
Facility capacity: 6
Census: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Sunderraj | Administrator | Met during the inspection and provided information regarding the half rails |
| Satvinder Kaur | Caregiver | Met during the inspection and explained the purpose of the visit |
| Patricia Manalo | Licensing Program Analyst | Conducted the inspection |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Plan of Correction
Census: 6
Capacity: 6
Deficiencies: 0
Oct 3, 2024
Visit Reason
Unannounced Case Management Plan of Correction visit regarding deficiencies observed during the annual visit on 2024-09-19.
Findings
No deficiencies were issued during this visit. The Licensing Program Analysts confirmed that the bedridden resident (R6) had moved out and observed six residents present at the facility.
Report Facts
Residents present: 6
Facility capacity: 6
Days bedridden resident was to stay: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Sunderraj | Administrator/Licensee | Named in relation to the bedridden resident and authorization for report signing |
| Satvinder Kaur | Caregiver | Met with Licensing Program Analysts during the visit and signed report |
| Ravinder Singh | Caregiver | Met with Licensing Program Analysts during the visit |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 14
Sep 19, 2024
Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing regulations and facility standards.
Findings
The inspection identified multiple deficiencies related to fire clearance, storage of hazardous materials, personal rights postings, resident accommodations, medical assessments, admission agreements, emergency drills, care of bedridden residents, postural supports, and hospice care notifications. Plans of correction were requested with due dates, and an immediate civil penalty was assessed for one deficiency.
Severity Breakdown
Type A: 4
Type B: 9
Deficiencies (14)
| Description | Severity |
|---|---|
| Lock latch on gated fence posed an immediate health, safety or personal rights risk. | Type A |
| No fire clearance for bedridden persons, posing immediate health, safety or personal rights risk. | Type A |
| Tide Laundry Pods and Clorox wipes were accessible to clients, posing immediate health, safety or personal rights risk. | Type A |
| Unlocked medications and vitamins were accessible to residents with dementia, posing immediate health, safety or personal rights risk. | Type A |
| Personal rights posters were not posted in the facility, posing potential health, safety or personal rights risk. | Type B |
| Three residents sharing one bedroom, exceeding the maximum of two per bedroom. | Type B |
| PUB 475 complaint poster not posted in facility entryway. | Type B |
| Missing medical assessment for resident R6. | Type B |
| Missing admission agreement for resident R6. | Type B |
| Quarterly fire drills not conducted by staff. | Type B |
| No fire clearance or supporting documents to care for bedridden residents; immediate civil penalty assessed. | Type B |
| Missing doctor's orders for half bed rails/hospital beds postural/mobility support for residents R2-R6. | Type B |
| Failure to notify Department in writing within five working days of initiation of hospice care services for resident R1. | Type B |
| Missing updated medical assessments and Appraisal Needs and Services (ANS) for residents R2-R6. | Type B |
Report Facts
Capacity: 6
Census: 6
Immediate Civil Penalty: 500
Deficiencies cited: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Sunderraj | Licensee/Administrator | Met with Licensing Program Analysts during inspection and involved in plans of correction |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted inspection and authored report |
| Bennett Fong | Licensing Program Manager | Supervisor overseeing inspection |
Inspection Report
Annual Inspection
Census: 3
Capacity: 6
Deficiencies: 3
Aug 25, 2023
Visit Reason
The inspection was an unannounced 1-Year Annual Required Inspection conducted to evaluate compliance with licensing regulations and facility safety standards.
Findings
The inspection found several deficiencies including unlocked medication and cleaning supplies accessible to residents, missing needs and service plans for residents, and outdated physicians' reports. The facility was otherwise observed to maintain adequate safety measures such as fire clearance, smoke detectors, and proper environmental conditions.
Severity Breakdown
Type A: 2
Type B: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Medication and cleaning supplies unlocked and accessible to persons in care. | Type A |
| Residents R1, R2, and R3 had no needs and service plan on file. | Type B |
| Residents R1, R2, and R3's physicians' reports dated 2020 were on file and not updated yearly. | Type B |
Report Facts
Capacity: 6
Census: 3
Deficiencies cited: 4
POC Due Date: Sep 1, 2023
POC Due Date: Aug 26, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liridon Fici | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Harpreet Humpal | Licensing Program Manager | Supervisor overseeing the inspection |
| Deogracias Concha | Care Staff | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 3
Aug 26, 2022
Visit Reason
The inspection was an unannounced annual infection control visit conducted to evaluate compliance with infection control and care standards at the facility.
Findings
The inspection found the facility generally compliant with infection control measures, including sufficient PPE and food supplies, operable safety equipment, and no obstructions posing health risks. However, deficiencies were cited for unlocked knives and medication cabinets accessible to residents, and missing appraisal needs/service plans for all residents.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Knives were stored in an unlocked cabinet accessible to residents, posing an immediate health and safety risk. | Type A |
| Medication cabinet was unlocked and accessible to residents, posing an immediate health and safety risk. | Type A |
| Six out of six residents did not have appraisal needs/service plans in their files, posing a potential health and safety risk. | Type B |
Report Facts
Residents without appraisal needs/service plans: 6
Facility capacity: 6
Facility census: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Sunderraj | Licensee | Named in relation to deficiencies regarding unlocked knives and medication cabinets |
| Yvonne Flores-Larios | Licensing Program Manager | Conducted inspection and cited deficiencies |
| Liridon Fici | Licensing Program Analyst | Conducted inspection and cited deficiencies |
| Deogracia Concha | Care Staff | Greeted inspectors at facility entrance |
Inspection Report
Routine
Census: 4
Capacity: 6
Deficiencies: 0
Sep 10, 2021
Visit Reason
The inspection was an unannounced Infection Control Inspection conducted as a required 1-year visit.
Findings
The Licensing Program Analyst toured the facility and observed COVID-19 signage, sufficient PPE, food and paper supplies, hand sanitizer at entry, and daily disinfection of common areas. The facility had a Mitigation Plan on file. No deficiencies were cited during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deogracias Concha | Staff | Met with Licensing Program Analyst during inspection. |
| Mary Sunderraj | Licensee/Administrator | Called during the inspection. |
| Allison O'Hollaren | Licensing Program Analyst | Conducted the Infection Control Inspection. |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report header. |
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