Inspection Report Summary
Most inspections found no deficiencies, with the facility generally meeting licensing requirements and maintaining a safe environment. Several complaint investigations were unsubstantiated, including allegations related to resident care, hygiene, and facility maintenance. However, some deficiencies were cited, primarily involving failure to submit required incident reports, a medication administration error posing immediate risk, and staff rudeness affecting resident dignity. The most recent report from June 30, 2025, was clean with no deficiencies noted, indicating improvement since earlier issues. No fines, license suspensions, or severe enforcement actions were listed in the available reports.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 158
Capacity: 220
Deficiencies: 0
Jun 30, 2025
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
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.
Report Facts
Capacity: 220
Census: 158
Water temperature: 110
Fire extinguisher last tested: 2024
Smoke and carbon monoxide detectors last inspected: 2025
Last disaster drill: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yolanda Delgado | Licensing Program Analyst | Conducted the annual inspection |
| Vanessa Escalon | Business Services Director | Facility representative met during inspection and exit interview |
| Rance Leth | Administrator | Facility administrator with current certification |
| Anthony Perez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 200
Capacity: 220
Deficiencies: 1
Apr 29, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit Unusual Incident/Injury Reports for three falls experienced by Resident 1, posing a potential health, safety, and/or personal rights risk to residents in care. | Type B |
Report Facts
Falls documented: 3
Capacity: 220
Census: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Administrator | Met with Licensing Program Analyst during inspection and informed of visit purpose |
| Janette Romero | Licensing Program Analyst | Conducted the unannounced inspection visit and authored the report |
| Tricia Danielson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 200
Capacity: 220
Deficiencies: 0
Apr 29, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 220
Census: 200
Number of falls documented: 3
Frequency of status checks: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janette Romero | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rance Leth | Administrator | Facility administrator met during the investigation |
| Tricia Danielson | Licensing Program Manager | Oversaw the complaint investigation |
| Staff 1 | Interviewed staff member who reported on resident falls and supervision |
Inspection Report
Complaint Investigation
Census: 198
Capacity: 220
Deficiencies: 0
Apr 22, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 220
Census: 198
Complaint received date: Nov 18, 2024
Staff response time: 15
Staff response time tested: 2
Number of care staff assigned during day: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Rance Leth | Executive Director | Facility representative met during the investigation and exit interview |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Yolanda Delgado | Licensing Program Analyst | Conducted initial complaint visit on 2024-11-22 |
Inspection Report
Complaint Investigation
Census: 198
Capacity: 220
Deficiencies: 0
Apr 22, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Resident care level: 7
Resident care level: 5
Resident care level: 4
Medication refusal dates: 3
Medication refusal incident dates: 3
Resident census: 198
Facility capacity: 220
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Rance Leth | Executive Director | Met with Licensing Program Analyst during investigation |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 198
Capacity: 220
Deficiencies: 1
Apr 22, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Deficiencies (1)
| Description |
|---|
| 87468.1 Personal Rights of Residents in All Facilities (a)(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by staff rudeness and sharing personal information with residents. |
Report Facts
Residents interviewed: 6
Staff interviewed: 6
Deficiency Type: 1
Plan of Correction Due Date: May 6, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Rance Leth | Executive Director | Facility representative met during the investigation |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 198
Capacity: 220
Deficiencies: 0
Apr 22, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 220
Census: 198
Complaint Control Number: 18-AS-20250121133146
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melisa Rankin | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Kelly Dulek | Conducted resident interviews during the visit | |
| Rance Leth | Executive Director | Facility representative met during the investigation |
| Kelly Burley | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 198
Capacity: 220
Deficiencies: 0
Apr 22, 2025
Visit Reason
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.
Findings
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 Details
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.
Report Facts
Capacity: 220
Census: 198
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melisa Rankin | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rance Leth | Executive Director | Facility representative met during investigation |
| Kelly Burley | Licensing Program Manager | Named in report as Licensing Program Manager |
| Stephanie Torres | Licensing Program Analyst | Conducted initial visit on 09/14/2022 related to the complaint |
Inspection Report
Complaint Investigation
Census: 198
Capacity: 220
Deficiencies: 0
Apr 22, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Facility capacity: 220
Census: 198
Complaint control number: 18-AS-20240818221750
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melisa Rankin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rance Leth | Executive Director | Met with Licensing Program Analyst during investigation |
| Kelly Burley | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 198
Capacity: 220
Deficiencies: 1
Apr 22, 2025
Visit Reason
The inspection was an unannounced visit conducted in conjunction with an investigation of complaint control #18-AS-20231129162111.
Findings
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.
