Inspection Reports for
Melrose Gardens

CA, 90046

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Deficiencies (last 5 years)

Deficiencies (over 5 years) 1.6 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

60% better than California average
California average: 4 deficiencies/year

Deficiencies per year

4 3 2 1 0
2022
2023
2024
2025
2026

Occupancy

Latest occupancy rate 52% occupied

Based on a January 2026 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Occupancy rate over time

0% 30% 60% 90% 120% Dec 2022 Oct 2023 Oct 2024 Mar 2025 Nov 2025 Jan 2026

Inspection Report

Complaint Investigation
Census: 52 Capacity: 100 Deficiencies: 0 Date: Jan 15, 2026

Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations received on 10/29/2024 regarding staff safeguarding resident's personal belongings and allowing residents to have visitors.

Complaint Details
The complaint involved two allegations: 1) staff does not safeguard resident's personal belongings, and 2) staff do not allow resident to have visitors. Both allegations were investigated and found to be unsubstantiated based on inspections, interviews, and record reviews.
Findings
The investigation found insufficient evidence to substantiate the allegation that staff did not safeguard resident's personal belongings. The allegation that staff did not allow a resident to have visitors was also deemed unsubstantiated, as the visitor was prohibited due to health and safety concerns for the resident and others. No immediate health and safety hazards were noted.

Report Facts
Capacity: 100 Census: 52

Employees mentioned
NameTitleContext
Raymond ComerLicensing Program AnalystConducted the complaint investigation visit
Joseph "Yossi" WiederAdministratorMet with the Licensing Program Analyst during the investigation
Marco VillegasAdministratorNamed as facility administrator in the report header

Inspection Report

Complaint Investigation
Census: 52 Capacity: 100 Deficiencies: 0 Date: Jan 15, 2026

Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff did not safeguard resident's personal belongings and did not allow a resident to have visitors.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not safeguarding resident's personal belongings and not allowing a resident to have visitors. The visitor was prohibited due to aggressive behavior and health and safety risks, but the allegations were ultimately unsubstantiated.
Findings
The investigation found insufficient evidence to substantiate the allegation regarding safeguarding of personal belongings. The allegation that staff did not allow a resident to have visitors was also deemed unsubstantiated, as the visitor was prohibited due to health and safety concerns for the resident and others.

Report Facts
Facility capacity: 100 Resident census: 52

Employees mentioned
NameTitleContext
Raymond ComerLicensing Program AnalystConducted the complaint investigation visit
Joseph "Yossi" WiederAdministratorMet with Licensing Program Analyst during investigation
Marco VillegasAdministratorNamed as facility administrator

Inspection Report

Complaint Investigation
Census: 30 Capacity: 100 Deficiencies: 0 Date: Dec 4, 2025

Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2024-10-29 regarding inadequate food service, cleanliness, and linen provision at the facility.

Complaint Details
The complaint investigation was unsubstantiated based on observations and interviews. Allegations included inadequate food service, unclean facility and resident room, and failure to provide clean linens, all of which were found unproven.
Findings
The investigation found no evidence to support the allegations. Observations and interviews with residents indicated that meals were adequate, the facility and resident's room were clean, and linens were properly maintained. Therefore, all allegations were deemed unsubstantiated.

Report Facts
Residents interviewed: 4 Census: 30 Total capacity: 100

Employees mentioned
NameTitleContext
Raymond ComerLicensing Program AnalystConducted the complaint investigation
Joseph "Yossi" WiederAdministratorFacility administrator met during the investigation

Inspection Report

Complaint Investigation
Census: 30 Capacity: 100 Deficiencies: 0 Date: Dec 4, 2025

Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2024-10-29 regarding inadequate food service, unsanitary conditions, and unclean linens at the facility.

Complaint Details
The complaint investigation was unsubstantiated based on observations and interviews. Allegations included inadequate food service, unsanitary conditions, and unclean linens, all of which were found to be unproven.
Findings
The investigation found no evidence to support the allegations. Observations and interviews with residents indicated that meals were adequate, the facility and resident's room were clean and sanitary, and linens were clean and properly maintained. Therefore, all allegations were deemed unsubstantiated.

