Inspection Reports for Menifee Senior Living

The inspection was an unannounced annual inspection conducted to evaluate the facility's compliance with licensing requirements.

The facility was found to be in compliance with all applicable licensing requirements, including resident and employee record reviews, physical plant and safety standards, food service, and fire safety regulations. No deficiencies were cited during this inspection.

The visit was conducted unannounced on 04/29/2025 to address a deficiency discovered during a complaint investigation involving Resident 1 (R1) related to failure to submit required incident reports.

The facility failed to submit Unusual Incident/Injury Reports (UI/IRs) for three falls experienced by Resident 1 on 1/25/2023, 3/30/2023, and 4/5/2023, which is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8, Regulation 87211. Staff reported inconsistent reporting practices to the State.

The complaint investigation involved Resident 1 and focused on the facility's failure to submit required incident reports for three documented falls. The deficiency was substantiated based on review of records and interviews.

An unannounced complaint investigation was conducted in response to allegations of neglect/lack of supervision resulting in resident injuries, failure to seek timely medical attention after a resident's fall, and failure to notify the authorized representative of the resident's fall.

The investigation found that although the resident experienced multiple falls, staff assessments and notifications were documented, and medical evaluations were conducted. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence proving violations occurred.

The complaint involved allegations of neglect/lack of supervision resulting in resident injuries, failure to seek timely medical attention after a resident's fall, and failure to notify the authorized representative of the resident's fall. The investigation included interviews, record reviews, and medical documentation. The allegations were found unsubstantiated.

An unannounced complaint investigation visit was conducted in response to allegations received on 2024-11-18 regarding insufficient feeding of a resident and untimely staff response to resident requests for assistance.

The investigation found insufficient evidence to substantiate the allegations that staff did not ensure a resident was sufficiently fed or did not respond timely to resident requests for assistance. Resident and staff interviews, as well as record reviews, supported that meals were provided and staff responded within policy timeframes.

The complaint alleged that on 2024-11-16, a resident was not provided meals and staff did not respond timely to a pendant call. The resident clarified they chose not to eat and did not request meals, and staff response times were generally within 15-20 minutes as per facility policy. The allegations were deemed unsubstantiated due to lack of sufficient evidence.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not ensure adequate care and supervision was provided to a resident and that staff were not addressing a resident's need for a higher level of care.

The investigation found that although the resident had multiple falls and medication refusals, staff provided care consistent with the resident's care plan, including regular status checks and hospice care. The resident was eventually moved to the memory care unit and later transferred to another facility. Interviews and document reviews did not provide sufficient evidence to substantiate the allegations, and the complaint was deemed unsubstantiated.

The complaint involved two allegations: 1) inadequate care and supervision of a resident who screamed for help and had multiple falls, and 2) failure to address the resident's need for a higher level of care. The investigation included interviews with residents, staff, and management, as well as review of care plans, incident reports, and physician documentation. The allegations were found unsubstantiated due to insufficient evidence.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not treat a resident with dignity and respect and that staff dispensed medication not prescribed to a resident.

The allegation that staff did not treat residents with dignity and respect was substantiated based on interviews and record reviews indicating staff rudeness and sharing personal information with residents. The allegation that staff dispensed medication not prescribed to a resident was unsubstantiated due to lack of sufficient evidence.

The complaint alleged that Staff #1 bullied Resident #1 in an angry way and continued to demand care despite being told not to provide care. Interviews with residents and staff corroborated that staff had been rude and intimidating. The allegation was substantiated. Another complaint alleged that staff dispensed medication not prescribed to Resident #1, causing adverse effects. Review of medication records and interviews found no evidence to support this, so the allegation was unsubstantiated.

The inspection visit was conducted as an unannounced complaint investigation following a report received on 2025-01-21 regarding a missing ring reported by a resident.

The investigation found that although the allegation of the missing ring may have occurred, there was insufficient evidence to substantiate the claim. The facility followed proper theft and loss policies, including reporting to the Ombudsman, Community Care Licensing, and police.

The complaint alleged a resident's ring was missing from their room. Interviews and document reviews showed the resident and responsible representative did not list the ring on the personal property form. The facility documented the allegation and followed required reporting procedures. Based on the evidence, the allegation was unsubstantiated.

An unannounced visit was conducted to investigate a complaint received on 09/07/2022 regarding allegations that a resident was not provided a sanitized foley bag and was left soiled for an extended period of time.

The investigation included staff interviews and record reviews. The allegations may have happened or be valid, but there was not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations were unsubstantiated.

Complaint alleged that a resident presented at the emergency room with a Foley catheter partially pulled out, an unclean and improperly placed foley bag, and was covered in feces. The resident was confused and had a UTI when admitted to the hospital. The resident's stay at the facility was less than 24 hours. Based on interviews and records, the allegations were unsubstantiated due to insufficient evidence.