Complaint Details
The visit was triggered by a complaint investigation (control #18-AS-20231129162111). The deficiency cited was unrelated to the original complaint allegations.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident #1 was given metoprolol tartrate with parameters without confirmation if the medication was needed, posing an immediate health risk. | Type A |
Report Facts
Medication administration instances: 3
Capacity: 220
Census: 198
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced visit and authored the report. |
| Rance Leth | Executive Director | Met with the Licensing Program Analyst during the inspection. |
| Kristin Heffernan | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 210
Capacity: 220
Deficiencies: 1
Feb 25, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Based on interview and record review, Resident #2 received incorrect dose of Medication #1 due to staff error, posing a potential health, safety or personal rights risk to residents in care. | Type B |
Report Facts
Capacity: 220
Census: 210
Deficiencies cited: 1
Plan of Correction Due Date: Mar 3, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leith | Executive Director | Met with Licensing Program Analyst during investigation |
| Janira Arreola | Licensing Program Analyst | Conducted the complaint investigation |
| Tricia Danielson | Licensing Program Manager | Oversaw the complaint investigation |
| Staff #1 | Staff member who failed to document medication given to Resident #2 | |
| Staff #2 | Facility Nurse | Reported by staff regarding soiled clothing allegation |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 220
Deficiencies: 0
Feb 21, 2025
Visit Reason
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.
Findings
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.
Complaint Details
The complaint alleged mold presence and roof disrepair. After observations, interviews with residents and staff, and records review, both allegations were found unsubstantiated.
Report Facts
Capacity: 220
Census: 174
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation |
| Rance Leth | Executive Director | Facility representative interviewed during investigation |
| Ryan Kolster | Maintenance Director | Interviewed regarding mold testing and roof leak |
| Rachelle Wheaton | Resident Services Director | Interviewed regarding resident relocation offer due to roof leak |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 220
Deficiencies: 0
Feb 21, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 220
Census: 174
Date complaint received: Aug 15, 2024
Date of injury report: Aug 13, 2024
Date of staff retraining: Aug 16, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Executive Director | Met with Licensing Program Analyst during investigation and named in report |
| Javina George | Licensing Program Analyst | Conducted the complaint investigation |
| Tricia Danielson | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 210
Capacity: 220
Deficiencies: 0
Feb 19, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 220
Census: 210
Second Occupancy Rate Increase: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Executive Director | Met with Licensing Program Analyst during investigation and involved in interviews regarding allegations |
| Yolanda Delgado | Licensing Program Analyst | Conducted the complaint investigation |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 210
Capacity: 220
Deficiencies: 0
Feb 19, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 220
Census: 210
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yolanda Delgado | Licensing Program Analyst | Conducted the complaint investigation |
| Rance Leth | Executive Director | Met with Licensing Program Analyst during investigation and provided information |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 208
Capacity: 220
Deficiencies: 0
Feb 18, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 220
Census: 208
Complaint control number: 18-AS-20231102114046
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Executive Director | Met with Licensing Program Analyst during investigation |
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation |
| Jazmond D Harris | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 176
Capacity: 220
Deficiencies: 0
Dec 11, 2024
Visit Reason
The inspection visit was conducted as a Case Management visit pertaining to self-reports made regarding theft of money and a ring from residents.
Findings
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.
Complaint Details
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.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yolanda Delgado | Licensing Program Analyst | Conducted the unannounced Case Management visit and interviews. |
| Rance Leth | Administrator | Met with Licensing Program Analyst to explain the reason for the visit and provided information about the incidents. |
Inspection Report
Annual Inspection
Census: 200
Capacity: 220
Deficiencies: 0
Jun 5, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations.
Findings
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.
Report Facts
Residents on hospice: 13
Residents in memory care: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Administrator | Met with Licensing Program Analyst during the inspection |
| Venus Mixson | Licensing Program Analyst | Conducted the inspection |
| Jazmond D Harris | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 199
Capacity: 220
Deficiencies: 0
Dec 29, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 07/26/2023 regarding facility maintenance, temperature control, and dish sanitation.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 220
Census: 199
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Shaw Ross | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jazmond D Harris | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Christina Mulligan | Resident Care Coordinator | Met with the Licensing Program Analyst during the investigation |
| Rance Leth | Administrator | Facility Administrator named in the report |
Inspection Report
Census: 172
Capacity: 220
Deficiencies: 1
Nov 8, 2023
Visit Reason
An unannounced Case Management visit was conducted to assess deficiencies related to facility maintenance and sanitation.
Findings
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.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility was not clean, safe, sanitary, and in good repair at all times, with evidence of roach infestation in resident bedrooms and common areas. | Type A |
Report Facts
Capacity: 220
Census: 172
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Administrator | Met with Licensing Program Analyst during inspection and acknowledged infestation issue |
| Cheryl Goodrich | Licensing Program Analyst | Conducted the unannounced Case Management visit and authored the report |
| Jazmond D Harris | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 173
Capacity: 220
Deficiencies: 0
Jun 21, 2023
Visit Reason
An unannounced annual visit was conducted to inspect the facility for compliance with California Code of Regulations, Title 22, Division 6.
Findings
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.