Report Facts
Capacity: 100 Census: 30 Residents interviewed: 4

Employees mentioned
NameTitleContext
Raymond ComerLicensing Program AnalystConducted the complaint investigation
Joseph "Yossi" WiederAdministratorFacility administrator met during the investigation

Inspection Report

Annual Inspection
Census: 55 Capacity: 100 Deficiencies: 0 Date: Nov 6, 2025

Visit Reason
The inspection was a continuation of the required annual facility inspection initiated on 2025-11-03 to evaluate compliance with licensing requirements.

Findings
The facility was found to have no health and safety hazards at the time of inspection. Fire safety systems, medication storage, laundry areas, and staff records were all observed to be in compliance and properly maintained.

Report Facts
Staff files reviewed: 5

Employees mentioned
NameTitleContext
Joseph WiederExecutive DirectorMet with Licensing Program Analyst during inspection
Raymond ComerLicensing Program AnalystConducted the inspection
Nichelle GillyardLicensing Program ManagerNamed in report header and signature section

Inspection Report

Annual Inspection
Census: 55 Capacity: 100 Deficiencies: 0 Date: Nov 6, 2025

Visit Reason
The visit was a continuation of the required annual facility inspection initiated on 2025-11-03 to evaluate compliance with licensing requirements.

Findings
The inspection found the facility to be in compliance with fire safety, medication management, laundry safety, and staff records requirements. No health or safety hazards were observed during the inspection.

Report Facts
Staff files reviewed: 5

Employees mentioned
NameTitleContext
Joseph WiederExecutive DirectorMet with Licensing Program Analyst during inspection.
Raymond ComerLicensing Program AnalystConducted the inspection.
Nichelle GillyardLicensing Program ManagerNamed as Licensing Program Manager on report.

Inspection Report

Complaint Investigation
Census: 54 Capacity: 100 Deficiencies: 0 Date: Nov 4, 2025

Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that staff failed to ensure proper medication administration and violated resident rights to privacy and property security.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff leaving medications unattended and not ensuring residents took them, and staff not knocking before entering residents' rooms. Interviews and observations did not verify these allegations.
Findings
The investigation found insufficient evidence to substantiate the allegations. Observations and interviews indicated no medication was left unattended and staff generally respected residents' privacy by knocking before entering, though one resident reported otherwise. No health and safety hazards were noted.

Report Facts
Staff interviewed: 4 Residents interviewed: 6

Employees mentioned
NameTitleContext
Abeye DugumaLicensing Program AnalystConducted the complaint investigation and authored the report.
Marco VillegasAdministratorFacility administrator named in the report.
Joseph WeiderMet with Licensing Program Analyst during the investigation.
Troy AgardSupervisorSupervisor overseeing the licensing evaluation.

Inspection Report

Complaint Investigation
Census: 54 Capacity: 100 Deficiencies: 0 Date: Nov 4, 2025

Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that staff failed to ensure proper medication administration and violated resident rights to privacy and property security.

Complaint Details
The complaint investigation was unsubstantiated based on interviews, observations, and record reviews. Allegations included improper medication administration and violation of resident privacy rights, both found unsubstantiated.
Findings
The investigation found insufficient evidence to substantiate the allegations. Observations, interviews with staff and residents, and record reviews did not confirm medication was left unattended or that staff failed to respect residents' privacy by not knocking before entering. Therefore, both allegations were unsubstantiated.

Report Facts
Number of residents present: 54 Facility capacity: 100 Number of staff interviewed: 4 Number of residents interviewed: 6

Employees mentioned
NameTitleContext
Abeye DugumaLicensing Program AnalystConducted the complaint investigation
Joseph WeiderMet with during investigation
Marco VillegasAdministratorFacility administrator named in report header
Troy AgardSupervisorSupervisor overseeing the investigation

Inspection Report

Annual Inspection
Census: 55 Capacity: 100 Deficiencies: 0 Date: Nov 3, 2025

Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with licensing requirements and standards.

Findings
The facility was inspected for cleanliness, safety, and compliance across multiple areas including physical plant, kitchen, resident bedrooms, bathrooms, common areas, and outdoor spaces. Resident records were reviewed and found to be complete and current. The inspection was not fully completed due to time constraints and will be finished at a later date.

