Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
72% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Annual Inspection
Census: 158
Capacity: 220
Deficiencies: 0
Date: 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
Annual Inspection
Census: 158
Capacity: 220
Deficiencies: 0
Date: Jun 30, 2025
Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with licensing requirements and regulations.
Findings
The facility was found to be in compliance with all applicable licensing requirements, including resident and employee record reviews, physical plant safety, food service, and fire safety regulations. No deficiencies were cited during this inspection.
Report Facts
Records reviewed: 5
Records reviewed: 5
Fire safety inspection dates: Mar 27, 2025
Fire safety re-test date: Apr 21, 2025
Fire extinguisher inspection date: Apr 4, 2024
Last disaster drill date: Jun 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yolanda Delgado | Licensing Program Analyst | Conducted the annual inspection and signed the report |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Vanessa Escalon | Business Services Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Rance Leth | Administrator/Director | Facility Administrator with current certification |
Inspection Report
Complaint Investigation
Census: 200
Capacity: 220
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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.
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
Date: 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.
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.
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.
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: 200
Capacity: 220
Deficiencies: 0
Date: 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 a resident's fall.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included neglect/lack of supervision causing injuries, failure to seek timely medical attention, and failure to notify authorized representatives. Interviews and record reviews showed staff conducted assessments, notified family, and followed protocols. The resident was removed from the facility for further evaluation. No violations were substantiated.
Findings
The investigation found that although multiple falls occurred involving resident R1, staff assessed the resident and notified family or responsible persons as appropriate. Medical evaluations were conducted, including urgent care visits and imaging, which revealed fractures consistent with reported pain. Staff followed facility protocols for medical emergencies and resident checks. The allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 220
Resident census: 200
Number of falls documented: 3
Number of POA agents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janette Romero | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Rance Leth | Administrator | Facility administrator met during investigation and named in report |
| Tricia Danielson | Supervisor | Supervisor overseeing the licensing evaluation |
| Staff 1 | Staff interviewed regarding resident falls and supervision |
Inspection Report
Complaint Investigation
Census: 200
Capacity: 220
Deficiencies: 1
Date: Apr 29, 2025
Visit Reason
The visit was conducted unannounced to address a deficiency discovered during a complaint investigation involving Resident 1 (R1), specifically regarding the facility's failure to submit required incident reports for falls experienced by R1.
Complaint Details
The complaint investigation involved Resident 1 and focused on the facility's failure to submit incident reports for three falls occurring on 1/25/2023, 3/30/2023, and 4/5/2023. The deficiency was substantiated based on review of records and staff interviews.
Findings
The facility failed to submit Unusual Incident/Injury Reports (UI/IRs) for three falls experienced by Resident 1 between January and April 2023, which is a violation of California Code of Regulations reporting requirements. Staff reported inconsistent reporting practices, and the facility was cited for not meeting reporting requirements.
Deficiencies (1)
Failure to submit required incident reports for three falls experienced by Resident 1, posing a potential health, safety, and/or personal rights risk to residents in care.
Report Facts
Number of falls: 3
Capacity: 220
Census: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Administrator | Met with Licensing Program Analyst during inspection and reported plan for staff training regarding reporting requirements. |
| Janette Romero | Licensing Program Analyst | Conducted the unannounced inspection and complaint investigation. |
Inspection Report
Complaint Investigation
Census: 198
Capacity: 220
Deficiencies: 0
Date: 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.
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.
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.
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
Date: 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.
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.
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.
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
Date: 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.
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.
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.
Deficiencies (1)
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
Date: 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.
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.
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.
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
Date: 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.
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.
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.
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
Date: 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.
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.
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.
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
Date: Apr 22, 2025
Visit Reason
The inspection was an unannounced visit conducted in conjunction with an investigation of complaint control #18-AS-20231129162111.
Complaint Details
The visit was triggered by a complaint investigation (control #18-AS-20231129162111). The deficiency cited was unrelated to the original complaint allegations.
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.
Deficiencies (1)
Resident #1 was given metoprolol tartrate with parameters without confirmation if the medication was needed, posing an immediate health risk.