An unannounced complaint investigation was conducted in response to an allegation that staff did not meet a resident's hygiene needs, specifically regarding Resident 1's hygiene and toenail care.

The investigation included interviews and record reviews which confirmed that caregivers do not trim residents' nails and that a podiatrist visits every eight weeks. The allegation was unsubstantiated due to insufficient evidence to prove the violation occurred.

The complaint alleged that staff did not meet Resident 1's hygiene needs, specifically that toenails were long and unkept. The complaint was unsubstantiated after investigation.

The inspection was an unannounced visit conducted in conjunction with an investigation of complaint control #18-AS-20231129162111.

Deficiencies unrelated to the complaint allegations were observed, specifically a medication administration error where a resident was given medication without confirming required parameters, posing an immediate health risk.

The visit was triggered by a complaint investigation (control #18-AS-20231129162111). The deficiency cited was unrelated to the original complaint allegations.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations including medication dispensing errors, residents being left in soiled clothing, mal odors in the facility, and improper maintenance of resident records.

The investigation substantiated that Resident #2 received medication twice due to a staff documentation error, posing a potential health risk. The allegations regarding Resident #1 not receiving PRN medication as prescribed and residents being left in soiled clothing or malodorous conditions were unsubstantiated. The allegation that resident medication records were improperly maintained was also unsubstantiated.

The complaint investigation was substantiated for the allegation that staff did not ensure medications were dispensed as prescribed for Resident #2, who received a double dose of medication due to a documentation error. Other allegations regarding soiled clothing, mal odors, and improper record maintenance were unsubstantiated.

An unannounced complaint investigation was conducted in response to allegations received on 2024-01-25 regarding the presence of mold in resident bedrooms and disrepair of the facility roof.

The investigation found no evidence of mold in the facility or residents' bedrooms, and the allegation of mold was unsubstantiated. The roof had a leak that was discovered in December 2023 and repaired on 2024-01-22; residents affected declined to move units. The allegation of roof disrepair was also unsubstantiated.

The complaint alleged mold presence and roof disrepair. After observations, interviews with residents and staff, and records review, both allegations were found unsubstantiated.

An unannounced complaint investigation was conducted in response to an allegation that a staff member caused an injury to a resident by grabbing and pinching the resident's wrist.

The investigation included observations, interviews, and records review. The allegation was found to be unsubstantiated as there was insufficient evidence to prove the alleged violation occurred. The resident had a bruise on their left wrist, but staff retraining on proper lifting techniques was conducted post-incident.

The complaint alleged that a staff member caused an injury (bruising) to Resident #1 by grabbing and pinching their wrist. The resident was visually impaired and could not identify the staff member. The allegation was investigated and found unsubstantiated.

The visit was an unannounced complaint investigation conducted in response to allegations received on 04/22/2022 regarding staff stealing resident's bank statements, resident not having access to a phone, and the facility overcharging the resident for services.

After interviews with the administrator, staff, residents, and witnesses, and a review of documentation, the allegations were found to be unfounded. The investigation concluded that the resident had access to phones, was responsible for their own finances, and the facility charged appropriately as per the admission agreement.

The complaint alleged staff stole resident's bank statements, resident did not have access to a phone, and the facility overcharged the resident for services. The investigation found these allegations to be unfounded.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-04-22 regarding the facility not feeding a resident in a timely manner and staff financially abusing a resident.

After interviews with the administrator, staff, residents, and witnesses, as well as a review of documentation, the allegations were found to be unsubstantiated due to lack of preponderance of evidence. The facility was reported to provide timely meals and no financial abuse by staff was corroborated.

The complaint alleged that the facility did not feed a resident in a timely manner and that staff financially abused a resident. The investigation found no corroborating evidence for these allegations, and they were determined to be unsubstantiated.

An unannounced complaint investigation was conducted following allegations that residents became ill after eating food served at the facility and that a resident found hair inside the food and on plates.

The investigation included interviews, observations, and record reviews, and found no substantiated evidence that residents became ill due to food served or that hair contamination occurred. The allegations were determined to be unsubstantiated due to insufficient evidence.

The complaint alleged that three residents became ill after eating food at the facility and that a resident found hair inside their food and on plates. The investigation found no evidence of a foodborne outbreak or health and safety violations. The allegations were unsubstantiated.

The inspection visit was conducted as a Case Management visit pertaining to self-reports made regarding theft of money and a ring from residents.

The Licensing Program Analyst toured the facility, observed sufficient staff, and found no immediate health and safety concerns. No deficiencies were cited during this visit.

The visit was triggered by self-reports of theft of money from one resident and theft of a ring from another resident. Law enforcement was involved, police reports were filed, and partial recovery of the missing items was made.

The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations.

The facility was found to be in compliance with all applicable regulations, with no violations observed or cited. The physical plant, medication storage, food service, care and supervision, and records were all satisfactory.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 07/26/2023 regarding facility maintenance, temperature control, and dish sanitation.