Report Facts
Hospice residents: 5 Hospice waiver capacity: 20 Fire clearance capacity: 72 Fire clearance capacity: 28 Disaster drills last conducted: Sep 30, 2025 Hot water temperature range: 108 Hot water temperature range: 115.5 Room temperature: 76

Employees mentioned
NameTitleContext
Joseph WiederExecutive DirectorMet with Licensing Program Analyst during inspection
Raymond ComerLicensing Program AnalystConducted the inspection
Nichelle GillyardLicensing Program ManagerNamed in report header

Inspection Report

Complaint Investigation
Census: 54 Capacity: 100 Deficiencies: 0 Date: Oct 21, 2025

Visit Reason
The visit was conducted as a complaint investigation following allegations that staff failed to provide adequate food service and meal accommodation, and that the licensee failed to ensure staff could communicate with residents in care.

Complaint Details
The complaint was unsubstantiated based on record reviews, interviews, and observations. The allegations regarding inadequate food service and communication issues were not verified.
Findings
The investigation found that a variety of well-balanced foods were offered and served, and staff reported offering meal alternatives and effective communication with residents. Some residents stated the food was inedible and no options were offered, but most residents were satisfied. Overall, there was insufficient evidence to substantiate the allegations, and no health or safety hazards were noted.

Report Facts
Capacity: 100 Census: 54

Employees mentioned
NameTitleContext
Abeye DugumaLicensing Program AnalystConducted the complaint investigation visit
Marco VillegasAdministratorFacility administrator named in the report

Inspection Report

Complaint Investigation
Census: 54 Capacity: 100 Deficiencies: 0 Date: Oct 21, 2025

Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff failed to provide adequate food service and meal accommodation, and that the licensee failed to ensure staff could communicate with residents in care.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included inadequate food service and meal accommodation, and communication issues between staff and residents. Interviews, observations, and record reviews did not verify the allegations.
Findings
The investigation found that a variety of well-balanced foods were offered and served, and staff reported offering meal alternatives and effective communication with residents. Some residents stated the food was inedible and lacked options, but most residents were satisfied and able to communicate their needs. The allegations were unsubstantiated due to insufficient evidence.

Report Facts
Capacity: 100 Census: 54

Employees mentioned
NameTitleContext
Abeye DugumaLicensing Program AnalystConducted the complaint investigation and authored the report
Marco VillegasAdministratorFacility administrator named in the report
Joseph WeiderMet with Licensing Program Analyst during the investigation
Troy AgardSupervisorSupervisor named in the report

Inspection Report

Annual Inspection
Census: 31 Capacity: 31 Deficiencies: 0 Date: Sep 30, 2025

Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with licensing requirements and ensure the health and safety of residents.

Findings
The facility was found to be clean, well-maintained, and compliant with safety and health regulations. No immediate health or safety hazards were observed. Resident and staff records were complete and current. Fire safety systems and infection control measures were properly maintained.

Report Facts
Residents receiving hospice care: 2 Fire extinguishers last serviced: 2024 Hot water temperature: 114 Resident files reviewed: 4 Staff files reviewed: 6

Employees mentioned
NameTitleContext
Yossi WiederExecutive DirectorMet with Licensing Program Analyst during inspection
Raymond ComerLicensing Program AnalystConducted the inspection and authored the report
Nichelle GillyardLicensing Program ManagerNamed as Licensing Program Manager on the report

Inspection Report

Complaint Investigation
Census: 31 Capacity: 31 Deficiencies: 2 Date: May 23, 2025

Visit Reason
An unannounced case management visit was conducted in conjunction with complaint investigation #31-AS-20250516141919 to address deficiencies related to a complaint involving an aggressive incident between two residents and failure to follow reporting requirements.

Complaint Details
Complaint investigation #31-AS-20250516141919 was conducted due to an incident on 05/05/25 where Resident #2 committed an aggressive act upon Resident #1. Staff contacted physicians and family but failed to report the incident to the Administrator or submit required reports to the Licensing Division.
Findings
The investigation revealed that staff failed to report the incident to the Administrator and did not submit required incident reports to the Licensing Division, violating Title 22 reporting requirements. No immediate health or safety hazards were observed during the visit.