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: 198
Capacity: 220
Deficiencies: 0
Date: Apr 22, 2025
Visit Reason
This was an unannounced complaint investigation visit triggered by allegations that staff did not ensure residents were sufficiently fed and did not respond timely to resident requests for assistance.
Complaint Details
The complaint alleged that on 11/16/2024, a resident was not provided meals and staff did not respond timely to a pendant call. The investigation found no sufficient evidence to corroborate these allegations, and both were deemed unsubstantiated.
Findings
The investigation found insufficient evidence to substantiate the allegations. Resident and staff interviews, record reviews, and observations indicated that residents receive meals either in the dining room or delivered to their rooms, and staff generally respond timely to assistance requests. Therefore, both allegations were deemed unsubstantiated.
Report Facts
Capacity: 220
Census: 198
Staff response time: 2
Staff assigned: 4
Pendant response policy time: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Executive Director | Met with Licensing Program Analyst during the investigation and participated in exit interview |
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Yolanda Delgado | Licensing Program Analyst | Conducted initial complaint visit on 11/22/2024 |
Inspection Report
Complaint Investigation
Census: 198
Capacity: 220
Deficiencies: 0
Date: 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 the resident’s need for a higher level of care.
Complaint Details
The complaint alleged inadequate care and supervision and failure to address a resident’s need for a higher level of care. The investigation included interviews with residents, staff, and management, review of care plans, incident reports, and physician documentation. The allegations were unsubstantiated due to insufficient evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. Resident #1 received regular status checks and care, including hospice services, and was moved to the memory care unit as appropriate. Interviews with residents and staff indicated care needs were met and supervision was sufficient. The allegations were deemed unsubstantiated.
Report Facts
Census: 198
Total Capacity: 220
Resident Care Levels: 7
Resident Care Levels: 5
Resident Care Levels: 4
Medication Refusals: 3
Staff Interviews: 6
Resident Interviews: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Executive Director | Met with Licensing Program Analyst during the investigation and named in findings |
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Kristin Heffernan | Supervisor | Named as supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 198
Capacity: 220
Deficiencies: 1
Date: 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.
Complaint Details
The complaint alleged that Staff #1 bullied Resident #1 in an angry manner and continued to demand care despite being instructed not to. Interviews with residents and staff corroborated rude and intimidating behavior by staff. The medication allegation involved a resident receiving an unrecognized pill causing adverse effects; however, review of medication records and interviews found no evidence to substantiate this claim.
Findings
The investigation substantiated the allegation that staff did not treat residents with dignity and respect, citing rude behavior and sharing of personal information by staff with residents. The medication-related allegation was unsubstantiated due to insufficient evidence.
Deficiencies (1)
Failure to accord dignity in personal relationships with staff, residents, and others, evidenced by staff sharing personal information with residents and being rude, posing a potential personal rights risk.
Report Facts
Residents interviewed: 6
Staff interviewed: 6
Residents reporting rude behavior: 4
Facility capacity: 220
Facility census: 198
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Executive Director | Met with Licensing Program Analyst during investigation and agreed to conduct staff training |
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 198
Capacity: 220
Deficiencies: 0
Date: Apr 22, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2025-01-21 regarding a resident reporting a missing ring.
Complaint Details
The complaint alleged a resident's ring was missing. The investigation included interviews with residents, staff, and the resident's Responsible Representative, as well as review of documentation. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that the facility followed proper theft and loss policies, including documentation, notification to the Ombudsman, Community Care Licensing, and police. Interviews and record reviews did not provide sufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Report Facts
Census: 198
Total Capacity: 220
Residents interviewed: 6
Additional residents interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melisa Rankin | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Kelly Dulek | Licensing Program Analyst | Conducted resident interviews during the investigation |
| Rance Leth | Executive Director | Facility representative met during the investigation |
| Kelly Burley | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 198
Capacity: 220
Deficiencies: 0
Date: Apr 22, 2025
Visit Reason
An unannounced visit was conducted to investigate a complaint received regarding allegations that a resident was not provided a sanitized foley bag and was left soiled for an extended period of time.
