Inspection Report Summary
Most inspections found deficiencies related mainly to emergency preparedness and infection control plans, with some issues around resident activities. A complaint investigation on March 4, 2024, substantiated an immediate health and safety risk when a resident was improperly restrained, but the resident was promptly released without injury. Other complaints about care and facility conditions were unsubstantiated. The most recent report from February 7, 2025, cited deficiencies including failure to update key plans annually and lack of active fire alarm and sprinkler services. There is no indication of fines or enforcement actions in the available reports, and the facility’s record shows ongoing challenges with documentation and safety systems but no clear improvement trend.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
71% occupied
Based on a February 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 10
Capacity: 14
Deficiencies: 4
Feb 7, 2025
Visit Reason
The inspection was an unannounced required annual visit to the facility to evaluate compliance with licensing regulations.
Findings
The facility was found to have several deficiencies including failure to review/update the Infection Control Plan and Emergency Disaster Plan annually, lack of active fire alarm/sprinkler services, and failure to notify the local fire jurisdiction about oxygen administration in the facility. Plans of correction were submitted with due dates.
Deficiencies (4)
| Description |
|---|
| Licensee did not review/update the Infection Control Plan annually. |
| Licensee did not have active and operating fire alarm/sprinkler services. |
| Licensee did not review/update the Emergency Disaster Plan annually. |
| Licensee did not send a report to the local fire jurisdiction regarding oxygen administration in the facility. |
Report Facts
Capacity: 14
Census: 10
Deficiency due date: Feb 14, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica V. Villanueva | Administrator/Licensee | Facility administrator named in the report and during exit interview |
| Michelle Echeverria | Licensing Program Analyst | Conducted the inspection and authored the report |
| Nedra Brown | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 14
Capacity: 14
Deficiencies: 1
Mar 4, 2024
Visit Reason
The visit was an unannounced investigation of complaint number 56-AS-20240228135949 regarding the use of restraints on a resident.
Findings
It was found that Resident 1 was restrained to their bed with a sheet tied loosely to the bed rail, posing an immediate health and safety risk. Resident 1 was immediately released from the restraint with no observed bruising or skin discoloration.
Complaint Details
The visit was conducted for the investigation of complaint number 56-AS-20240228135949. The complaint was substantiated by the observation of improper restraint use.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident 1 was observed tied to their rail with a sheet, which poses an immediate health and safety risk to residents in care. | Type A |
Report Facts
Census: 14
Total Capacity: 14
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica V. Villanueva | Administrator | Licensee met during inspection and advised of visit purpose |
| Bianca Wolcott | Licensing Program Analyst | Conducted the inspection and signed the report |
| Anna Bueno | Licensing Program Analyst | Conducted the inspection |
| Nedra Brown | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 14
Capacity: 14
Deficiencies: 0
Mar 4, 2024
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2024-02-28 regarding allegations of inadequate care and facility conditions at Mission of Love II.
Findings
The investigation found the allegations unsubstantiated after observations, record reviews, and interviews. The facility was clean and odor-free, residents received appropriate incontinence care, pressure injuries were related to resident behavior and hospice care, and adequate food quantity and assistance were provided.
Complaint Details
The complaint included allegations that staff did not ensure the facility remained free of odors, did not assist residents with incontinence needs, did not prevent a resident from developing a pressure injury, and did not ensure an adequate quantity of food was served. All allegations were found unsubstantiated.
Report Facts
Capacity: 14
Census: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica V. Villanueva | Administrator | Met with during investigation and advised of visit purpose |
| Bianca Wolcott | Licensing Program Analyst | Conducted the complaint investigation |
| Anna Bueno | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Nedra Brown | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 13
Capacity: 14
Deficiencies: 3
Dec 19, 2023
Visit Reason
The visit was conducted as a required comprehensive annual inspection of the facility.
Findings
The inspection found that the facility was operating within its approved capacity and maintained a safe and clean environment with sufficient staffing and supplies. However, three deficiencies were cited related to the absence of an Emergency Disaster Plan, Infection Control Plan, and Planned Activities for residents.
Deficiencies (3)
| Description |
|---|
| Failure to have an emergency and disaster plan as required by HSC 1569.695(a). |
| Failure to develop and include an Infection Control Plan in the Plan of Operation as required by CCR 87470(c)(1)(C). |
| Failure to encourage residents to maintain and develop their fullest potential through planned activities as required by CCR 87219(a). |
Report Facts
Deficiencies cited: 3
POC Due Date: Dec 27, 2023
POC Due Date: Dec 28, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anita Oja | Care Giver | Met with Licensing Program Analyst during inspection and received exit interview. |
| Jessica V. Villanueva | Administrator | Named as facility administrator responsible for plan of correction submissions. |
| Mary Rico | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Efren Malagon | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Annual Inspection
Census: 14
Capacity: 14
Deficiencies: 0
Jan 19, 2022
Visit Reason
An unannounced required annual inspection was conducted with an emphasis on infection control due to the COVID-19 pandemic.
Findings
The facility was found to be in compliance with regulatory requirements, including infection control measures, operational standards, and safety protocols. No deficiencies were cited during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica V. Villanueva | Administrator | Named as facility administrator and present during inspection. |
| Stephanie Williams | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Efren Malagon | Licensing Program Manager | Named in the report as Licensing Program Manager. |
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