Deficiencies (2)
Failure to submit an Incident Report to the licensing agency within seven days of the incident's occurrence, posing a potential health risk to residents in care.
Failure to report suspected physical abuse to the local ombudsman and local law enforcement agency within 24 hours as required, posing a potential health risk to residents in care.
Report Facts
Capacity: 31 Census: 31 Deficiencies cited: 2

Employees mentioned
NameTitleContext
Marco VillegasAdministratorMet during inspection and informed of reporting deficiencies
Raymond ComerLicensing Program AnalystConducted the unannounced case management visit and complaint investigation
Eva MillerLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Complaint Investigation
Census: 53 Capacity: 100 Deficiencies: 0 Date: May 1, 2025

Visit Reason
The visit was an unannounced complaint investigation regarding an allegation that staff did not prevent a resident from entering other residents' rooms.

Complaint Details
The complaint alleged that staff were aware of a resident entering another resident's room multiple times but neglected to address it. Interviews and observations did not support this claim, and the allegation was unsubstantiated.
Findings
The investigation found no health or safety issues and interviews with staff, residents, and the Executive Director indicated that residents have locks on their rooms and staff actively monitor wandering residents. The allegation was deemed unsubstantiated.

Report Facts
Residents interviewed: 6

Employees mentioned
NameTitleContext
Marco VillegasAdministratorMet with Licensing Program Analyst during investigation.
Raymond ComerLicensing Program AnalystConducted the complaint investigation.
Eva MillerLicensing Program ManagerNamed as Licensing Program Manager on report.

Inspection Report

Complaint Investigation
Census: 52 Capacity: 100 Deficiencies: 0 Date: Mar 21, 2025

Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff do not answer the facility telephone and that visitors are unable to enter or leave due to lack of front desk coverage.

Complaint Details
The complaint alleged that staff do not answer the facility telephone during morning and afternoon hours and that visitors are unable to enter or leave due to lack of front desk coverage. The allegation was found to be unsubstantiated based on observations and interviews.
Findings
The investigation found that the telephone was in working order, staff consistently covered the front desk, and interviews with staff and residents confirmed no issues with telephone answering or visitor access. The allegation was unsubstantiated.

Report Facts
Residents interviewed: 6

Employees mentioned
NameTitleContext
Marco VillegasExecutive DirectorMet with Licensing Program Analyst and interviewed regarding complaint
Raymond ComerLicensing Program AnalystConducted complaint investigation visit
Eva MillerLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Annual Inspection
Census: 30 Capacity: 31 Deficiencies: 0 Date: Dec 12, 2024

Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with licensing requirements and overall condition.

Findings
The facility was found to be clean, well-maintained, and compliant with safety and health regulations. No immediate health or safety hazards were observed. All required systems, including fire detection and infection control, were functioning properly.

Report Facts
Residents receiving hospice care: 2 Disaster drills last conducted: Sep 25, 2024 Fire extinguishers last serviced: Dec 24, 2023 Resident files reviewed: 3 Staff files reviewed: 3 Hot water temperature: 113.5

Employees mentioned
NameTitleContext
Marco VillegasFacility AdministratorMet with Licensing Program Analyst during inspection and involved in facility tour.
Raymond ComerLicensing Program AnalystConducted the unannounced annual inspection.
Eva MillerLicensing Program ManagerNamed as Licensing Program Manager on the report.

Inspection Report

Complaint Investigation
Census: 54 Capacity: 100 Deficiencies: 0 Date: Nov 14, 2024

Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff did not distribute residents' medications as prescribed and did not safeguard residents' personal belongings.

Complaint Details
The complaint alleged that staff failed to distribute Resident#1's medications as prescribed and failed to safeguard personal belongings of Resident#3 and Resident#4. After review of records, observations, and interviews, the allegations were found unsubstantiated.
Findings
The investigation found no evidence to support the allegations. Medication distribution was confirmed to be as prescribed, and residents' personal belongings were safeguarded. Therefore, both allegations were deemed unsubstantiated.

Report Facts
Capacity: 100 Census: 54 Residents interviewed: 5

Employees mentioned
NameTitleContext
Marco VillegasExecutive DirectorMet with Licensing Program Analyst during the investigation
Raymond ComerLicensing Program AnalystConducted the complaint investigation visit
Eva MillerSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 54 Capacity: 100 Deficiencies: 0 Date: Nov 14, 2024

Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff did not distribute residents' medications as prescribed and did not safeguard residents' personal belongings.