Complaint Details
Complaint alleged that a resident presented at the emergency room with a Foley catheter pulled out but partially inserted, with an unclean and improperly placed foley bag, and was covered in feces. The resident was re-admitted to the facility after discharge from a Skilled Nursing Facility and was found confused and soiled, leading to a 911 call and hospital transfer. The resident's stay at the facility was less than 24 hours. The investigation found insufficient evidence to substantiate the allegations.
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.
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 | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 198
Capacity: 220
Deficiencies: 0
Date: Apr 22, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff did not meet a resident's hygiene needs, specifically that Resident 1's hygiene was poor and toenails were long and unkept.
Complaint Details
The complaint alleged that staff did not meet a resident's hygiene needs, specifically that Resident 1's toenails were long and unkept. The allegation was unsubstantiated after investigation.
Findings
The investigation included interviews and record reviews, confirming that caregivers do not trim residents' nails and that a podiatrist visits every eight weeks. The allegation was determined to be unsubstantiated due to insufficient evidence to prove or disprove the claim.
Report Facts
Capacity: 220
Census: 198
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melisa Rankin | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Rance Leth | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 210
Capacity: 220
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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.
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: 210
Capacity: 220
Deficiencies: 1
Date: Feb 25, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff did not ensure medications were dispensed as prescribed, residents were left in soiled clothing for extended periods, the facility was not kept free of mal odors, and resident records were not properly maintained.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not ensure medications were dispensed as prescribed, specifically Resident #2 receiving medication twice due to a documentation error. The allegations regarding residents being left in soiled clothing, mal odors in the facility, and improper maintenance of resident medication records were unsubstantiated.
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 being left in soiled clothing and malodorous conditions were unsubstantiated. The allegation that resident medication records were improperly maintained was also unsubstantiated based on interviews and record reviews.
Deficiencies (1)
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.
Report Facts
Capacity: 220
Census: 210
Deficiency count: 1
Plan of Correction Due Date: Mar 3, 2025
Medication error incident date: May 25, 2024
Resident #1 check frequency: 4
Resident #1 estimated time left in soiled clothing: 4
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 | Supervisor | Supervisor overseeing the investigation |
| Staff #1 | Staff who gave Medication #1 twice to Resident #2 due to documentation error | |
| Staff #2 | Facility Nurse | Recalled no instance of Resident #1 left in soiled clothing or diaper |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 220
Deficiencies: 0
Date: 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.
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.
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.
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
Date: 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.
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.
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.
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: 174
Capacity: 220
Deficiencies: 0
Date: Feb 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-01-25 regarding mold presence and roof disrepair at the facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included mold presence and roof disrepair. Observations, interviews with residents and staff, and records review did not confirm the allegations. The roof leak was repaired on 2024-01-22, and residents declined relocation despite the leak.
Findings
The investigation found no evidence of mold in the facility, including Resident #1 and Resident #2's bedrooms, and the mold allegation was unsubstantiated. The roof leak in the unit was repaired prior to the visit, and although a leak had occurred, the allegation of roof disrepair was also unsubstantiated.
Report Facts
Capacity: 220
Census: 174
Complaint received date: Jan 25, 2024
Leak repair date: Jan 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Executive Director | Met with Licensing Program Analyst during investigation and was aware of roof leak |
| Ryan Kolster | Maintenance Director | Interviewed regarding mold testing and roof leak repair |
| Rachelle Wheaton | Resident Services Director | Interviewed regarding resident relocation offer during roof leak |
| Javina George | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tricia Danielson | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 220
Deficiencies: 0
Date: 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.
Complaint Details
The complaint alleged that a staff member caused an injury (bruising) to Resident #1 by grabbing their wrist and pinching them. The resident was visually impaired and could not identify the staff member. Staff were initially unaware of the bruising but questioned the resident after becoming aware. The injury was believed to have occurred around August 7 or 8, 2024. The complaint was unsubstantiated.
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, though the resident had a bruise and staff were retrained on proper lifting techniques post-incident.
Report Facts
Facility capacity: 220
Resident census: 174
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation |
| Rance Leth | Executive Director | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Census: 210
Capacity: 220
Deficiencies: 0
Date: Feb 19, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit 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 a resident for services.