Report Facts
Residents on hospice: 13
Residents in memory care: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Cheryl Goodrich | Licensing Program Analyst | Conducted the unannounced annual visit |
| Jazmond D Harris | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 180
Capacity: 220
Deficiencies: 0
Apr 5, 2023
Visit Reason
An unannounced complaint investigation was conducted following an allegation that staff continued to administer medication after it was discontinued by a doctor.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 220
Census: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Torres | Licensing Program Analyst | Conducted the complaint investigation |
| Rance Leth | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 180
Capacity: 220
Deficiencies: 1
Apr 5, 2023
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Basic services requirement was not met as the Licensee did not ensure R1 received supervision; staff checked on R1 only once or twice on November 13, 2022, once on November 15, 2022, and did not check on November 14, 2022; R1 missed a scheduled appointment and appeared dehydrated when found. | Type B |
Report Facts
Capacity: 220
Census: 180
Deficiency count: 1
Plan of Correction Due Date: Apr 12, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Executive Director | Met during investigation and named in findings related to supervision failure |
| Stephanie Torres | Licensing Program Analyst | Conducted the complaint investigation |
| Deborah Mullen | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Census: 172
Capacity: 220
Deficiencies: 0
Dec 30, 2022
Visit Reason
The visit was an unannounced case management visit to check on the health, safety, and welfare of residents in care.
Findings
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.
Report Facts
Food supply duration: 2
Food supply duration: 7
Census: 172
Total capacity: 220
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Executive Director | Met with Licensing Program Analyst during the visit |
| Rachelle Wheaton | Resident Care Director | Met with Licensing Program Analyst during the visit |
| Chinwe Nwogene | Licensing Program Analyst | Conducted the case management visit |
| Deborah Mullen | Licensing Program Manager | Named in the report |
Inspection Report
Annual Inspection
Census: 165
Capacity: 220
Deficiencies: 0
Aug 2, 2022
Visit Reason
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.
Findings
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.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Executive Director | Met with Licensing Program Analyst during inspection and confirmed infection control practices. |
Inspection Report
Complaint Investigation
Census: 179
Capacity: 220
Deficiencies: 0
May 17, 2022
Visit Reason
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.
Findings
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.
Complaint Details
The complaint was unsubstantiated due to insufficient evidence to prove the alleged violation occurred.
Report Facts
Capacity: 220
Census: 179
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Rachelle Wheaton | Resident Care Director | Met with the Licensing Program Analyst during the investigation |
| Rance Leth | Administrator | Provided information regarding resident access to in-room safes |
| Joel Esquivel | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 159
Capacity: 220
Deficiencies: 0
Apr 28, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on a resident death at the facility.
Findings
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.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rachelle Wheaton | Resident Care Director | Met with Licensing Program Analyst during the visit and interviewed regarding the resident death. |
Inspection Report
Complaint Investigation
Census: 168
Capacity: 220
Deficiencies: 0
Feb 23, 2022
Visit Reason
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.
Findings
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.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false or without reasonable basis.
Report Facts
Capacity: 220
Census: 168
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Rance Leth | Executive Director | Met with Licensing Program Analyst during the investigation |
| Joel Esquivel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 220
Deficiencies: 0
Dec 21, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident sustained a fall while in care.
Findings
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.
Complaint Details
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.
Report Facts
Staff count: 4
Resident census: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Rance Leth | Executive Director | Met with Licensing Program Analyst during investigation and received report |
| Joel Esquivel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 151
Capacity: 220
Deficiencies: 0
Jul 28, 2021
Visit Reason
Licensing Program Analyst Deborah Mullen conducted an unannounced visit to follow up on current Covid-19 procedures and protocols at the facility.
Findings
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.
Report Facts
Capacity: 220
Census: 151
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ranch Leth | Executive Director | Met with Licensing Program Analyst during the visit and discussed facility procedures |
| Deborah Mullen | Licensing Program Analyst | Conducted the unannounced visit and evaluation |
| Karen Clemons | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Original Licensing
Census: 158
Capacity: 220
Deficiencies: 0
May 19, 2021
Visit Reason
The inspection was conducted as a Pre-Licensing visit to evaluate the facility for initial licensing approval.
Findings
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.
Report Facts
Fire Clearance capacity: 220
Water temperature: 109
Supply duration: 2
Supply duration: 7
PPE supply duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Administrator/Executive Director | Met with Licensing Program Analyst during the inspection. |
| Crystal Colvin | Licensing Program Analyst | Conducted the Pre-Licensing inspection and authored the report. |
Inspection Report
Original Licensing
Capacity: 220
Deficiencies: 0
May 4, 2021
Visit Reason
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.
Findings
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.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Administrator | Participant in Component II telephone call confirming understanding of Title 22 and regulatory requirements. |
| Mirella Quaranta | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Stefania Fonteno | Licensing Program Analyst | Named as Licensing Program Analyst on the report. |
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