Complaint Details
The complaint alleged that staff failed to distribute Resident #1's medication properly and failed to safeguard personal belongings of Residents #3 and #4. After review of records, observations, and interviews, the allegations were found unsubstantiated.
Findings
The investigation found no evidence to support the allegations. Medication distribution was confirmed to be as prescribed, and residents' personal belongings were safeguarded. Therefore, both allegations were deemed unsubstantiated.

Report Facts
Capacity: 100 Census: 54 Residents interviewed: 5

Employees mentioned
NameTitleContext
Marco VillegasExecutive DirectorMet with Licensing Program Analyst during investigation
Raymond ComerLicensing Program AnalystConducted the complaint investigation visit
Eva MillerSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 53 Capacity: 100 Deficiencies: 0 Date: Nov 4, 2024

Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that facility staff do not provide adequate incontinent care and do not ensure residents' hygiene needs are being met.

Complaint Details
The complaint was unsubstantiated. Allegations included inadequate incontinent care and failure to meet hygiene needs. The Licensing Program Analyst conducted interviews, observations, and record reviews but could not prove the allegations.
Findings
The investigation found no evidence to substantiate the allegations. Observations, record reviews, and interviews indicated that the resident was clean, dry, and able to perform most activities of daily living with minimal assistance. Staff and family interviews confirmed that the resident sometimes refuses assistance but accepts it with encouragement.

Report Facts
Facility capacity: 100 Census: 53

Employees mentioned
NameTitleContext
Marco VillegasExecutive DirectorMet with Licensing Program Analyst during investigation
Raymond ComerLicensing Program AnalystConducted the complaint investigation

Inspection Report

Complaint Investigation
Census: 53 Capacity: 100 Deficiencies: 0 Date: Nov 4, 2024

Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that facility staff do not provide adequate incontinent care and do not ensure resident's hygiene needs are being met.

Complaint Details
The complaint alleged inadequate incontinent care and failure to meet hygiene needs for Resident 1. The investigation included interviews with staff, the resident's family member, and review of medical and assessment records. The allegations were unsubstantiated as evidence showed the resident's needs were being met.
Findings
The investigation found no evidence to support the allegations. Observations, record reviews, and interviews indicated that the resident was clean, dry, and able to perform most activities of daily living with minimal assistance. Therefore, the allegations were deemed unsubstantiated.

Report Facts
Facility capacity: 100 Resident census: 53

Employees mentioned
NameTitleContext
Marco VillegasExecutive DirectorMet with Licensing Program Analyst during investigation
Raymond ComerLicensing Program AnalystConducted the complaint investigation
Eva MillerSupervisorSupervisor overseeing the investigation

Inspection Report

Annual Inspection
Census: 57 Capacity: 100 Deficiencies: 0 Date: Oct 22, 2024

Visit Reason
The visit was a continuation of the required annual facility inspection to evaluate compliance with licensing regulations.

Findings
The inspection found that fire detection and protection systems were functional and properly maintained, medication storage and documentation were secure and complete, laundry and common areas were clean and safe, resident bedrooms and bathrooms met safety and comfort standards, and resident and staff records were complete and current. No immediate health or safety hazards were observed.

Report Facts
Resident files reviewed: 6 Staff files reviewed: 6 Hot water temperature: 111 Fire extinguisher last serviced: 2023

Employees mentioned
NameTitleContext
Nancy AdamsAdministrator DesigneeMet with Licensing Program Analyst during inspection and received exit interview.
Raymond ComerLicensing Program AnalystConducted the annual facility inspection.
Eva MillerLicensing Program ManagerNamed in report as Licensing Program Manager.

Inspection Report

Annual Inspection
Census: 57 Capacity: 100 Deficiencies: 0 Date: Oct 21, 2024

Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with licensing requirements and overall condition.

Findings
The facility was found to be clean and well-maintained, with proper infection control measures and safety systems in place. Resident records were complete and current, and the kitchen met all health and safety standards. The inspection was not fully completed due to time constraints and will be finished at a later date.

Report Facts
Residents receiving hospice care: 5 Resident files reviewed: 6 Disaster drills last conducted: Sep 25, 2024 Room temperature: 77

Employees mentioned
NameTitleContext
Nancy AdamsWellness DirectorMet with Licensing Program Analyst during inspection and received copy of report
Raymond ComerLicensing Program AnalystConducted the inspection
Eva MillerLicensing Program ManagerNamed in report header and signature section

Inspection Report

Complaint Investigation
Census: 55 Capacity: 100 Deficiencies: 0 Date: Sep 24, 2024

Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations regarding food quality and quantity, staff communication with residents, and medication management.