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. After investigation, these allegations were determined to be unfounded.
Findings
Based on interviews with the administrator, staff, residents, witnesses, and review of documentation, all allegations were found to be unfounded, meaning the allegations were false, could not have happened, or were without reasonable basis.
Report Facts
Capacity: 220
Census: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Executive Director | Met during investigation and named in allegations |
| Yolanda Delgado | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 210
Capacity: 220
Deficiencies: 0
Date: Feb 19, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that the facility staff were not feeding a resident in a timely manner and that staff financially abused a resident.
Complaint Details
The complaint alleged that the facility staff were not feeding a resident in a timely manner, with a report that the resident had to wait 2 hours to eat, and that staff financially abused the resident. The investigation included interviews and document reviews, which did not corroborate these allegations. The complaint was determined to be unsubstantiated.
Findings
Based on interviews with staff, residents, witnesses, and review of facility records, the allegations that the facility did not feed the resident in a timely manner and that staff financially abused the resident were found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 220
Census: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yolanda Delgado | Licensing Program Analyst | Conducted the complaint investigation |
| Rance Leth | Executive Director | Facility representative interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 210
Capacity: 220
Deficiencies: 0
Date: 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.
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.
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.
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
Date: 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.
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.
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.
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
Date: Feb 18, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that residents became ill after eating food served at the facility and that a resident found hair inside the food and on plates.
Complaint Details
The complaint alleged that three residents became ill after eating food at the facility and that hair was found in food and on plates. Interviews with staff and residents, as well as documentation review, did not substantiate these claims. No foodborne outbreak reports or medical evaluations outside the facility were found. The complaint was unsubstantiated.
Findings
The investigation included interviews, observations, and record reviews, and found no substantiated evidence that residents became ill from the food or that hair contamination occurred. The allegations were determined to be unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 220
Census: 208
Number of residents alleged ill: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Executive Director | Met with Licensing Program Analyst during investigation and provided information regarding allegations |
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 208
Capacity: 220
Deficiencies: 0
Date: 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.
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.
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.
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
Date: 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.
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.
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.
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
Complaint Investigation
Census: 176
Capacity: 220
Deficiencies: 0
Date: Dec 11, 2024
Visit Reason
The visit was an unannounced Case Management inspection conducted due to self-reports of theft of money and a ring from residents, reported on 11/25/2024 and 12/3/2024 respectively.
Complaint Details
The visit was triggered by complaints of theft involving two residents. Law enforcement was involved, police reports were filed, and partial recovery of the missing money and the ring was made.
Findings
The Licensing Program Analyst found no immediate health or safety concerns during the visit, sufficient staffing was observed, and no deficiencies were cited under Title 22, Division 6 of the California Code of Regulations.
Report Facts
Capacity: 220
Census: 176
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Administrator | Met with Licensing Program Analyst during the inspection and provided information about the incident |
| Yolanda Delgado | Licensing Program Analyst | Conducted the unannounced inspection visit |
| Jazmond D Harris | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 200
Capacity: 220
Deficiencies: 0
Date: 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
Annual Inspection
Census: 200
Capacity: 220
Deficiencies: 0
Date: Jun 5, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations at the facility.
Findings
The facility was found to be in compliance with all applicable regulations with no violations cited. The physical plant, medication storage, food service, care and supervision, and records were all inspected and found 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 and received the report |
| Venus Mixson | Licensing Program Analyst | Conducted the inspection |
| Jazmond D Harris | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 199
Capacity: 220
Deficiencies: 0
Date: Dec 29, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 07/26/2023 regarding facility maintenance, temperature control, and dish sanitation.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included poor facility repair, uncomfortable temperature, and improper dish sanitation. Evidence showed timely elevator repairs, reasonable temperature accommodations, and clean dishes.
Findings
The investigation found all allegations to be unsubstantiated based on observations, interviews, and record reviews. The elevator was repaired timely, the dining area temperature was maintained at a comfortable level with fans and portable air conditioners, and dishes were properly cleaned and sanitized.
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 |
| Christina Mulligan | Resident Care Coordinator | Met with the Licensing Program Analyst during the investigation |
| Jazmond D Harris | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 199
Capacity: 220
Deficiencies: 0
Date: 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.