The investigation found all allegations to be unsubstantiated based on observations, interviews, and record reviews. The elevator was repaired timely, temperature was maintained at a comfortable level with fans and portable air conditioners, and dishes were properly cleaned and sanitized.

The complaint investigation addressed three allegations: the facility not being maintained in good repair, staff not ensuring a comfortable temperature, and staff not ensuring dishes were properly cleaned and sanitized. All allegations were found unsubstantiated.

An unannounced Case Management visit was conducted to assess deficiencies related to facility maintenance and sanitation.

The inspection found live roaches, roach casings, eggs, and active bug bites in resident bedrooms, indicating a failure to maintain a clean, safe, and sanitary environment as required by regulation.

An unannounced annual visit was conducted to inspect the facility for compliance with California Code of Regulations, Title 22, Division 6.

No deficiencies were observed during the visit. The facility was found to be in good repair, with proper food storage, medication handling, and compliance with regulatory requirements.

An unannounced complaint investigation was conducted following an allegation that staff continued to administer medication after it was discontinued by a doctor.

The investigation found that the facility did administer the medication to Resident One from February 21, 2023 to March 23, 2023, despite the medication being discontinued on February 21, 2023. However, the discontinuation document was not signed and dated, leading to the allegation being deemed unsubstantiated due to insufficient information.

The complaint alleged that staff administered a discontinued medication to Resident One from February 21, 2023 through March 21, 2023. The allegation was found unsubstantiated due to insufficient documentation.

An unannounced complaint investigation was conducted following an allegation that staff failed to check on the safety of a resident who fell and was not found for several days.

The investigation substantiated the complaint that staff did not adequately supervise Resident One (R1), who fell in their bedroom on or around November 13, 2022, and was not found until November 15, 2022. Staff interviews and documentation confirmed missed checkups and that R1 appeared dehydrated when found.

The complaint was substantiated based on the preponderance of evidence. The allegation involved failure to check on the safety of a resident who fell and was not found for multiple days, resulting in dehydration.

The visit was an unannounced case management visit to check on the health, safety, and welfare of residents in care.

No health or safety concerns were observed during the visit. Facility utilities were operating properly, staff levels were sufficient, food and medication supplies exceeded requirements, and no deficiencies were cited.

The inspection was an unannounced annual inspection limited to infection control to assess the facility's compliance with COVID-19 best practices and infection prevention measures.

The facility was found to have sufficient PPE supplies for a 30-day period, staff were trained on infection control and COVID-19 symptom recognition, and proper screening and surveillance testing protocols were in place for staff and visitors.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-03-21 regarding the allegation that the facility did not safeguard a resident's personal items.

The investigation found that the missing items included a pendant, 4 rings, and a bracelet given to Resident #1 by their spouse. The resident had access to an in-room safe, and there was no supporting documentation such as receipts or photographs of the items. Due to lack of evidence that the resident had the items or brought them to the facility, the allegation was unsubstantiated.

The complaint was unsubstantiated due to insufficient evidence to prove the alleged violation occurred.

An unannounced case management visit was conducted to follow up on a resident death at the facility.

No deficiencies were cited during the visit, and no health and safety concerns were observed. The cause of death was still being determined and a death certificate had not yet been issued.

The inspection was an unannounced complaint investigation visit triggered by allegations that a resident was being overcharged and not provided an itemized list of charges.

The investigation found no evidence to support the allegations. The resident's ledger and itemized statements matched charges, and a one-time credit was issued for a disputed laundry fee. Therefore, both allegations were determined to be unfounded.

The complaint was investigated and found to be unfounded, meaning the allegations were false or without reasonable basis.

The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident sustained a fall while in care.

The investigation included observation, interviews, and document review, concluding that the allegation was unfounded. The resident had been transferred to a skilled nursing facility and the complaint was determined to be false or without reasonable basis.

The complaint alleged that a resident sustained a fall while in care. The investigation found the allegation to be unfounded, meaning it was false, could not have happened, or was without reasonable basis.

Licensing Program Analyst Deborah Mullen conducted an unannounced visit to follow up on current Covid-19 procedures and protocols at the facility.

The facility is in compliance with current Department guidelines regarding Covid-19 procedures, including social distancing measures in dining, activities, and common areas. No further action was needed at this time.

The inspection was conducted as a Pre-Licensing visit to evaluate the facility for initial licensing approval.

The facility was toured and observed to be in compliance with regulations, including fire safety, food storage, emergency preparedness, and cleanliness. No deficiencies were observed during this visit.

The visit was conducted as part of the original licensing process, including a Component II telephone call to verify the applicant/administrator's understanding of Title 22 and various regulatory requirements.

The applicant/administrator successfully completed Component II via telephone call, demonstrating understanding of facility operation, staff qualifications, program policies, grievances, physical plant, and application document review including criminal record clearance and other licensing requirements.