Complaint Details
The complaint included allegations that staff did not ensure good quality and quantity of food, were rude to residents, and did not properly manage medications. The investigation found these allegations unsubstantiated based on observations, interviews with staff and residents, and review of medication records.
Findings
The investigation found that the facility had sufficient food stock and residents reported food quality and quantity as good. Staff were not found to be rude to residents, and medication management issues were related to insurance coverage and physician restrictions. All allegations were deemed unsubstantiated.

Report Facts
Residents interviewed: 8 Medication supply days: 90 Medication supply days: 7

Employees mentioned
NameTitleContext
Jose Gary TanLicensing Program AnalystConducted the complaint investigation visit.
Marco VillegasExecutive DirectorMet with Licensing Program Analyst during the investigation.
Troy AgardLicensing Program ManagerNamed as Licensing Program Manager on the report.

Inspection Report

Complaint Investigation
Census: 54 Capacity: 100 Deficiencies: 0 Date: May 29, 2024

Visit Reason
The visit was conducted as a case management and complaint investigation related to complaint report #31-AS-20240425102904, with an initial complaint investigation visit conducted on 2024-04-30.

Complaint Details
Complaint investigation associated with complaint report #31-AS-20240425102904; initial investigation visit conducted on 2024-04-30. The amended complaint investigation report was delivered on 2024-05-29.
Findings
The report documents the delivery of an amended LIC 9099 Complaint Investigation Report to the Assistant Administrator, Jennifer Rivera, summarizing the complaint investigation findings.

Employees mentioned
NameTitleContext
Raymond ComerLicensing Program AnalystDelivered the amended LIC 9099 Complaint Investigation Report.
Jennifer RiveraAssistant AdministratorReceived the amended LIC 9099 Complaint Investigation Report.
Marco VillegasAdministrator/DirectorNamed as facility administrator/director.
Eva MillerLicensing Program ManagerNamed as Licensing Program Manager.

Inspection Report

Complaint Investigation
Census: 54 Capacity: 100 Deficiencies: 0 Date: Apr 30, 2024

Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that staff do not allow a resident to have visitors.

Complaint Details
The complaint alleged that staff prohibited a resident from having visitors. The investigation revealed that the family member was restricted from visiting by their own facility's medical team pending a medical evaluation. The allegation was unsubstantiated.
Findings
The investigation found no issues with visitation rights; the facility does not prohibit residents' visitation. The family member in question was temporarily unable to visit due to medical restrictions at another facility. The allegation was unsubstantiated.

Report Facts
Capacity: 100 Census: 54

Employees mentioned
NameTitleContext
Marco VillegasAdministratorNamed in relation to the allegation about visitation rights
Raymond ComerLicensing Program AnalystConducted the complaint investigation
Micheal CavaLicensing Program AnalystConducted the health and safety inspection
Eva MillerLicensing Program ManagerOversaw the complaint investigation

Inspection Report

Complaint Investigation
Census: 54 Capacity: 100 Deficiencies: 1 Date: Feb 29, 2024

Visit Reason
This case management visit was conducted in conjunction with a complaint investigation to address deficiencies unrelated to the complaint.

Complaint Details
The visit was complaint-related; deficiencies unrelated to the complaint were observed and cited.
Findings
Deficiencies were observed including a non-working parking lot buzzer, trash containers blocking an exit door, cigarette butts scattered around, and old broken furniture with sharp corners obstructing the parking and recreational area posing health and safety hazards. The parking lot and recreational areas were not maintained as required.

Deficiencies (1)
Facility parking lot and outside recreational area were not clean and free of obstructions, posing potential health and safety hazards to residents.
Report Facts
Capacity: 100 Census: 54

Employees mentioned
NameTitleContext
Marco VillegasAdministratorMet during the visit and discussed noted issues
Naira MargaryanLicensing Program ManagerSupervisor and Licensing Program Manager involved in the inspection
Leizl De La CerraLicensing Program AnalystLicensing Program Analyst involved in the inspection

Inspection Report

Complaint Investigation
Census: 54 Capacity: 100 Deficiencies: 2 Date: Feb 29, 2024

Visit Reason
Unannounced complaint investigation visit conducted due to a complaint received on 2024-01-12 regarding untimely medication refills for residents.