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.
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.
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
Date: 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.
Deficiencies (1)
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.
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
Complaint Investigation
Census: 172
Capacity: 220
Deficiencies: 1
Date: Nov 8, 2023
Visit Reason
An unannounced Case Management visit was conducted to investigate observed live roaches, roach casings, eggs, and active bug bites on residents in multiple bedrooms.
Complaint Details
The visit was complaint-related due to observed roach infestation and resident bug bites. The Administrator was aware of infestation in some rooms but unaware of others. The deficiency was substantiated with observations and interviews.
Findings
The facility was found to have a roach infestation in resident bedrooms, with residents showing bite marks or rashes. The facility was cited for not maintaining a clean, safe, sanitary, and in good repair environment as required by CCR 87303(a).
Deficiencies (1)
The facility shall be clean, safe, sanitary, and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
Report Facts
Capacity: 220
Census: 172
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Administrator | Met during inspection and referenced in findings |
| Cheryl Goodrich | Licensing Program Analyst | Conducted the inspection |
| Jazmond D Harris | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 173
Capacity: 220
Deficiencies: 0
Date: 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
Annual Inspection
Census: 173
Capacity: 220
Deficiencies: 0
Date: Jun 21, 2023
Visit Reason
An unannounced annual visit was conducted to inspect the facility and ensure compliance with California Code of Regulations, Title 22, Division 6.
Findings
No deficiencies were observed during the inspection. 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
Food supply duration: 7
Food supply duration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Administrator | Met during inspection and involved in exit interview |
| Cheryl Goodrich | Licensing Program Analyst | Conducted the inspection |
| Jazmond D Harris | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 180
Capacity: 220
Deficiencies: 1
Date: Apr 5, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2022-11-21 alleging that staff failed to check on the safety of a resident.
Complaint Details
The complaint was substantiated based on the preponderance of evidence. Resident One (R1) fell and was not checked on by staff for multiple days, resulting in missed appointments and dehydration.
Findings
The investigation substantiated the allegation that staff did not ensure adequate supervision of 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 revealed inconsistent checks on R1, including no checks on November 14, 2022, and R1 appeared dehydrated when found.
Deficiencies (1)
Basic services requirement was not met as the Licensee did not ensure R1 received supervision.
Report Facts
Census: 180
Total Capacity: 220
Deficiency Type B: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Torres | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rance Leth | Executive Director | Facility representative involved in the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 180
Capacity: 220
Deficiencies: 0
Date: 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.
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.
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.
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
Date: 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.
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.
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.
Deficiencies (1)
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.
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
Complaint Investigation
Census: 180
Capacity: 220
Deficiencies: 0
Date: 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 the doctor.
Complaint Details
The complaint alleged that staff administered a discontinued medication to a resident. After review of medication administration records and physician orders, the allegation was found unsubstantiated due to lack of signed and dated discontinuation documentation.
Findings
The investigation found that the facility did administer the discontinued medication to Resident One from February 21, 2023 to March 23, 2023; however, the physician's order discontinuing the medication was not signed and dated, resulting in insufficient information to substantiate the allegation. The complaint was deemed unsubstantiated.
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
Census: 172
Capacity: 220
Deficiencies: 0
Date: 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
Census: 172
Capacity: 220
Deficiencies: 0
Date: 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 at the facility.
Findings
No health or safety concerns were observed during the visit. Facility utilities were operating without issue, staff levels were sufficient, food and medication supplies met requirements, and no deficiencies were cited.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rance Leth | Executive Director | Met with Licensing Program Analyst during the visit and discussed the report. |
| Rachelle Wheaton | Resident Care Director | Met with Licensing Program Analyst during the visit and discussed the report. |
Inspection Report
Annual Inspection
Census: 165
Capacity: 220
Deficiencies: 0
Date: 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
Annual Inspection
Census: 165
Capacity: 220
Deficiencies: 0
Date: Aug 2, 2022
Visit Reason
The inspection was an unannounced annual inspection limited to infection control to evaluate 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 and confirmed infection control practices and staff training. |
| Crystal Colvin | Licensing Program Analyst | Conducted the annual inspection focused on infection control. |
| Joel Esquivel | Supervisor | Named as supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 179
Capacity: 220
Deficiencies: 0
Date: 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.