Complaint Details
Complaint was substantiated. Allegation was that staff did not order resident’s medication refills in a timely manner. Investigation confirmed medication refill delays and inaccurate medication administration record keeping.
Findings
The investigation found that medication for Resident #1 was not refilled in a timely manner, resulting in a medication gap from 01/03/2024 to 01/08/2024. Additionally, staff continued to initial medication administration records for Resident #1 after the resident had relocated, indicating inaccurate documentation. These findings were substantiated and posed immediate health and safety risks.

Deficiencies (2)
Facility did not refill medication in a timely manner for Resident #1, posing an immediate health and safety risk.
Facility staff marked medication administration records days in advance, which is conduct inimical to resident safety.
Report Facts
Capacity: 100 Census: 54 Plan of Correction Due Date: Mar 1, 2024

Employees mentioned
NameTitleContext
Marco VillegasAdministratorMet with during investigation and named in findings
Huma RahimiLicensing Program AnalystConducted the complaint investigation
Nichelle GillyardLicensing Program ManagerOversaw the complaint investigation

Inspection Report

Complaint Investigation
Census: 54 Capacity: 100 Deficiencies: 0 Date: Feb 29, 2024

Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff did not prevent a resident from handling another resident roughly, did not prevent threatening comments between residents, and did not provide a comfortable environment for a resident.

Complaint Details
The complaint involved allegations of staff failing to prevent rough handling and threatening comments between residents, and not providing a comfortable environment. The allegations were found to be unsubstantiated based on interviews, observations, and record reviews.
Findings
The investigation found that although an incident of verbal and physical abuse occurred between two residents who are a married couple, staff intervened promptly to prevent escalation and assisted the residents. Interviews and record reviews supported that staff took appropriate actions and the allegations were unsubstantiated. No immediate health and safety issues were noted.

Report Facts
Capacity: 100 Census: 54

Employees mentioned
NameTitleContext
Marco VillegasAdministratorMet with during investigation and named in findings
Huma RahimiLicensing Program AnalystConducted the complaint investigation
Nichelle GillyardLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Complaint Investigation
Census: 54 Capacity: 100 Deficiencies: 1 Date: Feb 29, 2024

Visit Reason
This case management visit was conducted in conjunction with a complaint investigation to address deficiencies unrelated to the complaint.

Complaint Details
The visit was complaint-related and conducted in conjunction with case management to address deficiencies unrelated to the complaint.
Findings
Deficiencies were observed including a non-working parking lot buzzer, trash containers blocking an exit door, cigarette butts scattered around, and the parking lot and recreational areas being obstructed with old broken furniture posing safety hazards. The facility was not maintained as required.

Deficiencies (1)
Facility parking lot and outside recreational area were not clean and free of obstructions, posing potential health and safety hazards to residents.
Report Facts
Capacity: 100 Census: 54 Deficiencies cited: 1

Employees mentioned
NameTitleContext
Marco VillegasAdministratorFacility Administrator involved in addressing deficiencies
Naira MargaryanSupervisorSupervisor conducting the inspection and discussing issues with Licensee Representative
Leizl De La CerraLicensing EvaluatorLicensing evaluator conducting the inspection and signing the report

Inspection Report

Original Licensing
Census: 25 Capacity: 31 Deficiencies: 0 Date: Oct 25, 2023

Visit Reason
The visit was an announced Pre-Licensing inspection conducted to evaluate the facility's readiness for licensing and compliance with regulatory requirements.

Findings
The facility was found to be clean, well-maintained, and appropriately equipped with no deficiencies noted. All safety systems, medication storage, resident and staff records, and common areas were observed to be in compliance with regulations.

Report Facts
Fire extinguishers: 5 Facility capacity: 31 Current census: 25 Hot water temperature: 115

Employees mentioned
NameTitleContext
Marco VillegasAdministratorMet with Licensing Program Analysts during inspection and participated in entrance and exit interviews
Evelin RiosLicensing Program AnalystConducted the inspection and signed the report
Michael CavaLicensing Program AnalystConducted the inspection
Eva MillerLicensing Program ManagerNamed in the report as Licensing Program Manager

Inspection Report

Original Licensing
Census: 49 Capacity: 100 Deficiencies: 0 Date: Aug 25, 2023

Visit Reason
The visit was a Pre-Licensing reinspection to inspect the facility and ensure compliance with California Code of Regulations, Title 22, Division 6.