Complaint Details
The complaint was unsubstantiated due to insufficient evidence to prove the alleged violation occurred.
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.
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
Complaint Investigation
Census: 179
Capacity: 220
Deficiencies: 0
Date: 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.
Complaint Details
The complaint was unsubstantiated due to insufficient evidence to prove the alleged violation occurred. The allegation was that the facility did not safeguard 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 proving the items were brought into the facility. Due to lack of evidence, the allegation was unsubstantiated.
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 and received the report |
| Rance Leth | Administrator | Facility administrator mentioned in the report |
| Joel Esquivel | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Census: 159
Capacity: 220
Deficiencies: 0
Date: 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
Census: 159
Capacity: 220
Deficiencies: 0
Date: Apr 28, 2022
Visit Reason
Licensing Program Analysts made an unannounced case management visit to follow up on a resident death at the facility.
Findings
No deficiencies were cited during this 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 |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Rachelle Wheaton | Resident Care Director | Met with Licensing Program Analyst during the visit and provided information regarding the resident death. |
| Joel Esquivel | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 168
Capacity: 220
Deficiencies: 0
Date: 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.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false or without reasonable basis.
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.
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: 168
Capacity: 220
Deficiencies: 0
Date: Feb 23, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that a resident was being overcharged and not provided an itemized list of charges.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false or without reasonable basis.
Findings
The investigation found no evidence to support the allegations. The resident's ledger and itemized statements matched charges, and the allegations were determined to be unfounded.
Report Facts
Capacity: 220
Census: 168
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation |
| Rance Leth | Executive Director | Facility representative met during investigation |
| Joel Esquivel | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 220
Deficiencies: 0
Date: 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.
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.
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.
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
Complaint Investigation
Census: 167
Capacity: 220
Deficiencies: 0
Date: 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.
Complaint Details
The complaint alleged that a resident sustained a fall while in care. The investigation included observation, interviews, and document review. The allegation was found to be unfounded, meaning it was false, could not have happened, or was without reasonable basis.
Findings
The investigation found that the resident exhibited confusion, dizziness, and paranoia, was sent out for medical evaluation multiple times, and sustained a fall within 15 minutes of returning to the facility. The allegation was determined to be unfounded based on interviews, observations, and documentation review.
Report Facts
Staff present in memory care: 4
Residents in memory care unit: 21
Medical evaluations: 3
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 | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Census: 151
Capacity: 220
Deficiencies: 0
Date: 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
Census: 151
Capacity: 220
Deficiencies: 0
Date: 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 is needed at this time.
Report Facts
Capacity: 220
Census: 151
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Mullen | Licensing Program Analyst | Conducted the unannounced visit and evaluation |
| Ranch Leth | Executive Director | Met with Licensing Program Analyst during the visit and discussed facility procedures |
Inspection Report
Original Licensing
Census: 158
Capacity: 220
Deficiencies: 0
Date: 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
Census: 158
Capacity: 220
Deficiencies: 0
Date: May 19, 2021
Visit Reason
The inspection was conducted as a Pre-Licensing visit to evaluate the facility for initial licensing purposes.
Findings
The facility was toured and inspected with no deficiencies observed. The property and services met regulatory requirements including fire clearance, safety measures, food storage, emergency plans, and resident accommodations.
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 Pre-Licensing inspection |
| Crystal Colvin | Licensing Program Analyst | Conducted the Pre-Licensing inspection and authored the report |
Inspection Report
Original Licensing
Capacity: 220
Deficiencies: 0
Date: 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. |
Inspection Report
Capacity: 220
Deficiencies: 0
Date: May 4, 2021
Visit Reason
The visit was an office evaluation conducted via telephone call to complete Component II (COMP II) with the applicant/administrator to confirm understanding of Title 22 and various regulatory requirements.
Findings
The applicant/administrator successfully completed COMP II, demonstrating understanding of facility operation, staff qualifications, program policies, grievance procedures, physical plant, food service, and application document requirements.
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