Findings
The inspection found that all four emergency exits equipped with delayed egress systems were operational and functioning properly. The facility was in compliance with Title 22 Regulations and had no deficiencies.

Report Facts
Number of emergency exits tested: 4

Employees mentioned
NameTitleContext
Marcos VillegasAdministratorMet with Licensing Program Analyst during inspection
LaQueena LacyLicensing Program AnalystConducted the Pre-Licensing reinspection visit
Naira MargaryanLicensing Program ManagerNamed in report header

Inspection Report

Original Licensing
Census: 41 Capacity: 100 Deficiencies: 1 Date: Jun 13, 2023

Visit Reason
The inspection was a subsequent pre-licensing visit conducted to evaluate the facility's compliance with regulations prior to licensing approval.

Findings
The inspection found that 2 out of 6 exit doors equipped with the Delayed Egress Locking System (DELS) were not operational or functioning properly, resulting in non-compliance with Title 22 Regulations at the time of the visit.

Deficiencies (1)
Two out of six exit doors with Delayed Egress Locking System were not operational or functioning properly.
Report Facts
Exit doors inspected: 6 Exit doors tested: 4 Exit doors not operational: 2 DELS timer setting: 15

Employees mentioned
NameTitleContext
LaQueena LacyLicensing Program AnalystConducted the inspection and physical plant tour
Marco VillegasAdministratorFacility administrator met during inspection and exit interview
Naira MargaryanLicensing Program ManagerNamed in report header

Inspection Report

Original Licensing
Census: 41 Capacity: 100 Deficiencies: 1 Date: May 12, 2023

Visit Reason
The visit was an announced pre-licensing inspection to ensure the facility's compliance with California Code of Regulations, Title 22, Division 6.

Findings
The facility was generally clean, well-maintained, and equipped with operational safety features; however, it was found not in compliance due to delayed egress doors on the 1st and 2nd floor exit doors lacking proper fire clearance as per the fire clearance dated 12/08/2022.

Deficiencies (1)
Delayed egress doors on the 1st and 2nd floor exit doors do not have fire clearance as required.
Report Facts
Capacity: 100 Census: 41 Fire extinguisher service tag date: Dec 13, 2022 Fire protection report date: Oct 11, 2022 Hot water temperature range: 113.6 Hot water temperature range: 115.6

Employees mentioned
NameTitleContext
Marcos VillegasAdministratorMet with Licensing Program Analyst during inspection and exit interview
LaQueena LacyLicensing Program AnalystConducted the pre-licensing inspection
Naira MargaryanLicensing Program ManagerNamed in report header and signature section

Inspection Report

Original Licensing
Census: 9 Capacity: 31 Deficiencies: 0 Date: Feb 8, 2023

Visit Reason
The visit was conducted as a pre-licensing inspection and Component II evaluation via telephone call to verify the applicant and administrator's understanding of Title 22 and facility operation requirements.

Findings
The Component II evaluation was successfully completed, confirming the applicant and administrator's understanding of facility operation, staff qualifications, training, applicant and administrator qualifications, grievances, complaints, community resources, food service, medication management, and application document review.

Report Facts
Capacity: 31 Census: 9

Employees mentioned
NameTitleContext
Marco VillegasAdministratorParticipant in Component II evaluation
Baruch BerkowitzOwnerParticipant in Component II evaluation
Shannon BetkerAnalystCAB analyst conducting Component II evaluation
Jude De La ConcepcionLicensing Program ManagerNamed in report header and signature

Inspection Report

Original Licensing
Census: 33 Capacity: 100 Deficiencies: 0 Date: Dec 28, 2022

Visit Reason
The visit was conducted as part of a Change of Ownership (CHOW) application process for the facility.

Findings
The applicant and administrator participated in a telephone call with the analyst to confirm understanding of facility operation, staff qualifications, program policies, and application document requirements. Component II of the evaluation was successfully completed with no deficiencies noted.

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